DIARRHOEA

CHETAN RASTOGIM.Pharm Pharmacology Ist Year

HIPER Lucknow

Introduction

Diarrhoea is defined as passage of unusually loose

or watery stools usually at least three times in a 24

hour period. (WHO)

For adults stool weight >200 g/d can generally be

considered diarrhoeal. Passage of even one large watery stool in young

child is diarrhoea. Frequent passage of normal stool is no diarrhoea.

Types & Causes Based on Clinical Syndrome

Diarrhoea

Persistent

Multiple cause

Dysentery

Bacillary Amoebic

Watery

Cholera E. coli Rotavirus

Diarrhoea: types, etiology, pathogenesis

Acute (up to 1-2 weeks)Food poisoning (due for microbs or not)Bacterial infections: E.coli, Shigella, Salmonella, Campylobacter, Yersinia Viral infections: RotavirusProtozoan infections: Entamoeba, Giardia lamblia Drugs:antibiotics (Сl.deficile)laxativesantacids (Mg)anticholinesterase drugscolchicinpreparations with Auquinidinecardiac glycosides

Chronic (> 4 weeks)

Osmotic diarrhoea (osmotic laxatives and lactose)

Secretory diarrhoea (bacterial toxins, hormones, fatty and bile acids, laxatives)

Inflammatory diarrhoea (infections, inflammatory bowl diseases, celiacia, lymphoma, iscemia)

Hypermotoric diarrhoea (irritated bowl syndrome)

TRANSMISSION• Most of the diarrheal agents are transmitted by the fecal-oral

route• Cholera: water-borne disease; transmitted through water

contaminated with feces.• Some viruses (such as rotavirus) can be transmitted through

air• Nosocommial transmission is possible• Shigellosis (blood dysentery) is mainly transmitted person-to-

person• Shigellosis is a water-washed disease; transmitted more

when there is scarcity of water

Pathophysiological Mechanismssecretory diarrhea (increased intestinal

secretion)

infections (cholera toxin, E-coli, salmonella, staphylococcal)

Hormonal (Gut Hormones, ZES, VIP), cancer (calcitonin, Prostaglandins)

miscellaneous (laxatives abuse, villous adenoma of the rectum)

agentsAdenylate

cyclasecAMP system

secretory diarrhea

activate NaCl

• secretory diarrhea (increased intestinal secretion)

• Osmotic diarrhea• Decreased intestinal surface area and/or

intestinal absorption• Inflammatary diarrhea• Rapid transit of intestinal contents

(shortened transit time)

• secretory diarrhea (increased intestinal secretion)

• Osmotic diarrhea

• Decreased intestinal surface area and/or intestinal

absorption

• Inflammatary diarrhea

• Rapid transit of intestinal contents (shortened transit

time)

Pathophysiological Mechanisms

Symptoms Accompany Diarrhoea1. Dehydration

Diarrhea can cause dehydration. Loss of electrolytes through dehydration affects

the amount of water in the body, muscle activity, and other important

functions.

Signs of dehydration in adults include:

• thirst

• less frequent urination than usual

• dark-colored urine

• dry skin

• fatigue

• dizziness

• light-headedness

Signs of dehydration in infants and young children include:• dry mouth and tongue• no tears when crying• no wet diapers for 3 hours or more• sunken eyes, cheeks, or soft spot in the skull• high fever• listlessness or irritability

SIGNS OF DEHYDRATION

2. Functional bowel disorders: Diarrhea can be a symptom of irritable bowel

syndrome.

3. Intestinal diseases: Inflammatory bowel disease, ulcerative colitis, Crohn’s

disease, and celiac disease often lead to diarrhea.

4. Food intolerances and sensitivities: Some people have difficulty digesting

certain ingredients, such as lactose, the sugar found in milk and milk

products. Some people may have diarrhea if they eat certain types of

sugar substitutes in excessive quantities.

5. Reaction to medicines: Antibiotics, cancer drugs, and antacids containing

magnesium can all cause diarrhea.

