Diarrhea & Dehydration

Prof. Dr. M. Juffrie, SpAK, Ph.D

Quantum of ProblemGreat public health problem in developing

countries II killer disease

High Morbidity & Mortality. 70% deaths due to dehydration.

ORS brought revolution : Greatest invention of century.

5 Millions - 1.5 millions deaths/ annum now. Main focus on Prolonged/ Persistent diarrhea/CD.

Physiological Definition of Diarrhea

Loss of fluid and electrolytes via stools is net result of imbalance between secretory and absorptive processes in small & large intestine. Electrolytes have a critical role in the regulation of water absorption and secretion across the intestine.Watery stools, more than 3 time a day (24 hours) (WHO, 2007)

Walker Smith 2004

Normal Villi

What is not Diarrhea ?

• Stools of an infant– Breast fed– Artificially fed

• Exaggerated gastrocolic reflex• Irritable bowel syndrome (IBS)• Spurious / factitious diarrhea

Age specific incidence for diarrhoea episode per Child per year from 2 reviews of prospective studies in developing areas,1980 - 2000

0

1

2

3

4

5

0-5m 6-11m 1 year 2 years 3 years 4 years

1980-19901990-2000

Number of episodes/person/year

Kosek et al. Bulletin of the WHO 2003; 81:197-204.

2-5 episodes/year

Types of Diarrhea(a) Depending upon duration.

Acute diarrhea 3 - 7 days Prolonged or Indeterminate 8 - 14 days

Persistent diarrhea > 14 days (b) Depending upon characteristics of stools. Watery diarrhea --- Secretory & Osmotic

Bloody diarrhea --- Blood & Mucus (Dysentery)(c) Severity of diarrhea

Diarrhea with severe malnutrition Diarrhea with HIV infection

Diarrhea with the other immune deficient states.

Pathogenesis

• Absorption disorder• Secretory disorder• Osmotic disorder

Overview ofGI Processes

Food

Secretion

Digestion

Absorption

Blood Vessels

Motility

Na+

Cl -

1. Active2. Change H+3. Change Cl-4. Glucose

EnterocytecAMP

Osmotic

1

2

3

Common Causes of Acute Common Causes of Acute DiarrhoeaDiarrhoea

• Infection – highly contagiousViral gastroenteritis (“stomach flu”)

Rotavirus

Usually cause explosive, watery diarrhoea

Typically last only 48-72hrs

Usually no blood and pus in stool

Bacterial enterocolitis Sign of inflammation – blood or pus in

stool, fever

E. Coli bacteria•Contaminated food or

water•Usually affect small kids

Bacterial enterocolitis Sign of inflammation – blood or pus in

stool, fever

Salmonella enteritidis bact

•In contaminated raw or undercooked chicken and

eggs

Bacterial enterocolitis Sign of inflammation – blood or pus in

stool, fever

Shigella bacteria Campylobacter

bacteria

Cryptosporidium• in contaminated

water – can survive chlorination

Parasites

Giardia lamblia• in contaminated

water •Usually not associated

with inflammation

Common Causes of Acute Common Causes of Acute Diarrhoea – cont.Diarrhoea – cont.

• Food PoisoningBrief illness cause by toxins produced by

bacteriaCause abdominal pain, vomittingCause SI secrete high amnt of water –

diarrhoeaSome bacteria produce toxins in food

before intake or in intestine after food is eaten

Symptoms usually appear within sev. hours

• Food Poisoning

Staphylococcus aureus• Produces toxins in food before it is eaten•Usually food contaminated left unrefrigerated overnight

• Food Poisoning

Clostridium perfringens• Multiplies in food•Produces toxins in SI after contaminated food is eaten

Common Causes of Acute Common Causes of Acute Diarrhoea – cont.Diarrhoea – cont.• Traveller’s Diarrhoea• Drugs / medications

DIARE

Diare akut keluarnya BAB 1x/ lebih yg berbentuk cair dlm 1 hari/ lebih & berlangsung < 14 hari (Cohen MB)

Diare episode keluarnya tinja cair sebanyak 3x/ lebih, atau lebih dari 1x keluarnya tinja cair yg berlendir atau berdarah dalam 1 hari (Shahid NS)

