Acute Diarrhea – Approach

There is no standard definition of diarrhea. Diarrhea may be defined with one or combination of the following criterion:

1. Change in consistency of stool: Increased water-content
2. Increase in freqency of stool: >3 times per day
3. Increase in weight of stool: >200 grams per day or >10 grams/kg/day

Among all these, diarrhea is best explained by the change is consistency of the stool. Acute diarrhea is short-lived i.e. less than 2 weeks.

CAUSES OF ACUTE DIARRHEA

1. Infectious:

• Viral (more common): Rotavirus, Norwalk (calcivirus), Adenovirus, Astrovirus
• Bacterial:
  • With or without dysentery: Enterohemorrhagic E.coli, Shigella, Campylobacter, Plesiomonas shigelloides, Salmonella
  • Without dysentery: Enterotoxigenic E.coli, Enteropathogenic E.coli, Vibrio cholera, Aeromonas, Bacillus cereus, Clostridium difficile, Clostridium perfringes, Staphylococcus aureus
• Parasitic:
  • With or without dysentery: Entamoeba histolytica, Trichuris trichuria
  • Without dysentery: Giardia lamblia, Cryptosporidium parvum, Cyclospora cayetanensis, Isospora belli
• Fungal: Candida albicans

2. Non-infectious:

• Drugs: Antibiotics and laxatives
• Allergic colitis
• Lactose intolerance
• Radiation/Chemotherapy enteritis
• Appendicitis
• Niacin deficiency (Pellagra)
• Copper or Zinc toxicitiy

EPIDEMIOLOGICAL TYPES OF ACUTE DIARRHEA

1. Community acquired diarrhea

2. Hospital acquired diarrhea:

• Onset of diarrhea 3 days after hospitalization and not incubating at the time of admission to hospital
• Related to antibiotic use , non-antibiotic medications or tube feeds

PATHOGENESIS OF ACUTE DIARRHEA

In healthy adults, 93% of fluid entering the intestines is absorbed by the time it reaches the ileocecal valve. Children become volume depleted more rapidly than adults (due to an increased surface/volume ratio and limited renal compensatory capacity). Loss of electrolytes in stool:

• Sodium: 20-25 mEq/L
• Potassium: 50-70 mEq/L
• Chloride: 20-25 mEq/L.

	Osmotic diarrhea	Secretory diarrhea
Response to fasting	Diarrhea stops	Diarrhea continues
Volume of stool	<200 ml/day	>200 ml/day
Stool Na+	<70 mEq/l	>70 mEq/l (Increased Na+ and K+ secretion in stool)
Stool osmotic-gap i.e. 2 (Na + K)	>100 mOsm/kg	<50 mOsm/kg
Reducing substances	Positive	Negative
Stool pH	<5	6

1. Osmotic diarrhea: Lactose intolerance, Malabsorption via damaged intestinal epithelial cells (rotavirus, shigella, etc.)
2. Secretory diarrhea: Via enterotoxins or invasion of bowel mucosa

ASSESSMENT OF DEGREE OF DEHYDRATION

Symptom/Signs	Mild (A)	Moderate (B)	Severe (C)
Look:
General condition	Alert, active	Restless, irritable	Lethargic, unresponsive
Eyes	Normal	Slightly sunken	Very sunken
Tears	Normal	Decreased	Absent
Thrist	Normal	Eagerly drinking	Not able to drink
Feel:
Skin pinch	Instant recoil	Recoil in <2 sec	Recoil in >2 sec
Other things to be looked (not in IMCI guidelines)
Respiratory rate	Normal	Normal; fast	Deep
Heart rate	Normal	Normal or increased	Increased or decreased when most severe
Pulse volume	Normal	Normal or decreased	Weak/impalpable
CRT	Normal	Prolonged	Prolonged, minimal
Anterior fontanelle	Normal	Depressed	Depressed
Extremities	Warm	Cool	Cool, mottled, cyanotic
Urine output	Normal to decreased	Decreased	Minimal

