ACUTE DIARRHOEA

DIARRHOEADefined as passage of abnormally liquid or

unformed stools at an increased frequencyStool weight more than 200 g/ dayClassification •Acute - < 2 weeks •Persistent- 2 to 4 weeks •Chronic- > 4 weeks

Two common conditions associated with passage of stools < 200g/day

1.Pseudo diarrhoea 2.Fecal incontinence

Acute DiarrhoeaCauses 90 % - INFECTIOUS AGENTS 10 % - Medications , Toxic ingestions, Ischeamia

Infectious AgentsFecal-oral transmissionBacterias,Viruses,Parasites

Pathogenesis of Bacterial Diarrhoeawithout mucosal injury

mediated by:EnterotoxinsAdhesins

with mucosal injurymediated by:

AdhesinsInvasinsCytotoxins

PATHOGENESIS VIRUS DIARRHOEAVIRUS DIARRHOEA

Effect on villus structure and functionEnzyme damageSignificant effect on digestion and absorption

Rotavirus

Norwalk virus

Enteric Adenovirus

Astrovirus

HIGH RISK GROUPS1.Travellers – ETEC, EAEC ,Campylobacter, Shigella2 . Consumers of certain foods - picnic,banquet,restaurant3.Immunodeficiancy persons4. Institutionalised persons

The agents include1 . Toxin producers Preformed toxin – B.Cereus , Staph

aureus, C.perfringens Enterotoxin – V.cholera,ETEC2. Enteroadherant EAEC,Giardia,Cryptosporidium

3 . Cytoxin Producers C. difficile 4 . Invasive Rota virus,Salmonella,Campylobacter V. parahmolyticus,Shigella

Clinical featuresPreformed & Entero toxin Profuse watery diarrhoea + vomitting•Enteroadherant High fever + Abdominal cramps•Invasive – Bloody diarrhoea

Other CausesA/E of certain drugs – Antibiotics,NSAIDs, Antiarrythmics, Bronchodialaters,AntacidsOcclusive or Non occlusive colitis Above 50 years Lower abdominal pain preceeding watery, then bloody diarrhoea

Approach to PatientMost acute diarrhoeas – Mild & self limitedIndications for evaluation Profuse diarrhoea with dehydration Grossly bloody stools Duration >48 hrs without improvement Recent antibiotic use

Severe abdominal pain in patient >50 years Elderly Immunocompromised patients

Algorithm for Management

History and Physical Exam

Main goalsEstimate the level of dehydration Identify likely causes on the basis of history and clinical findings

HistoryOnset, frequency, quantity, and character

of diarrheaAssociated symptoms: nausea, vomiting,

fever, abdominal pain, tenesmus, malaise Recent oral intakeSigns and symptoms of dehydration

Physical ExamVitals, vitals, vitals!

Abdominal exam

Presence of occult blood

Signs of dehydration

InvestigationsCorner stone of diagnosis –

Microbiologic analysis of stoolsInvestigations – Cultures for bacterial

& viral pathogens - Inspection for ova & parasites - Immunoassays

TreatementFluid & electrolyte replacemet Oral sugar & electrolyte solution I.V rehydrationModerately severe, non febrile & non bloody

diarrhoea – LoperamideAntibiotics

Empirical therapy Febrile – Ciprofloxacin 500 mg bid for

3-5 days Suspected giardiasis – Metronidasole 250 mg qid for 7 daysAntibiotic prophylaxis Cotrimoxazole,Ciprofloxacin

In SummaryExtremely commonMost is viral in origin and self-limitedA good H&P is crucial Warning signs include high fever,

severe abd. pain, dehydration, and bloody stool

Fluid replacement is most importantAntibiotics are usually not necessary

Good nutrition and hygiene can prevent most diarrhea

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