Faktor2 yang mempengaruhi kejadian diare: Lingkungan kebersihan lingkungan & perorangan Gizi pemberian makanan Kependudukan insiden diare pd daerah kota yg padat/

kumuh lebih Pendidikan pengetahuan ibu Perilaku masyarakat kebiasaan2 Sosial ekonomi

ETIOLOGI DIARE

1. Faktor infeksia. Infeksi enteral infeksi pada GIT (penyebab utama)

Bakteri : Vibrio cholerae, Salmonella spp, E. coli dllVirus : Rotavirus (40-60%), Coronavirus, Calcivirus dllParasit: Cacing (Ascaris, Oxyuris,dll), Protozoa (Entamoba histolica,Giardia Lambia, dll) Jamur (Candida Albicans)

b. Infeksi parenteral infeksi di luar GIT (OMA, BP, Ensefalitis,dll)

2. Faktor malabsorbsi : KH, Lemak, P3. Faktor makanan : basi/ beracun, alergi4. Faktor psikologis : takut dan cemas

PATOFISIOLOGI

VIRUS masuk enterosit (sel epitel usus halus) infeksi & kerusakan fili usus halus

Enterosit rusak diganti oleh enterosit baru (kuboid/ sel epitel gepeng yg blm matang) fungsi blm baikFili usus atropi tdk dpt mengabsorbsi makanan & cairan dgn baik

Tek Koloid Osmotik motilitas DIARE

BAKTERI NON INFASIF (Vibrio cholerae, E. coli patogen) masuk lambung duodenum berkembang biak mengeluarkan enzim mucinase (mencairkan lap lendir) bakteri masuk ke membran mengeluarkan subunit A & B mengeluarkan (cAMP) merangsang sekresi cairan usus, menghambat absobsi tampa menimbulkan kerusakan sel epitel tersebut volume usus dinding usus teregang DIARE

BAKTERI INFASIF (Salmonella spp, Shigella spp, E. coli infasif, Champylobacter) prinsip perjalanan hampir sama, tetapi bakteri ini dapat menginvasi sel mukosa usus halus reaksi sistemik (demam, kram perut) dan dapat sampai terdapat darah

Toksin Shigella masuk ke serabut saraf otak kejang

BERDASARKAN PATOFISIOLOGIDiare osmotik : diare akibat adanya bahan yang tidak dapat diabsorbsi oleh lumen usus hiperosmoler hiperperistalsisDiare sekretorik : terjadi akibat stimulasi primer dari enterotoksin atau oleh neoplasmaDiare akibat gangguan motilitas usus : gangguan pada kontrol otonomik

Treatment of Acute Diarrhea

• Oral Rehydration Therapy• Dietary therapy• Zinc therapy• Antimicrobials • Education

Oral Rehydration Therapy (ORT)

Oral Rehydration Solution (ORS)

WHO - ORS = Physiological Basis

Other Fluids & Liquid Diets

Home Available FluidsRecommended• Salt sugar solution• Lemon water(Sikanjabi)• Rice water / Kanjee• Soups • Dal water• Lassi• Coconut water• Plain water

Not recommended• Simple sugar solution• Glucose solution• Carbonated soft

drinks• Fruit juices-tinned or

fresh• Fluids for athletes• Gelatin desserts• Tea/Coffee

Composition of WHO High & Low Osmolality ORS

------------------------------------------------------------------------------------------------------------------------------------Ingredients / L High Osmolality Low Osmolality Components / Litre_________

Sodium Chloride 3.5 2.6 Na 90 75Sodium Citrate 2.9 2.9 Citrate 1010

or Sodium Carbonate 2.5 2.5 H CO3 30 30

Potassium Chloride 1.5 1.5 K 2020Glucose 20 13.5 Glucose 111 75

Osmolality 311 245-------------------------------------------------------------------------------------------------------------------------------------

Limitations of WHO High Osm-ORS Does not lower volume, frequency and duration of

diarrhea Induces vomiting due to taste, acceptability poor

Enhances volume, purge rate & duration of diarrhea due to high osmolality

More chances of dehydration – Dehydrating fluid So more oftenly IV fluids required

Hypernatremia Good to correct deficit fluids but not good for

maintenance therapy

Need of Low Osm-ORS

• Does lower volume, frequency & duration • Equally effective in cholera, toxin related & RV

diarrhea : Deficit & maintenance therapy• No need of IV fluids• Good for all ages infancy to adulthood• Asymptomatic hyponatremia.

