Watery Watery diarrhoeadiarrhoeaBy Dr. Osman SadigBy Dr. Osman Sadig

DefinitionsDefinitions - Diarrhoea is passage of 3 motions per - Diarrhoea is passage of 3 motions per

day OR passage of loose or watery stools day OR passage of loose or watery stools irrespective of the frequency.irrespective of the frequency.

- - Acute diarrhoeaAcute diarrhoea: less than 2Ws : less than 2Ws durationduration

- - Chronic diarrhoeaChronic diarrhoea: more than 2WS : more than 2WS durationsdurations

Causes:Causes: - V. cholerae- V. cholerae - Algid malaria- Algid malaria

- ETEC- ETEC

- Food poisoning- Food poisoning

- viral.- viral.

JustificationJustification 1- To increase za 1- To increase za awarenessawareness about cholera about cholera

and its diagn & managementand its diagn & management

2- 2- High mortalityHigh mortality if not properly managed. if not properly managed.

3- 3- Epidemics & pandemicsEpidemics & pandemics can occur can occur

4- 4- Management can save livesManagement can save lives if properly if properly plannedplanned

5- 5- Preventive measures are effectivePreventive measures are effective

6- 6- Economic drawbacksEconomic drawbacks..

7-7-Notifiable Notifiable and and quarantinablequarantinable under under international health regulation.international health regulation.

- - CholeraCholera is an is an acute GIT infectionacute GIT infection caused caused by Vibrio cholerae:by Vibrio cholerae:

- Curved, motile & flagellated G-ve bacilli- Curved, motile & flagellated G-ve bacilli - Rapidly killed by heat at 100C, but can- Rapidly killed by heat at 100C, but can survive for 6/12 in ice, 8/52 in salted survive for 6/12 in ice, 8/52 in salted

waterwater and 2/52in fresh waterand 2/52in fresh water - Possess somatic Ags & accordingly - Possess somatic Ags & accordingly

subdividsubdivid into O1 & O139 serotypesinto O1 & O139 serotypes - - Classic Classic ( Inaba, Ogawa & Hikojima) and( Inaba, Ogawa & Hikojima) and Eltor V. cholerae biotypes.Eltor V. cholerae biotypes. - Passed in za stools & vomitus of patients, - Passed in za stools & vomitus of patients, clinical or sub-clinicalclinical or sub-clinical

EpidemiologyEpidemiology - The - The home land of cholerahome land of cholera is za fertile, humid is za fertile, humid

and highly populated and highly populated valleys of za Gangesvalleys of za Ganges in in Far East.Far East.

- - PandemicsPandemics have spread za dis across za world have spread za dis across za world following trade routes claiming thousands of following trade routes claiming thousands of

lives.lives. - Transmission is - Transmission is faecal-oralfaecal-oral through through

contaminated contaminated waterwater, foodstuffs & achlorhydria, foodstuffs & achlorhydria facilitates infection.facilitates infection. - - Source of infectionsSource of infections are patients & sub-clinical are patients & sub-clinical carriers who are import in maintainingg carriers who are import in maintainingg

infection.infection.

PathogenesisPathogenesis - V. cholerae are - V. cholerae are non-invasivenon-invasive but but

proliferate in proliferate in

in small bowel lumenin small bowel lumen

- Powerful - Powerful exotoxin & 5-HTexotoxin & 5-HT released by za released by za organism cause organism cause out pouring of isotonic out pouring of isotonic alkalinealkaline small intestinal secretionssmall intestinal secretions through cyclic AMP and neural secretory through cyclic AMP and neural secretory reflex respectively. reflex respectively. Absorption is also Absorption is also impairedimpaired. The out-come is depletion of . The out-come is depletion of fluids, salt, K & acidosis causing fluids, salt, K & acidosis causing peripheral circulatory failure & ARF & peripheral circulatory failure & ARF & deathdeath If not corrected. If not corrected.

Clinical featuresClinical features - - IPIP is hours to 5 days is hours to 5 days - - Asym & mild cases out number za classic Asym & mild cases out number za classic

casescases - The dis is - The dis is more severe in childrenmore severe in children - 3 phases are recognized in za classical case- 3 phases are recognized in za classical case 1- 1- Evacuation phaseEvacuation phase: acute painless, effortless: acute painless, effortless severe diarrhoea followed by vomiting. Firstsevere diarrhoea followed by vomiting. First faecal gut contents are evacuated followed faecal gut contents are evacuated followed

by typical rice by typical rice water motions.water motions.

2- 2- Collapse phaseCollapse phase: If appropriate management : If appropriate management is not offered enormous loss of fluids andis not offered enormous loss of fluids and electrolytes causes acute circulatory failure electrolytes causes acute circulatory failure

and shock followed by ARF & death if and shock followed by ARF & death if fluids and electrolytes are not replaced. fluids and electrolytes are not replaced. Signs of dehydration are detected. Signs of dehydration are detected. Cholera siccaCholera sicca and death can occur sp in and death can occur sp in children.children.

