Diarrhoea

Diarrhoea

Definition:

Diarrhea is defined as the passage of loose, liquid, or watery stool, usually more than three times a day and associated with dehydration. The consistency and character of stool is more important than the number of passage.

Problem Statement:

Acute Diarrhoea is rivaled in importance only by respiratory infections as a cause of morbidity on a worldwide scale. It is a major health problem in developing countries. In diarrhoea the small intestine loses it's capacity to absorb water and electrolytes and instead secretes electrolytes-rich fluid. Fluid loss of up to 5 per cent of body weight produces thirst.

Agent Factor:

  1. Virus:

    Rotavirus, Astro virus, Adeno virus, Corona virus, Norwalk virus, Coxsackie virus, Entero virus.

  2. Bacteria:

    Vibrio cholerae, E. coli, Shigella, Salmonella, Campylobacter jejuni, Yersinia enterocolitica, Bacillus cereus, Staphylococcus pyogenes.

  3. Protozoal:

    E histolytica, Giardia intestinalis, Balantidium coli, Cryptosporidium, Isospora belli.

  4. Helminthic:

    Ascaris lumbricoides, Strongyloides stercoralis.

  5. Fungal:

    Candida.

Host Factor:

  1. It is most common in children (six month- two years); highest in the age group 6-11 months.
  2. Also common in babies < 6 month who are fed cow's milk or infant feeding formula.
  3. Common in persons with malnutrition.
  4. Poverty, pre maturity, reduced gastric acidity, immunodeficiency, lack of personal and domestic hygiene, incorrect feeding practice all predispose to it's occurrence.

Environmental Factor:

In temperate climate, bacterial diarrhea occurs more frequently during the warm season where as viral diarrhea occurs during winter.

In tropical areas, Rota virus diarrhoea occurs throughout the year, increasing in frequency during the drier cool month; where as bacterial diarrhoea peak during the warmer rainy season.

Mode of Transmission :

Primarily or exclusively by the faecal-oral route; it may be water borne, food borne, finger or fomite borne.

Reservoir:

  1. For some enteric pathogens man is the principal reservoir, eg. E coli, Shigella vibrio, Giardia, E histolytica.
  2. For other enteric pathogens animal are important reservoir, eg, campylobacter, Salmonella, Yersinia, Enterocolitica.

Mechanism & Consequences:

Mechanism of action : Any process, which either interferes with reabsorption of fluid from the gut of lumen or increases fluid secretion in to the gut, results in diarrhea. Most infectious agent cause secretory diarrhea by one of the following two mechanisms.

Enterotoxigenic (Non-invasive):

The microorganism elaborate toxin which act by stimulating the production of an enzyme called adenyl cyclase in the mucosal cells of small intestinal epithelium. This enzyme catalyses increased formation of cyclic AMP which stimulates active secretion of fluid from small intestine in large quantities, diarrhoea is thus produced by toxin.

Destructive (Invasive):

In this type there is actual penetration and destruction of intestinal mucosa by the organism.

Consequences of Diarrhea:

The primary consequences of watery diarrhea is the loss of fluid and electrolytes (i.e. sodium, chloride, potassium and bicarbonate); clinically known as dehydration.

The clinical signs of dehydration are restlessness, sunken eyes, and absence of tears, dry mouth and going back of pinched skin slowly. The patient is thirsty and drinks largely but in severe dehydration he is lethargic and drinks poorly.

Management and Treatment:

Oral rehydration solution (ORS): These could be of different varieties eg. bicarbonate based, citrate based, rice based, laban-gur solution and super ORS.

The aim of oral fluid therapy is to prevent dehydration and reduce mortality; it is based on the observation that glucose given orally enhances the intestinal absorption of salt and water and is capable of correcting the electrolyte and water deficit.

Principles:

  1. Patient should be given as much ORS as they want and dehydration should be checked until subside.
  2. For children <2 years, give a tea spoon every 1-2 minutes, adults may drink as much as they like.</li>
  3. If the child vomits, wait 10 minute then try again slowly; a spoonful every 2-3 minutes.
  4. When the child refuses to drink the required amount and signs of dehydration has disappeared; rehydration is completed.
  5. If the child is breastfed, nursing should be pursued during treatment with ORS solution,
  6. Non breast fed infants <6 month should be given an additional 100-200 ml of clean water during the first four hours.</li>

Intra-venous Rehydration:

  1. Ringer's lactate solution (Hartman's Solution)
  2. Diarrhea treatment solution.

Antibiotic Therapy:

  1. Doxycycline
  2. Tetracycline
  3. Furazolidone
  4. Trimethoprim
  5. Sulphamethaxazole.

Control Measures:

Short Term:

Appropriate Clinical Management:

Oral rehydration Therapy

Appropriate Feeding:

During episodes of diarrhoea, normal food intake should be promoted. Newborn infants with diarrhoea who show little or no signs of dehydration can be treated by breast-feeding alone. Once the infant is dehydrated, breast-feeding is continued along with ORS after each liquid stool.

Chemotherapy:

Unnecessary prescription of antibiotics and other drugs is of so value, such as.

Neomycin:

Damages intestinal mucosa and causes malabsoption.

Steroids:

Useless, has many adverse effects and expensive.

Long Term:

Better Care:

Improving prenatal and postnatal nutrition will reduce low birth weight and improve the quality of breast milk.

Preventive Strategies:

Sanitation:

Improvement of pure water supply, improved excreta disposal and improving in domestic and food hygiene.
Simple hygienic measures e.g.; hand washing with soap before preparing food, eating, feeding child, after defecation.

Health Education:

Regarding breast-feeding, improved weaning, clean drinking water, use of latrine.

Immunisation:

Especially against measles.

Epidemic Control :

National programme for control of diarrhoeal diseases can control epidemics of diarrhoeal disease like cholera by ensuring the implementation of strategies described below:

Submitted By
Dr. Md. Faizul Islam

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