LABORATORY DIAGNOSIS

• Stool microscopy

• Dark field microscopy of stool for cholera

• Stool cultures

• ELISA for rotavirus

• Immunoassays, bioassays or DNA probe tests

to identify E. coli strains

ASSESSMENT OF DEHYDRATION

Dehydration Mild Moderate Severe

Appearance irritable, thirsty

irritable, very thirsty

lethargy, coma, or unconscious

Anterior Fontanelle

normal depressed markedly depressed

Eyes normal sunken sunken

ASSESSMENT OF DEHYDRATION (contd.)

DehydrationMild Moderate Severe

Tongue normal dry very dry,furred

Skin normal slowretraction

very slowretraction

Breathing normal rapid very rapid

ASSESSMENT OF DEHYDRATION (contd.)

DehydrationMild Moderate Severe

Pulse normal rapid andlowvolume

feeble orimperceptible

Urine normal dark scanty

Weightloss

< 5% 6 - 9% 10% or more

DIARRHOEA: PREVENTION AND CONTROL

When should adults with diarrhea see a health care provider?

Adults with any of the following symptomsshould see a health care provider:• signs of dehydration• diarrhea for more than 24 hours• a fever of 102 degrees or higher• stools containing blood or pus• stools that are black and tarry

When should children with diarrhea see a health careprovider?

Children with any of the following symptomsshould see a health care provider:• signs of dehydration• diarrhea for more than 24 hours• a fever of 102 degrees or higher• stools containing blood or pus• stools that are black and tarry

DIARRHOEAFLUID DEFICIT CLINICAL SIGNS TREATMENT

SEVEREDEHYDRATION

greater than 10percent of their body weight

• Lethargic or unconscious• Sunken eyes• Skin pinch goes back

very Slowly (longer than 2 seconds)

WHO Treatment Plan C

SOMEDEHYDRATION

5 to 10 percent of their body weight

Two of the following signs:• Restless, irritable• Sunken eyes• Skin pinch goes back

slowly (skin stays up even for a brief instant)

WHO Treatment Plan B

NODEHYDRATION

Less than 5 percent of their body weight

• No sign to classify as some or severe dehydration

• Skin pinch goes back immediately.

WHO Treatment Plan A

WHO Treatment Plan C• Severe dehydration require immediate IV

infusion, nasogastric or oral fluid replacement according to WHO treatment guidelines

• Give 100 ml/kg IV fluids.

Age 30 ml/kg 70 ml/kg

Infant 100 ml/kg In 6 hrs First hour Next 5 hrs

Older children 100 ml/kg In 3 hrs First 30 mins Next 2.5 hrs

• Ringer's lactate solution is the preferred commercially

available solution.

• If IV infusion is not possible, urgent referral to the

hospital for IV treatment is recommended.

• When referral takes more than 30 minutes, fluids

should be given by nasogastric tube.

• If none of these are possible and the child can drink,

ORS must be given by mouth.

WHO Treatment Plan B• Some dehydration• The approximate amount of ORS required is

75 ml/kg; during first four hours, the mother slowly gives the recommended amount of ORS by spoonfuls or sips.

• After four hours, the child is reassessed and reclassified for dehydration, and feeding should begin

• If dehydration persists- the same amount of ORS may be repeated for another 4 hours.

If the child is breastfed, breast-feeding should continue

WHO Treatment Plan A• Plan A focuses on the three rules of home

treatment: – Give extra fluids, – Continue feeding, and – Advise the caretaker when to return to the

health facility

if the child develops blood in the stool, drinks poorly, becomes sicker, or is not better in 48 hours

ORAL REHYDRATION SALT(ORS)