3- 3- Recovery phaseRecovery phase: recovery is usually : recovery is usually completecomplete

if za pt survives za collapse phase.if za pt survives za collapse phase.

ASSESSMENT OF DEHYDRATION ASSESSMENT OF DEHYDRATION DEGREEDEGREE

ASKASK mild mild DEHYDRATIODEHYDRATIOnn

moderatemoderate DEHYDRATIODEHYDRATIOnn

SEVERE SEVERE DEHYDRATIODEHYDRATIOnn

DIRRHEADIRRHEA LESS LESS THAN 4THAN 4 Sessions/DASessions/DAYY

4-104-10 MOREMORE THAN 10THAN 10

VOMITINGVOMITING MILDMILD SOMETIMESOMETIMESS

FREQUENTFREQUENT

Thirst Thirst Normal Normal Eager Eager Unable to Unable to DrinkDrink

Urine Urine NormalNormal Few & Few & darkdark

Not Not present for present for 6hrs6hrs

Assessment of Assessment of dehydration degreedehydration degree

NOTICENOTICE Mild Mild dehydrationdehydration

Moderate Moderate dehydrationdehydration

Severe Severe Dehydration Dehydration

General General condition condition

Active & Active & alert alert

Irritable Irritable Convulsing Convulsing Drowsy Drowsy comatosecomatose

Tears Tears Normal Normal Dry Dry V-Day V-Day

Eyes Eyes NormalNormal SunkenSunken V. SunkenV. Sunken

Mouth & Mouth & Tongue Tongue

Wet Wet Dry Dry V-Day V-Day

Respiratory Respiratory NormalNormal Rapid Rapid V. Rapid and V. Rapid and deepdeep

DiagnosisDiagnosis - - ClinicalClinical, during epidemics, during epidemics

- - Stool or rectal swab microscopy and Stool or rectal swab microscopy and cultureculture and sensitivity. and sensitivity.

ManagementManagement 1-1- Assess degree of Assess degree of dehydrationdehydration 2- 2- ReplaceReplace fluid & electrolyte loss fluid & electrolyte loss 3- 3- AntibioticsAntibiotics 4- Nutritional 4- Nutritional rehabilitationrehabilitation

Generally:Generally: - - ORSORS for for mild & moderatemild & moderate dehydration dehydration - - IV Ringer lactateIV Ringer lactate if za pt is if za pt is vomitingvomiting and and

in in severesevere dehydration dehydration (Darrows, (Darrows, Hartmann's, isotonic saline wz NaHCO3 & Hartmann's, isotonic saline wz NaHCO3 & K supplements).K supplements).

-Shift to ORS as soon as dehydration is -Shift to ORS as soon as dehydration is corrected in severe dehydration.corrected in severe dehydration.

Treatment of severe Treatment of severe dehydrationdehydration

Establish L.V line Establish L.V line Give Ringers lactate or Give Ringers lactate or

normal saline .normal saline . Give 100 ml/kg Give 100 ml/kg

according to the according to the following table .following table .

Age/ Age/ years years

Amount Amount

ml/ kgml/ kg Time Time in hrs in hrs

1>1> 3030 ½ ½

7070 2 ½ 2 ½

1<1< 3030 11

7070 55

If the patient is able to drink , give O.R.S If the patient is able to drink , give O.R.S while giving intravenous fluid : O.R.S while giving intravenous fluid : O.R.S 5ML/KG / hour5ML/KG / hour

Watch and follow the pt- closely . Watch and follow the pt- closely . Re – assess the patient condition after 3 Re – assess the patient condition after 3

hours (6 hours for children less than one hours (6 hours for children less than one year) .year) .

If still severe dehydration is present :If still severe dehydration is present : Re hydrate the patient intravenouslyRe hydrate the patient intravenously If dehydration is not present Replace If dehydration is not present Replace

output.output.

Treatment of mild and Treatment of mild and moderatemoderatedehydration.dehydration.

Give the patient Give the patient O.R.S O.R.S according to according to the following the following table :table :

AgAge e

Less Less than than 4 mo 4 mo

4 – 4 – 11 11 momo

12-12-23 23 momo

2-4 2-4 yrs yrs

5-5-14 14 yrsyrs

15 15 yrs yrs and and mormore e

WTWT/ / kg kg

Less Less than than 5kg 5kg

5-75-7 8-8-1010

11-11-1515

16-16-3030

MorMore e thathan 30n 30

O.RO.R.S .S MLML

200-200-400400

400400--600600

600600--800800

800800--12012000

120120--22022000

2202200-0-40040000

Treatment of mild & Treatment of mild & moderatemoderatedehydration:dehydration:

Follow up the patient – to make sure that the Follow up the patient – to make sure that the patient is taking fluid sufficiently.patient is taking fluid sufficiently.