HISTORY FOR ACUTE DIARRHEA

1. Diarrhea – Onset, duration, frequency, pattern, severity
2. Dysentery – Blood/mucus?
3. Osmotic vs secretory – fasting reduces stooling amount (osmotic)?
4. Small bowel vs large bowel diarrhea?
5. Associations –
   • Gastrointestinal: nausea, vomiting, anorexia, abdominal pain
   • Respiratory tract infection: fever, cough, coryza
   • Arthralgia/arthritis and rash
6. Recent family history or contact history
7. Underlying disease, recent infections, medications, HIV
8. Incubation period: shorter in toxigenic than inflammatory diarrhea
9. Temporal relation with food

	Small bowel diarrhea	Large bowel diarrhea
Stool	Large volume, watery	Frequent, small volume
Associated features	Abdominal cramps, bloating, gas	Gripping pain in lower abdomen
Fever	Not common	Common
Tenesmus	Absent	Present
Blood or mucus in stool	Absent	Present

PHYSICAL EXAMINATION FOR ACUTE DIARRHEA

1. Assess for severity of dehydration
2. Abdominal tenderness/mass? Peritoneal signs?
3. Perianal inspection: Rash? Ulcer? Active bleeding?
4. Stool if present: Blood? Mucus?
5. Extraintestinal signs: Rash? Hepatosplenomegaly? Lymphadenopathy? Arthritis?
6. Hypokalemia: Abdominal distension? Muscle strength and reflexes?

INVESTIGATIONS FOR ACUTE DIARRHEA

1. Serum electrolytes (Volume depletion)

2. BUN and serum creatinine:

• Significant rise in BUN with relatively normal creatinine suggests dehydration
• If RFT is markedly deranged: screen for HUS, including coagulation studies and markers of hemolysis (LDH, Peripheral blood smear, Haptoglobin)

3. CBC with differential count:

• Infection: Abnormal WBC or differential count
• Dehydration: Increased hematocrit
• HUS: Anemia and thrombocytopenia

Risk factors for bacterial etiology:

1. Age <6 months
2. Immunocompromised
3. Weight <8 kg
4. Severe (>5 episodes/24 hour)
5. History of prematurity
6. Bloody diarrhea
7. Fevere
8. Moderate to severe dehydration
9. Failed ORS therapy
10. Nonbloody to bloody diarrhea within 5 days of onset
11. Abdominal pain and tenderness
12. Pain worse with defecation (especially E.Coli O157:H7)
13. Rectal prolapse (Shigellosis and E.Coli O157:H7)
14. Minimal vomiting
15. Recent antibiotic use

Vomiting and respiratory symptoms are common in viral etiology of acute diarrhea.

Lab investigations for supsected bacterial etiology:

1. Stool culture including E.Coli O157:H7, C.difficile assay, Giardia, Cryptosporidia assay
2. Fecal WBC
3. Consider:
   • Fecal occult blood
   • Blood culture
   • Urine culture
   • Abdominal X-ray

CONSIDER HOSPITAL ADMISSION

1. Inability to care or return if necessary
2. Intractable vomiting
3. Inadequate ORS intake because of refussal
4. Lack of improvement
5. Co-morbid illness
6. Severe dehydration
7. Other risk factors

TREAT DEHYDRATION (IMCI guidelines)

Plan A: No signs of dehydration (Mild dehydration)

1. Treat at home
2. ORS per each loose stool:
   • <24 months (with Tea spoon): 50-100 ml
   • 2-10 years (Cup sips): 100-200 ml
   • >10 years (Cup sips): Ad lib
3. Teach ORS preparation
4. If vomiting: wait 10 minutes and feed slowly
5. If ORS packet used up, give other fluids

Plan B: Some signs of dehydration (Moderate dehydration)

1. Treat at home or hospital
2. Provide daily requirement
3. Replace deficit:
   • ORS 75 ml/kg over 4 hours OR by NG tube
   • Assess after 4 hours:
     • If still “some signs of dehydration”: Continue deficit replacement
     • If improved to “no signs of dehydration”: ORS 10 ml/kg per stool

