Acute Diarrhoea

Definition
Increased frequency and water content of stools
than is normal for the individual
Usually: > 3 stools per day
Descriptive
Watery, mucoid, dysenteric
Pathogenetic:
Infective, non-infective

Acute Infective Diarrhoea

Epidemiology and predisposition
Aetiology
Virus (commonest: Rotavirus)
Bacteria Invasive
Enterotoxigenic
Parasites
Fungi

Pathogenesis of Diarrhoea
Depends on pathogen
VIRUS DIARRHOEA (eg Rotavirus)
Effect on villus structure and function
Enzyme damage
Significant effect on digestion and
absorption
Secretion-absorption imbalance

Pathogenesis of Bacterial Diarrhoea

without mucosal injury
mediated by:
Enterotoxins
Adhesins

with mucosal injury

mediated by:
Adhesins
Invasins
Cytotoxins

Paediatric Diarrhoea
Emerging issues
Food borne organisms of increasing importance with contamination of
stored/transported food
Campylobacter
Salmonella
Yersinia
Bacillus cereus
Vibrio parahaemolyticus

Poultry, meat
Poultry, Dairy Produce
Meat
Reheated cereals
Fish products

Unhygienic handling of food

Esch coli 0157
Staph aureus

mince meat

Mechanisms of acute diarrhoea

Osmotic
eg Lactose intolerance

Secretory
eg Cholera

Mixed secretory-osmotic
eg Rotavirus

Mucosal inflammation
eg Invasive bacteria

Motility disturbance

Effects of Diarrhoea
Dehydration
Biochemical disturbances
Sodium, Potassium
Metabolic acidosis
Blood glucose
Uraemia
Convulsions
Severe gut damage : ileus, NEC, PLE

Clinical patterns
Some associated features depend on
pathogen:
Rotavirus
Invasive bacteria
Toxigenic bacteria
Fever, abdominal pain, early or late
vomiting, other symptoms

Management of diarrhoea
Replace the fluids and electrolytes which are lost
Drug therapy has very little place
Antibiotic
Antisecretory
Antimotility
Nutritional management
Follow-up to ensure recovery

Chronic diarrhoea
Diarrhoea can be categorized as:
Acute: less than 7 - 10 days
Persistent: More than 7 - 10 days
Chronic: More than 14 - 21 days
(Persistent diarrhoea often a prolonged course of
acute insult - different management)

Chronic diarrhoea
With failure to thrive and excessive stool
water losses
Small intestinal mucosal injury
With failure to thrive but without excessive
stool water losses
Malabsorption syndromes
Without failure to thrive
Motility disorder

Small intestinal mucosal injury

Initiating acute insult - infection
Contributing malnutrition, young age, feeding
problem
Acute diarrhoea does not stop
Leads to malnutrition
Aggravation by unmodified food
Immunological consequences
Contributes big percentage of deaths from
diarrhoeal disease

Diarrhoea in symptomatic HIV infection

Chronic diarrhoea: AIDS-defining condition
Severe mucosal damage with multiple
defects of digestion and absorption
Associated infections
Intestinal super-infection with
cryptosporidium, salmonella, opportunists
Protein-losing enteropathy can mask
hyperglobulinaemia

Lactose intolerance
Development of symptoms following lactose
exposure due to lactase deficiency
Luminal fermentation of undigested lactose
Acid diarrhoea with lactose in stools
Diagnosed:
History, low stool pH, positive reducing sugars

Relative lactase deficiency at birth improves with

time
Needs feed change only with failure to thrive

Lactose intolerance
Congenital deficiency very rare
Watery, acid diarrhoea from birth

Genetic primary adult lactase deficiency very

common in Africa
Acquired deficiency common in severe
gastroenteritis, malnutrition
Usually self-limiting without treatment
Feed change with persistent high stool water
output

Fat malabsorption
Diagnosis : stool microscopy, quantitative
Pancreatic deficiency (eg cystic fibrosis)
Increased appetite cf intestinal disease
Greasy floating stools, foul-smelling
Treated with enzyme replacement

Bile salt deficiency (chronic liver disease)

Bile salt deconjugation
Bacterial overgrowth in gut disease
Treated with bowel cocktail

Food allergy
Not equivalent to food intolerance
Requires exposure and sensitization before
symptoms develop
GIT and/or skin, nose, resp. symptoms

Not common 1 - 4% of children, most < 2yr

Careful diagnosis
Atopic family history, allergy tests,
food elimination and challenge

Beware nutritional adequacy of elimination diets

Food intolerance
Symptoms after ingestion of food, the word does not
indicate the pathology. Can be:
Allergic or immunological
Allergic enteropathy
Biochemical - enzyme deficiencies
Lactose intolerance
Chemical
Laxative, salicylate

Coeliac disease
Gluten-induced enteropathy : gliadin fraction of
wheat protein
Symptoms after exposure to wheat
Genetic factors : HLA-B8
Auto-immune disorder
Villous atrophy with malabsorption
Resultant malnutrition
Anti-Endomysium, -gliadin IgA, jejunal biopsies
Total wheat product exclusion lifelong

Motility disorders
Irritable bowel syndrome, Toddler diarrhoea

Between 6 months and 4 years

Normal growth and weight gain
Intermittent episodes, not at night
Stools get progressively more loose through the
day, may contain undigested vegetables
Family history of spastic colon
Reassurance most important