Role of Diet in Acute Diarrhea Dietary therapy

• Key role in treatment of diarrhea• Gained great importance in recent years.• Early refeeding during or after rehydration

mandatory• Delayed feeding even by one day-slow recovery• Fasting deterimental for outcome

Advantages of Dietary Therapy

• Maintains nutrition, helps in absorption• Faster recovery• Take care of infection and avoids malnutrition• Prevents prolongation of diarrhea• Corrects malnutrition in mal-nourished

children.• Extra diet in convalescence / on recovery

What are the Diets to be Continued or Given ?

• Age appropriate diets• Breast feeding : Aseptic paint.• Artificially fed – milk• Whatever child taking earlier• Rice, khichri, pulses/ curd/yogurt• Small frequent aliquots – Spoon & Katori

Foods to be Avoided

• Fat rich• Fruits and fruit juices• Junk foods• Spicy foods• Carbonated fluids• Sugar & glucose rich foods

Diarrhea

ORSContinue breast

feeding

Cereal supplementsMalnutrition(Marasmus)

Mucosal injury(Malabsorption)

“TREAT THE DIARRHEA WITH REGULAR DIET”

PD

Role of Zinc in Acute Diarrhea

Acute as well as persistent diarrheaTremendous loss in stools.Absorption of Zinc intact

Deficiency during diarrhea results into lowering of Cell division & maturation.Tissue growth & repair.Maturation of enterocytes.Brush border enzymes.Water & electrolyte absorption. Immune functions.

Zinc Supplementation in AD

Responsible for > 200 enzymes in body. Improves the immune function & absorption. Supplementation in AD and PD helpful in 20-30%

reduction in diarrhea. 42% lower rate of treatment failure or death.

Dosageso Infants 10mg daily x 2 weeks.o Older children 20mg daily x 2 weeks.o Persistent diarrhea x 4 weeks

Acta Pediatr 2001Am J Clin Nutr 2000

ASCODD 2001

Antimicrobial Therapy in AD

No proof that antibiotics effective in reducing the duration of diarrhea

Cochrane review of 12 trials – no advantage rather adverse effects more in acute watery diarrhea.

Why Antibiotics are not Required in AD?

Lack of knowledge of sensitivity of drug

against causative agent Risk of development of resistant bacteria Risk of adverse reactions (AAD) Cost of treatment

Indications for Antimicrobials ----------------------------------------------------------------------------------------------------Micro

- organisms Drugs----------------------------------------------------------------------------------------------------

Bacteria - Shigella Nalidixic acid, Norfloxaclin Ciprofloxacin

Ofloxacin, Cefotaxime, Ceftriaxone- Salmonella typhi Ciprofloxacin, Ofloxacin

- Vibrio cholera Cotrimoxazole, Tetracycline,Ciprofloxacin, - Compylobacter jejuni Nalidixic acid, Norfloxacin, Furazolidine

- EPEC (PD) Furazolidine, Norfloxacin, Cotrimoxazole Protozoa

- Giardia lamblia } Mitronidazole, - Entameba histolytica } Tinidazole, Nitazoxanide, Furazolidine

-Cryptosporidium parvum Pramomycin, Nitazoxanide----------------------------------------------------------------------------------------------------

Other Special Indications of Antibiotics. Severity of symptoms Host related risk factors

* Severely sick child * Neonatal age* Septicemia * Malnutrition* Neurological involvement * HIV Infection

* Septic shock State * Other immune deficiency* Invasive diarrhea

Socio- environmental indications* Cholera

* Nosocomial infection* At risk contacts.

* Epidemics

Probiotics

• Duration of acute diarrhea decreases by one day in meta-analysis

• Saccharomyces boulardii : Strong benefit in AAD • Shown in meta-analysis of seven studies

Aliment Pharmacol Ther 2002

Diet in Indeterminate Diarrhea(8-14 days)

• Breast feeds continue • Diet A : Low lactose diet• Diet B : Lactose free diet, if no response to

Diet A.• Diet C : Monosaccharide based diet if no

response to Diet B.