Re- examine (evaluate) after 4 hrs .Re- examine (evaluate) after 4 hrs . Detect severe dehydration and treat Detect severe dehydration and treat

accordingly accordingly if there is no severe dehydration – re hydrate if there is no severe dehydration – re hydrate

according to degree of dehydration give fluid according to degree of dehydration give fluid & food & food

If no signs of dehydration replace fluid If no signs of dehydration replace fluid output.output.

Continue to re-evaluate every 4hrs (at least) Continue to re-evaluate every 4hrs (at least) Give suitable antibiotic .Give suitable antibiotic .

The patient should The patient should return to the health unit return to the health unit if there is :if there is : Increase frequency of diarrhea .Increase frequency of diarrhea . Unable to drink or eat Unable to drink or eat Severe thirst .Severe thirst . Frequent vomiting .Frequent vomiting . FeverFever Blood in stool .Blood in stool .

Treatment if no Treatment if no dehydrationdehydration Patient should be :Patient should be :

1-Given O.R.S at home for two 1-Given O.R.S at home for two day 2-Taught how to use it .day 2-Taught how to use it .

3-Taught the dose .3-Taught the dose .

O.R.S AT HOMEO.R.S AT HOME

AGE /YRSAGE /YRS Amount /ml Amount /ml No of cases No of cases day day

Less than two Less than two 50-100 per 50-100 per motion motion

One One

2-9year2-9year 100-200100-200 OneOne

More than More than 10year 10year

Any if able Any if able Two Two

- - AntibioticsAntibiotics as soon as vomiting stops. as soon as vomiting stops.

-- Discharge Discharge (-ve culture ??) and follow up. (-ve culture ??) and follow up.

- Epidemics need - Epidemics need preparation & preparation & fundingfunding..

AntibioticsAntibioticsStarted after vomiting stops, usually Started after vomiting stops, usually after fluid replacementafter fluid replacement..

Drug Drug Children Children Adult Adult tetracyclintetracyclinee

-- 250-500mg 6 hr 250-500mg 6 hr forfor

3 days. 3 days.

DoxycyclinDoxycyclinee

-- 300mg single 300mg single dose dose

Septrin : Septrin : twice daily twice daily for 3 days for 3 days

5 mg /kg 5 mg /kg trimethoprintrimethoprin+ 25mg/kg + 25mg/kg suphadoxine suphadoxine

1600mg TM + 800 1600mg TM + 800 mg SD for 5 daysmg SD for 5 days

FerozilipdiFerozilipdin n

1 mg/kg 6= 1 mg/kg 6= for 3 days for 3 days

100mg 6 hrs for 3 100mg 6 hrs for 3 days days

AntibioticsAntibiotics Tetracycline is contraindicated in :Tetracycline is contraindicated in :-Children -Children -Pregnancy -Pregnancy Septrin is preferred for children Septrin is preferred for children Ferozilipdine is preferred in Ferozilipdine is preferred in

pregnancy .pregnancy . Prevention of co-pt Prevention of co-pt - Doxycycime (300mg) single dose for - Doxycycime (300mg) single dose for

adult adult - Erythromycin (syrup or tablets )- Erythromycin (syrup or tablets ) 30-50 mg/kg for children for 5 days30-50 mg/kg for children for 5 days 500mg6 hrs for 5 days in pregnancy500mg6 hrs for 5 days in pregnancy . .

ComplicationsComplications - - Hyponatraemia, hypokalaemia, Hyponatraemia, hypokalaemia,

hypoglycemia,hypoglycemia,

acidosis & seizures sp in childrenacidosis & seizures sp in children

- - Fluid overloadFluid overload in children, elderly, in children, elderly, anaemics and cardiac patients. anaemics and cardiac patients.

- - AbortionAbortion in pregnant ladies in pregnant ladies

- - cholecystitis & pneumoniacholecystitis & pneumonia

- - Renal failureRenal failure

-- Mortality Mortality is 5% in adults & may reach is 5% in adults & may reach 15% in15% in

children.children.

PreventionPrevention 1- Improved sanitation & control of house 1- Improved sanitation & control of house

fliesflies 2- Personal hygiene 2- Personal hygiene 3- Safety disposal of excreta3- Safety disposal of excreta 4- Clean water supply ( piped or boiled)4- Clean water supply ( piped or boiled) 5- Control of water source of infection5- Control of water source of infection 6- Disinfection6- Disinfection 7- Chemoprophylaxis (mass tetracycline TR)7- Chemoprophylaxis (mass tetracycline TR) 8- Quarantine8- Quarantine 9- Control of population movement9- Control of population movement 10- Health education10- Health education 11- Vaccination ? ( limited protection) 11- Vaccination ? ( limited protection)