Diarrhea is defined as an increase in the: Fluidity

Volume Number relative to the usual habits of each

.individual
Essential element is the increased Fluidity= loose (
)stools
• Children can have acute
and chronic forms of
diarrhea:
• Acute diarrhea may be in
the form of: 10
10

– Acute watery diarrhea.

– Dysentery.
80
– Persistent diarrhea
• Chronic diarrhea. Acute Watery
Dysentery
Persistent
• Passage of frequent loose or watery stools
without visible blood.
• Constitutes 80% of cases of diarrhea
• Begins acutely (abruptly)
• Lasts less than 14 days (usually < 7 days)
• May be accompanied by:
– Flatulence, Abdominal pain and cramps
– Nausea and Vomiting
– Fever
 Infectious diarrhea Non infectious diarrhea

Drug-induced
Antibiotic-associated

:Gastrointestinal infections Laxatives
Antacids that contain magnesium
Viral-1
Bacteria .2
Food allergies or intolerances
Protozoa-3 Cow's milk protein allergy
Extraintestinal infections Soy protein allergy
Otitis media Nutrients
Urinary tract infections digestive/absorptive processes
Pneumonia Surgical conditions
Dietary practices
•The most common pathogens causing diarrhea are :

Enterotoxigenic
Rotavirus Shigella Campylobacter jejuni
Escherichia coli
)15-25%( 5-15% 10-15%
10-20%

Cryptosporidium
Secretory Osmotic Motility-related Inflammatory
diarrhea diarrhea Diarrhea diarrhea

oMaldigestion
o Osmotic laxatives water is drawn
o Lactose intolerance into the bowels
o Fructose malabsorption
Intestinal Physiology

NET ABSORPTION
Pathogenesis of Secretory Diarrhea

Impaired absorption of Na

NET SECRETION

Cl , HCO3
++++

+++++
 Motility-related Diarrhea Inflammatory diarrhea

food moves too damage to

quickly through the mucosal lining
the GI tract or brush border

not enough time for a passive loss

sufficient nutrients of protein-rich
and water to be
fluids , and
absorbed
a decreased
ability to absorb
-: As in
vagotomy these lost fluids
diabetic neuropathy,
 acomplication of menstruation. -:It can be caused by
Hyperthyroidism  bacterial infection
 viral infection
 parasitic infections
autoimmune problems such as
inflammatory bowel diseases
I) Dehydration
Dehydration is caused by the loss of water and
electrolytes in the liquid stool and vomitus.
The Clinical signs of dehydration
are the result of 2 important factors:

1. Degree of 2. Type of dehydration:

dehydration: Mild, Isotonic,Hypertonicor
Moderate or Hypotonic
Severe
I. Degree of dehydration:
• No dehydration (or No signs of dehydration): Weight
loss <5%) of body weight accompanied by any signs
or symptoms of dehydration.
• Some (or moderate) dehydration: Weight loss 5-10%
of body weight (average 7.5%).
• Severe dehydration: Weight loss >10 %of body
weight.
 :II. Type of dehydration
Hypotonic Hypertonic Isotonic
(Hypernatremic (Isonatremic)
)Hyponatrmic(
5-10% 10-15% 75%> Prevalence
Water <Sodium Water > Sodium Water = Sodium Losses
275< 295> 295 - 275 Plasma Osmolarity
(mOsm/L)

130< 150> 130-150 Serum Sodium

(mEq/L)
↓↓↓ ↓ ↓↓ ECF volume
↓ ↓ Maintained ICF volume
-/+ ++++ ++ Thirst
+++ Not lost ++ Loss of skin turgor

Uncommon Common In severe cases Seizures

Lethargy/ Coma Very irritable Irritable/ lethargic Mental state
Common Uncommon In severe cases Shock
II) Hypokalemia:

