Diarrhoea

Notes

## Basic Introduction

  • The World Health Organization definition of diarrhoea is the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual.
  • The main causes of diarrhoea are: bacterial [mainly Escherichia coli], viral [mainly rotaviruses] and parasitic infections and infestation; malnutrition and contaminated water or food.
  • Diarrhoeal disease is the second leading cause of death in children under five years old after pneumonia.
  • Under normal situation, 99% of the fluid taken orally or secreted from GIT is absorbed in the small intestine and colon. Defect in absorption of this fluid can result in diarrhea

## Types of diarrhoea:

  • Secretory diarrhoea occurs when there is an increase in the active secretion of ions or when there is an inhibition of absorption of the same. Examples include: diarrhoea due to cholera toxin in which chloride ions [and others anions] are secreted actively and sodium and water are carried with it to maintain electrical potential and tonicity.
  • Osmotic diarrhoea results from water that is substantially drawn into intestine osmotically. Causes of osmotic diarrhoea include: maldigestion, osmotic laxatives, lactose intolerance etc.
  • Exudative diarrhoea is characterized by blood and pus in the stool as observed in the inflammatory bowel diseases [e.g. Crohn's disease, ulcerative colitis, coli and food poisoning]. Motility-related diarrhoea that results from hypermotility e.g. vagotomy and diabetic neuropathy].
  • Inflammatory diarrhoea as a result of damage to the mucosal lining or brush border. [e.g. pathogenic infections, autoimmune diseases that include inflammatory bowel diseases].
  • Dysenteric diarrhoea that is characterized by blood in the stool signifies GIT infections by Shigella, Entamoeba histolytica, and Salmonella among others
  • Persistent diarrhoea is the diarrhoea that last for more than 14 days
Symptoms
  • Three clinical types of diarrhoea include: acute watery diarrhoea e.g. cholera; acute bloody diarrhea [dysentery] and persistent diarrhoea for ≥ 14 days.
Diagnosis
  • Diarrhoea lasting less than 4 days may not require any further tests
  • Otherwise, the following tests are done: complete blood count (CBC); electrolytes; blood urea nitrogen (BUN); blood creatine levels; stool microscopy for ova and parasites; stool culture; stool leucocyte tests; stool pH; colonoscopy with biopsy; Sudan stain for fat and pancreatic functions in case of steatorrhoea.
Differential
  • Dehydration
  • Loss of essential electrolytes [sodium, chloride, potassium, bicarbonate, magnesium and chloride]
  • Vascular collapse and death
  • These complications are more fatal in young children, malnourished and immunocompromised patients.
Management
  • Treatment includes: prevention and restoration of fluid and electrolyte loss [as the first objective of man;agement of diarrhea]; antidiarrhoeals; zinc supplements [which reduce the duration of a diarrhoeal episode]; nutrient-rich foods; antimicrobials in case of infections.
  • Anti-diarrhoeals are classified into two groups: Antimotility drugs (e.g. codeine phosphate, loperamide and co-phenotrope) and Adsorbentsand bulk forming drugs (e.g. light kaolin, attapulgite).
  • Oral rehydration therapy constitutes the first line of treatment in acute diarrhoea, especially in infants, frail and elderly.
  • Antispasmodics are used in treatment of abdominal cramps associated with diarrhoea.
  • Attapulgite is a purified native hydrated aluminium magnesium silicate. Activated attapulgite has been heated to increase its adsorptive activity.
  • Kaolin is hydrated aluminium silicate with adsorbent property.
  • Pectin is a purified carbohydrate obtained from rind of citrus or apple pomace. It is an adsorbent and as well as an absorbent.
  • Furazolidone is a synthetic nitrofuran antimicrobial. It has antibacterial, antifungal and antiprotozoal actions. It is active against coli,staphylococci, Salmonella, Shigella, Proteus, Aerobacter aerogenes, Vibrio cholera and Giardia lamblia.
  • Charcoal has adsorbent, defoliant, soothing properties. It reduces the volumes of intestinal gas.
  • Cholestyramine can be used for treatment of diarrhoea after ileal disease or resection. It acts by to bile salts.

## Antidiarrhoeals in the Essential Drug List:

  • Oral Rehydration Salts (ORS).
  • Dispersable zinc sulphate tablets 20mg

Other general products useful in cases of diarrhoea

  • Ringer’s or Hartmann’s solution
  • Half-strength Darrow’s solution or
  • Normal saline solution
  • Sodium bicarbonate solution
  • Potassium chloride solution
  • 5% dextrose solution

## Standard doses of anti-diarrhoea in the Essential Drug List.

  • Oral Rehydration Salts (ORS): According to the extent of fluid loss. Usually 200 - 400ml solution after every loose motion. Infant: 1-1½ times usual feed volume. Children: 200ml after every loose motion. Other fluids such as plain water, porridge and rice can be given provided ORS constitutes 2/3 of the total fluid intake. Fresh fruits or mashed are te good source of potassium in diarrhea.
  • Dispersable zinc sulphate tablets: For acute and persistent diarrhoea: orally For children below 6 months: 20mg OD for 10-14 days. For children 0.5-5 yrs: 20mg OD for 10-14 days. Administered between meals and a repeat dose given in case vomiting occurs within 30 minutes.

## In case of severe dehydration one of the following IV fluids is administered:

  • Ringer’s or Hartmann’s solution (most effective); if NOT available give;
  • Half-strength Darrow’s solution orNormal saline mixed with sodium bicabonate and potassium chloride or Normal saline mixed with 5% dextrose

## Therapeutics using drugs that are NOT in the Essential Drug List

  • Oral Rehydration Salts (ORS): According to the extent of fluid loss. Usually 200 - 400ml solution after every loose motion. Infant: 1-1½ times usual feed volume. Children: 200ml after every loose motion.
  • Dispersable zinc sulphate tablets: For acute and persistent diarrhoea: orally For children below 6 months: 20mg OD for 10-14 days. For children 0.5-5 yrs: 20mg OD for 10-14 days. Administered between meals and a repeat dose given in case vomiting occurs within 30 minutes.
  • Diphenoxylate / atropine sulphate [Co-phenotrope]: 4 tablets stat, then 2 every six hours until the diarhoea is controlled. 4-8 yrs: 1TID. 9-12yrs: 1 QID. 13-16 years: 2 TID.
  • Loperamide: Acute diarrhoea: 4mg stat, then 2mg after each loose stool for up to 5 days [max. 8 mg daily in divided dose then 16mg daily]. 4-8 yrs: 1mg QID up to 3 days. 9-12 years: 2mg QID up to 5 QID up to 3 days. 9-12 yrs: 2mg QID up to 5 days. Chronic diarrhoea in adults: Initially 4-adjusted according to response and given BD.
  • Racecadotril: 100mg PO TID for adults and 1.5 mg/kg PO TID for children.
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