Dietary Algorithm for Treatment Of PD Stabilize

Success Start Diet A

Treatment failure (Screen for infections)

Start Diet B

Discharge Success Failure (Screen for infection) Appropriate Discharge Diet Cdiet 7-14 days

Diet A after 10 days Success Failure

After 7-14 days Gradually Parenteralnormal diet Diet B then nutrition

Diet A & normal Bull WHO 1996

Traditional Practices to be Avoided

• Antimotility & antispasmodic drugs• Stool binding agents• Enzyme preparations & steroids• Antimicrobial agents in combination• Bottle feeding• IV fluids to every case • Starvation-Nothing like bowel rest• These will hamper natural clearance, lower

immunity, promote growth of unusual organisms & PEM

Practices to be Adopted

• Breast feeding: Aseptic paint for GIT

• Cereal supplementation

• Spoon & katori/ directly from pot

• Judicious use of antimicrobials

• Proper hygiene & sanitation

• Rotavirus vaccine

When to refer to higher center

• Duration of diarrhea more than 7 days• Fast deteriorating condition • No response to usual therapy• Associated complications• Severely malnourished child• HIV positive

… to conclude

Low Osm-ORS.. quite effective

Zinc therapy ..important component

Treat diarrhea with regular diet

Limited use of antibiotics : Dysentery

DEHYDRATION

OBJECTIVES

At the end of this lecture you will able to know the followings:

*What is dehydration?*What are the causes of dehydration?*The clinical manifestaions of dehydration.*The investigations required.*Management of dehydration.

Fluid and electrolytes requirementsWater: : Constitutes about 70% of infant's body weight as

compared to 60% in adults.

Most of the water is found within the cells of the body (intracellular space). The rest is found in the extracellular space, which consists of the blood vessels (intravascular space) and the spaces between cells (interstitial space).

Total body water = intracellular space + intravascular space + interstitial space

DEHYDRATION

Average daily requirement of water (ml/kg): -First year: 130 – 150. -2 to 4 years: 100 – 130. -4 to 10 years: 70 – 100.-10 to 18 years: 50- 70.

Dietary Reference Intakes (DRI) of electrolytes:Sodium (mg/day): 120 in the 1st 6months, 200 in the age 7-12 months, 225 in the age 1-3 years, and 300 from 4-8 years of age.

Potassium (mg/day): 500 in the 1st 6 months, 700 from7-12 months, 1000 from1-3 years, and 1400 from 4-8 years of age.

What is dehydration? Dehydration occurs when the amount of water leaving the body is

greater than the amount being taken in. We lose water routinely when:• We breathe and humidified air leaves the body;• We sweat to cool the body; and, • We urinate or have a bowel movement to get rid the body waste

products. Hyponatremia ; Is a condition in which the body's stores of sodium are too low, and

this condition can result from drinking extreme amounts of water. Hyponatremia can lead to confusion, lethargy, agitation, seizures,

and in extreme cases, even death. Early symptoms are nonspecific may include disorientation, nausea,

or muscle cramps. The symptoms of hyponatremia may also mimic those of dehydration, so athletes experiencing these symptoms drinking more water that result in further worsening the condition.

CONSERVATION OF BODY WATER• In a normal day, a person has to drink a significant amount of water

to replace the routine losses. • If intravascular water is lost, the body can compensate by shifting

water from cells into the blood vessels, but this is a very short-term solution. Signs and symptoms of dehydration will occur quickly if the water is not replenished.

• The thirst mechanism signals the body to drink water when the body is dry. As well, hormones like anti-diuretic hormone (ADH) work within the kidney to limit the amount of water lost in the urine.

• The electrolytes in our body include sodium, potassium, chloride, calcium and phosphate, but sodium is the substance of most concern when replacing fluids lost through exercising.

Hypernatremic dehydration• Dehydration,characterized by increased concentrations of sodium

and chloride in the extracellular fluid, it results from diarrhea in infants.

• The occurance of the hypernatremia and hyperchloremia lies in the relatively greater expenditure of water than electrolyte via skin, lungs, stool and urine. The water deficit in these infants is primarily intracellular.

• The majority of infants with this type of dehydration show varying

degrees of depression of central nervous system varying from

lethargy to coma. Convulsions are frequently observed.