III) Base-deficit acidosis

(metabolic acidosis):
Mechanisms:
• Loss of large amount of bicarbonate in
stools.
• Excessive lactic acid production when
patient is in a state of shock.
• Formation of inorganic acids in bowel from
incomplete breakdown of carbohydrates.
 Hypenatremic or hyponatremic
dehydration:
 Post-acidotic tetany:
Acidosis
++Ca

After correction of
acidosis hypocalcaemia

tetany

++Ca
CNS complications:
convulsions

Gastrointestinal complications
• Secondary carbohydrate malabsorption or intolerance.
• Protein intolerance and protein losing enteropathy.
• Persistent diarrhea.
• Intestinal perforation
• Pseudo-membranous colitis

toxic mega-colon
 Nutritional complications:

 Cardiovascular complications:
• Shock
• Phlebitis and thrombosis
• Pulmonary edema
 Renal complications:
• Pre-renal failure
• Renal vein thrombosis
• DIC
• History Taking:

• Ask:
Does the child have diarrhea? (According to definition of diarrhea).

Duration of diarrhea: For how long? Diarrhea which lasts 14 days or more is
persistent diarrhea.

Consistency, frequency and volume of stools.

Presence of mucus and blood in stools (blood and mucus in the stools, with
associated fever, suggest an invasive organism).

Presence of fever, vomiting, convulsions or other problems (e.g. cough, discharging

ear, etc).

Frequency of vomiting and color of vomitus (coffee ground vomitus occurs in DIC).

Type and quantity of fluids, milk and food consumed during the illness.
Drugs received.
• Nutritional history
• Vaccination history
• Past history of similar attacks
• Family history

• Clinical examination:
General look:
Vital signs:
• Pulse:
Exclude signs of shock: rapid, weak pulse (with cold cyanotic extremities).
• Blood pressure:
Hypotension may be present in severe cases.
• Temperature: fever due to the infection and dehydration.
• Respiratory rate:
• Rapid deep breathing (in acidosis).
• Rapid shallow (if there is associated pneumonia).
 Anthropometric measurements:

Head and Neck:

Extremities:

Skin:

Chest:
 Exclude pneumonia.
Abdomen:
 Abdominal distension with diminished peristalsis (most
probably due to hypokalemia or toxic ileus).
CNS
 Exclude meningitis
Checking signs of dehydration.
 Assessment of dehydration :-
SIGNS No signs of Some (mod.) Severe
dehydration dehydration dehydration
G General well, restless, lethargic,
condition alert irritable unconscious
E Eyes normal sunken sunken

M Mouth & normal thirsty, drink poor or una-

Drinking eagerly ble to drink
S Skin pinch returns rapidly returns slowly very slowly
Always start from Red Column
2 or more signs in 1 column indicate that the child falls in that
column
1-Fluid therapy: prevent & correct
dehydration.
2-Feeding: during & after diarrhea.
3-Zinc supplementation.
4-Treatment of possible causes.
5-Treatment of complications.
:Fluid therapy-1

Home based fluids

ORAL REHYDRATION
SOLUTION (ORS)
 :Feeding during diarrhea

Continue breast feeding as usual

.during and after rehydration therapy

Continue same “normal” formula

and same “normal” concentration
AFTER rehydration

Children on Mixed Diet

Continue normal feeding
as usual
 plan C plan B planA treatme
severe ( no signs of(
some ( nt
)dehydration ) dehydration )dehydration

hospital Outpatient At home Where

rehydration center ?given
I.V. Fluids: ORS MORE FLUIDS: Fluid-1
Pansol , Zinc HOME MADE , therapy
Polyelectrolyte, supplementation ORS, BREAST
Ringer lactate, MILK , PLAIN What
Normal saline CLEAN WATER ?type
Zinc syrup ZINC
(whenever the SUPPLEMENTATIO
child can drink) N
100ml/kg body wt. 75ml/kg body after each loose How
in3-6 hours 1st weight in 4-6 stool <2y:50-100 ml
30ml/kg:in1/2-1hr
?much
hours >2y:100-200ml
Next 70ml/kg:in
2.5-5hrs
Zinc supplementation
< 6 mo : 10mg/d
For 14 days
> 6mo: 20mg/d

