DIARRHOEA AND

DEHYDRATION
MANAGMENT
 PRESENTATION
OUTLINE
0 Introduction
0 Definition
0 Aetiology
0 Classification
0 Pathophysiology
0 Clinical manifestation
0 Complications
0 Management
0 Hypernatremic(hypertonic) Dehydration
0 References
 Introduction
Commonest cause of death among children in
developing countries.

Much of which is acute diarrhoea and most commonly

due to infections [90%].

It is the leading cause of malnutrition in children under

five year old.

[WHO].
 Definition
 Diarrhoea is defined as the passage
of three or more times of loose or
liquid stool per day.

NOTE: Frequent passing of formed stool is not diarrhea,

[WHO]
 Aetiology
Causes of acute diarrhoeal
diseases can be classified as
infectious and non infectious
causes.
Infectious causes of diarrhoea:
Infectious causes can be further classified as
 Viral [70%]
0 Rotavirus(40%)
0 Norwalk virus
0 Enteric adenovirus
0 Others: astroviruses, enteroviruses
 Bacterial [10-20%]
0 E. Coli(a number of strains)
0 Campylobacter jejuni
0 Salmonella sp
0 Shigella spp
0 Salmonella typhi
0 Vibrio cholera
Parasitic [< 10%]
0 Entamoeba histolytica
0 Giardia lamblia
0 Cryptosporidium parvum
0 Isospora belli
0 Cyclospora cayetanensis
0 Microsporidia
(Enterocytozoon bieneusi, Encephalitozoon intestinalis)
NON INFECTIOUS CAUSES OF
DIARRHOEA
 Drugs:Antibiotics,anti-
hyyertensives,Cancer drugs,and ant-acid
containg magnesium
 Intestinal diseases: Inflammatory bowel
and coeliac disease
 Food allergy : Cow’s Milk, soya
 CLASSIFICATION OF
DIARRHOEA
There various ways of classifying diarrhoea:
 Duration[WHO]
0 Acute-< 14 days
0 Persistent-14 days or longer
 Nature: Watery or bloody
 Pathophysiology of diarrhoea
 Based on aetiology: Infectious and non infectious
 PATHOPHYSIOLOGY
The following are the mechanisms by which diarrhoea develop:
1.Secretory mechanism
 Enterotoxins[V.cholera,E.coli]
 Hormones [vasoactive intestinal peptide in the vermer-
morrison syndrome]
 Some laxative [docusate sodium]
2.Osmotic mechanism [The act as a semi-pearmeable membrane
and fluid enter the bowel if there is large quantities of non
absorbed hypertonic Substances in the lumen]
 Magnesium containing antaacid
 Malabsroption
 Absorptive defects
3.Inflammatory diarrhoea[mucosal destruction]
Diarrhoea occurs due to mucosal demage resulting in fluid and
blood loss.
Dysentery due to shigella
Inflammatory conditions[ulcerative colitis and crohns disease]
 Secretory diarrhoea
0 Large volumes of water are normally secreted into
the small intestinal lumen, but a large majority of
this water is efficienty absorbed before reaching
the large intestine.
0 Diarrhea occurs when secretion of water into the
intestinal lumen exceeds absorption.
0 Vibrio cholerae, produces cholera toxin, which
strongly activates adenylyl cyclase, causing a
prolonged increase in intracellular concentration of
cyclic AMP within crypt enterocytes. This change
results in prolonged opening of the chloride
channels that are instrumental in
secretion of water from the crypts
0 , allowing uncontrolled secretion of water.
0 Exposure to toxins from several other types of
bacteria (e.g. E. coli heat-labile toxin) induce the
same series of steps and massive secretory
diarrhea that is often lethal unless the person or
animal is aggressively treated to maintain
hydration.
Osmotic diarrhoea
[Rotavirus]
 Clinical features
The clinical features of diarrhoea may vary from patient to
patient based among others reasons;
 Duration
 Aetiology
Some of the common clinical features include
 Watery or loose stool+/-blood
 Abdominal cramps
 Tenesmus- where there is a feeling of constantly needing to
pass stools, despite an empty colon.
 Urgency-the strong desire to evacuate stool
 Abdominal pain
 May be associated with vomiting and fever