It is a balanced mixture of glucose and electrolytes

Almost all deaths from diarrhoea can be prevented by ORS

MECHANISM OF ACTION

Sodium promotes absorption of water from the intestine

Glucose promotes the absorption of sodium and water

from the intestine

Composition grams/Litre

Glucose, anhydrous 13.5

Trisodium citrate, dihydrate 2.9

Sodium chloride 2.6

Potassium chloride 1.5

Total weight 20.5

Composition mmol/Litre

Glucose 75

Sodium 75

Chloride 65

Potassium 20

Citrate 10

Total osmolarity 245

WHO ORS

RICE BASED ORS• Tastes better and provides more calories than the glucose-

based ORS • Culturally acceptable,• Reduces stool volume (by about 40 %)• Shortens the duration of diarrhea in both cholera and other

severe diarrheal diseases.• Starches other than rice, including wheat flour and maize,

have also been shown to reduce stool volume in patients with cholera.

• Reduce diarrhea by adding more substrate to the gut lumen without increasing osmolality, thus providing additional glucose molecules for glucose-mediated absorption.

REHYDRATION THERAPYAmount of ORS to be given in first 4 hrs

Age < 4 months

4 -12 months

12m- 2 yrs 2-6 yrs

Wt (kg) < 6 6 - < 10 10 - <12 12 - 19

ORS(ml) 200-400 400-700 700-900 900-1400

Glass(No.) 1 - 2 2 - 3 3 – 4 4 - 7

Rate & Quantities of I/V infusion for severe dehydration

Age 30 ml/kg 70 ml/kg 100 ml/kg

Infant First hour Next 5 hrs 6 hrs

Older children

First 30 mins Next 2.5 hrs 3 hrs

ZINC THERAPY

• 10 mg/day orally for 14 days in children <6 months of age

• 20 mg/day orally for 14 days in children ≥6 months of age

• It is used as adjunct therapy (in all cases of diarrhoea) that decreases the duration and severity of the episode and the likelihood of subsequent infections on the 2-3 months following treatment.

Role of Probiotics

Probiotics means "for life" and is currently used to

name bacteria associated with beneficial

effects for humans and animals.

Coined in 1960 to name substances

which promoted the growth of other

organisms.

Effect of probiotics in diarrhoea- The strongest evidence of a beneficial effect

has been for the following probiotics - Lactobacillus rhamnosus GG and Bifidobacterium lactis BB-12

These probiotics are effective for both treatment and prevention of acute diarrhoea caused mainly by rotavirus in children

Antibiotic associated diarrhoea has also been found to respond when probiotics have been used as prophylaxis and also for therapy

POTENTIAL USES OF PROBIOTICS

Diarrhoea Helicobacter pylori infection Inflammatory bowel disease Cancers To increase Immunity Allergy Heart disease Urogenital tract infections

FEEDING IN DIARRHOEA

Children should continue to be fed during diarrhoea.

Milk should not be diluted with water during any phase of

acute diarrhoea.

Milk can also be given as milk cereal mixture e.g. dalia,

milk-rice mixture.

This technique reduces the lactose load & preserving

energy density.

To make foods-energy dense some of preparation are:- - Khichri with oil - Rice with curd & sugar- Mashed banana with milk or curd - Mashed potatoes with oil.

Breast feeding should be continued uninterrupted even during rehydration with ORS.

FEEDING IN DIARRHOEA

Rota virus vaccination Rotashield vaccine -1999 Withdrawn because of its association with intussuscption Two new oral, live attenuated rotavirus vaccines were

licensed in 2006 with very good safety and efficacy The first dose administered between ages 6-10 weeks . subsequent doses at intervals 4-10 weeks. Vaccination should not be initiated before 6weeks and after

12 weeks of age. All doses should be administered before 32 weeks.

Rota Rix vaccine Rota Teq vaccine

Oral, live attenuated Oral, live attenuated, pentavalent

vaccine. Contains 5 live reassortant rotaviruses

2 dose schedule 3 dose schedule

1st dose - 2 month of age at 2 month of age

2nd dose- 4 month 4 month of age…………………………. 6 month of age

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Antidiarrhoeal agents

Thanks