Treatment of possible causes

Antibiotics
Antiparasitics
Ant emetics
Ant motility
Adsorbents
Consultations
• Treatment of complications
• Probiotics

Probioict
bacteria
pathogens

intestinal
epithelium

Bind and neutralize toxins in the gut lumen or interfere with the
.adherence of pathogens (white) to the intestinal epithelium
INTRAVE Slowly(1spoon/1- Slowly (1spoon/1-2 min) ?How given
NOUSLY 2 min),ORALLY .,ORALLY
or NGT
.Breast feeding: never stop even during initial rehydration Feeding-2
Milk pr milk formula: usual formula used to feed the child,
.in normal conc. (after rehydration)
Soft &semisolid weaning food: after rehydration in
.children >4 months old
AVOID HYPEROSMOLAR FOODS OR FOOD WITH HIGH
.FIBER CONTENT
Reassess the patient Advise the mother to come Further-3
condition if: back if: Baby not able to assessment
: No signs of dehydration drink or breast feed
Becomes sicker or no
and follow
shift to plan A
:Some dehydration improvement up
shift to plan B Develops fever
Blood in stools
:Severe dehydration Repeated vomiting
repeat plan C Increased thirst
.is defined as diarrhea with visible blood in stools

The most important and most frequent cause of

acute dysentery is
1) Shigella,
2) Campylobacter jejuni
3) Salmonella
4) Escherichia coli (Enteroinvasive, Enterohemorrhagic)
5) Entamoeba histolytica
• 10% of all diarrheal episodes in children
under 5 years
• 15% of all deaths
•

Mainly Clinical
? Lab
especially when the cause is Shigella
intestinal perforation,
toxic mega colon
rectal prolapse

convulsions (with or without a high fever),

septicaemia,
hemolytic- uraemic syndrome
prolonged hyponatremia.
weight loss and rapid worsening of nutritional status
Antimicrobials.
Fluids.
Feeding.
Follow-up.
 Episodes of diarrhea lasting for more than
14 days

Malnutrition
 Recent introduction of animal
milk or formula
Young age
Immunological impairment
Recent diarrhea
 Pathology •

Normal intestinal epithelium

Cell borders are not well visible and

a bacilliform microorganism is seen
tightly adhering to the epithelial
surface
.surrounded by particles of mucus

Enterocytes are distorted in

appearance
and microvilli are shortened in
.height
Stool microscopy
 Stool culture and sensitivity
 Stool PH
1) Fluid therapy
2) Appropriate antibiotics or anti
parasitic
3) Nutritional therapy
• Diarrhea that lasts for more than 2 weeks
• for someone who has a weak immune
system, chronic diarrhea may represent a
life-threatening illness.

ADOLESCENT
INFANT
CHILD
 I. Intraluminal
factors

Johansson-Blizzard
syndrome
 Mucosal factors.2

Crohn's disease

Ulcerative colitis

Celiac disease
:The history
The family history
The age of onset
The mode of onset
The dietary history
Growth and developmental history
The history of repeated infections
history of previous abdominal surgery
The type of diarrhea
The Physical Examination:
periorificial skin lesions
acroder­matitis enteropathica

Peripheral edema
protein-losing enteropathy or severe malnutrition

Clubbing of the fingers

chronic conditions (cystic fibrosis or inflammatory bowel

.diseases )
Retinitis pigmentosa and ataxia
abetalipoproteinemia
The Laboratory Investigations
 positive occult blood
 low stool pH, positive fat globules and positive-
reducing substances
 peripheral eosinophilia

 serum protein and albumin

 cholesterol and triglycerides blood
 zinc blood level
 sweat chloride test
 rectosigmoidoscopy or colonoscopy and
histopathology