• Dilute solutions of electrolyte are indicated in rehydration. Rapid adjustment, however, appears to accentuate the CNS disturbance. Rehydration is best carried out slowly over a 2- to 3-day period.

What causes dehydration? • Diarrhea: is the most common reason for loss of excess water.

Worldwide, more than four million children die each year because of dehydration from diarrhea. -Vomiting: can also be a cause of fluid loss .

• Sweat: The body can lose significant amounts of water when it tries to cool itself by sweating whatever the cause of hotness of the body such as intense exercising in a hot environment, or presence of fever .

• Diabetes: In people with diabetes, elevated blood sugar levels cause sugar to spill into the urine and water then follows. For this reason, frequent urination and excessive thirst are among the symptoms of diabetes.

• Chronic renal failure: dehydration occurs due to polyuria.• Burns: dehydration occur because water moves into the damaged skin.

Other inflammatory diseases of the skin are also associated with fluid loss.

• Inability to drink fluids: The inability to drink adequately is the other potential cause of dehydration.

Clinical picture:Examination. - Body weight. - Temperature.- Signs of

dehydration. - Systemic examination.General manifestations:- Dry skin and mucous membrane.- Decrease all body secretions (urine, sweats,

tears, saliva) - Depressed fontanel, sunken eyes, thirst,

irritability, lately hypotension, acidosis and coma.

DEGREES OF DEHYDRATION:Degree of dehydration Plan A:

No dehydrationPlan B: Some dehydration

Plan C: Severe dehydration

General condition Calm, alert Restless irritable

Lethargic, unconscious

Eye manifestation Normal Sunken Sunken

Ability to drink Normal Thirsty, eager to drink

Poor

Skin pinch Goes back quickly

Slowly Very slowly

IMCI MANAGEMENT: Integrated management of childhood illness ( WHO)

* Plan A: Give fluid and food to treat diarrhea at home • If child is 2 years or older and there is Cholera in your area, give

antibiotic for cholera.• Advise mother when to return immediately• Follow-up in 5 days if not improving.* Plan B: Give fluid and food for some dehydration.• If child has also a severe classification:• Refer URGENTLY to hospital with mother giving frequent sips of

ORS on the way• Advise the mother to continue breast-feeding• If child is 2 years or older and there is Cholera in your area, give

antibiotic for cholera.• Advise mother when to return immediately• Follow-up in 5 days if not improving.

IMCI MANAGEMENT: Integrated management of childhood illness ( WHO)

* Plan C: - Give fluids for severe dehydration or If child has also another severe classification:

• Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way

• Advise the mother to continue breast-feeding• If child is 2 years or older and there is Cholera in your area,

give antibiotic for cholera.• 100 cc/kg/bw: 30 cc/kg in first ½ hour, 70 cc/kg in second

21/2 hour for child > 1 year; and in first 1 hour and 5 hours further for child < 1 year (WHO 2007)

MANAGEMENT OF DEHYDRATION-Replace Phase 1: Acute Resuscitation :

– Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV over 30-60 minutes.

– May repeat bolus until circulation stable -Calculate 24 hour maintenance requirements

– Formula: • First 10 kg: (100 cc/kg/24 hours) • Second 10 kg: (50 cc/kg/24 hours) • Remainder: (20 cc/kg/24 hours)

Example: 35 Kilogram Child • Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day

-Calculate Deficit:– Mild Dehydration: (40 ml/kg) – Moderate Dehydration: (80 ml/kg) – Severe Dehydration: (120 ml/kg)

MANAGEMENT Continue ----------Calculate remaining deficit:

– Substract fluid resuscitation given in Phase 1 -Calculate Replacement over 24 hours:

– First 8 hours: 50% Deficit + Maintenance – Next 16 hours: 50% Deficit + Maintenance

• Determine Serum Sodium Concentration – Hypertonic Dehydration (Serum Sodium > 150) – Isotonic Dehydration – Hypotonic Dehydration (Serum Sodium < 130)

• Add Potassium to Intravenous Fluids after patient voids urine – Potassium source

• Potassium Chloride • Potassium Acetate for Metabolic Acidosis

– Potassium dosing • Weight <10 kilograms: 10 meq KCl /liter glucose • Weight >10 Kilograms: 20 meq KCl /liter glucose