Plan C: Severe dehydration

1. Treat at hospital
2. Intravenous Ringer Lactate:
   • For <12 months:
     • 1st hour: 30 ml/kg (repeat if feeble pulse)
     • Next 5 hours: 70 ml/kg
   • For >12 months:
     • 1st 1/2 hour: 30 ml/kg
     • Next 2 and 1/2 hours: 70 ml/kg
   • OR NG feeding 20 ml/kg/hr until IV opened
3. Reassess every 15-30 minutes
4. Shift plan of treatment according to improvement or continue same treatment

Dehydration at tertiary centers can be treated as following:

1. Stabilization: Bolus 20 ml/kg upto 3 times

2. Deficit replacement: According to the severity of dehydration

3. Maintenance fluid: (Daily requirement* – Bolus amount) over 24 hours

• Half of total in 1st 8 hours
• Other half in next 16 hours

Daily requirement* = 4 ml/kg/hr for 1st 10 kg + 2 ml/kg/hr for next 10 kg body weight + 1 ml/kg/hr for subsequent body weight

Causes of ORS failure:

1. High purge rate >5 ml/kg/hr
2. Persistent vomiting >3/hr
3. Paralytic ileus
4. Incorrect ORS preparation

Content of ORS:

1. Glucose 13.5 gm/L
2. Na+ 2.6 gm/L
3. K+ 1.5 gm/L
4. Citrate 2.9 gm/L

Total osmolarity: 245 mmol/L

MEDICAL THERAPY FOR ACUTE DIARRHEA

1. Antibiotics: Antibiotic therapy is usually not indicated because illnesses are often self-limited. Indications for antibiotic therapy are:

1. Shigella, Enterotoxigenic E.Coli, Enteroinvasive E.Coli, Salmonella typhi, Vibrio cholera
2. Extraintestinal infections (including sepsis) and complications
3. Infants (<3 months)

Antibiotics for uncomplicated Salmonella is contraindicated as it may prolong the “carrier-state”.

Antibiotics used are:

• C.difficile: Metronidazole 7.5 mg/kg Or Vancomycin 10 mg/kg
• Shigella: Azithromycin 10 mg/kg/day Or Ceftriaxone 50 mg/kg/day X 3 days
• Salmonella: Ceftriazone 100 mg/kg/day BD Or Azithromycin 20 mg/kg/day X 7 days
• E.Coli O157:H7: None
• Enteroinvasive E.Coli: As shigella
• V.Cholera: Erythromycin 30 mg/kg/day divided TID OR Azithromycin 10 mg/kg/day X 3 Days
• Giardiasis: Metronidazole 15 mg/kg TDS X 5-7 days OR Tinidazole 50 mg/kg PO once (max 2 gm) OR Nitazoxanide
• Cryptosporidium: Nitazoxanide
• ETEC, EAEC, Traveller’s diarrhea: Azithromycin or Ceftriaxone X 3 days

2. Antidiarrheals: not recommended because it may cause abdominal distension and bacterial overgrowth

3. Zinc supplementation: 20 mg Elemental Zinc/day for child >6 months X 14 days

4. Ondansetron: 0.1-0.2 mg/kg/dose

5. Potassium (if patient is passing urine): KCl 30-40 mEq/L

6. Antisecretory (inhibit intestinal enkephalinase): Racecadotril

7. Probiotics: contains Lactobacillus rhamnosus, Enterococcus fecium, Saccharomyces boulardii

8. Vaccine: Rotavirus

NUTRITIONAL MANAGEMENT FOR ACUTE DIARRHEA

1. Avoid simple sugar foods (Carbonated beaverages, commercial fruit juices, sweetened tea)
2. Early feeding reduces infection induced permeability
3. BRAT (Banana, Rice, Apple sauce, Toast) are overly restrictive and increases recovery time
4. Age appropriate unrestricted diet must be given – complex carbohydrates, meats, yoghurt, fruits, vegetables

7 Basic principles of Management of Acute Diarrhea:

1. Give ORS when possible
2. ORS must be started within 3-4 hours
3. Age appropriate unrestricted diet must be given after dehydration correction
4. Continue breastfeeding
5. Diluted formula is not recommended
6. Replace ongoing losses with ORS
7. Minimize unnecessary lab investigation/medication