 Dehydration: Signs of dehydration include

Dry mucous membranes
Rapid t pulse,↓BP,capillary refil time > 2sec
No wet diapers for 3 hours or more
Sunken eyes or anterrior fontanelle
↓or ↑ temperature
irritability
Reuduced skin turgor
 RISK FACTOR OF
DEHYDRATION
children younger than 1 year, particularly those
younger than 6 months
infants who were of low birthweight
children who have passed more than five diarrhoeal
stools in the previous 24 hours
children who have vomited more than twice in the
previous 24 hours
infants who have stopped breastfeeding during the
illness
children with signs of malnutrition.
 Classification of levels of dehydration
No
[modified from WHO
Some dehydration Severe
and Shock
IMCI]
dehydration dehydration

•Alert with 2 or more signs: 2 or more signs: Signs of:

normal eyes • Restless and • Lethargic or • depressed level of
• Not thirsty irritable sleepy consciousness or
• Normal skin • Thirsty and drinks • Deeply sunken weakness
pinch eagerly eyes and • weak or absent
• Skin pinch returns fontanelle peripheral pulses
slowly • very slow skin • a prolonged
• Fontanelle is pinch capillary refill time
sunken of > 3 seconds
• tachycardia of >
120 bpm
 Investigations

Laboratory
 Stool mcs
 Immunoassay e.g ELISA
 Blood culture
 PCR
 Modifield ZN Microscopy-Paratic infections
 U&E,Creatinine
Radiological
 Barium enema or meal
 Management
PRINCIPLES OF MANAGEMENT
 Fluids
 Zinc supplements
 Continued feeding[Avoid juice and carbonated drinks]

FLUID MANAGEMENT
 Assess hydration and vitals
 If in shock manage shock
 Depending on the level of dehydration, give fluids as outlined
below
0 PLAN C : Children with severe dehydration
0 should be given rapid IV rehydration followed by oral
rehydration therapy. (100 ml/kg)
Age First give 30ml/kg in Then give 70ml/kg
in
<12 months old 1 hour 5 hours
≥12 months old 30minutes 2 ½ hours
 Repeat once if the pulses are weak or not detectable
 Reassess patient every 1-2 hours. If hydration is not improving, give IV
drip more rapidly.
 After completion of IV fluids, reassess the patient and choose the appropritte
treatment plan [A,B,C]
 If IV therapy is not available ,then ORS by NG tube or orally at 20ml/kg/ for
6hours[total of 120ml/kg] should be given.
 If the abdomen becomes distended or the child vomits repeatedly, the
ORS should be give more slowly.
PLAN B:SOME DEHYDRATION
75ml of ORS × patient’s weight(kg) to be given in 4
hours
After 4 hours, reassess the child and decide what
treatment to be given next as per level of dehydration.
Children who continues to have some dehydration
even after 4 hours should receive ORS by NG tube or
½ strength darrows intravenously(75ml/kg in 4hours)
If abdominal distension occurs, oral rehydration
should be withheld and only IV rehydration should
be given.
PLAN A:No dehydration: Amounts of ORS to be given
per loose dependent on specific age listed below.
Age(years) <2 2-5 Older
children

ORS(ml) 50-100 100-200 As much as

they want

ZINC SUPPLEMNTS
Give zinc supplements(10-20mg/kg for 10-14 days)
CONTINUED FEEDING
Give appropriate feeds. Avoid juices and carbonates
drinks
 HYPERNATREMIC DEHYDRATION

0 When proportionally more water than sodium is lost from

the body, the extracellular fluid has increased concentration
of sodium and becomes hypertonic regarding the
intracellular fluid and therefore attracts water from the
cells. This results in the cell shrinkage, which may cause
brain shrinkage.
THOSE THAT ARE AT RISK OF HAVING (HD)
Diarrhea in children, especially young infants (in 20% of
pediatric diarrhea)
Water deprivation
Excessive sweating Hyperventilation (prolonged fever,
anxiety)
Diabetes insipidus (both central and nephrogenic)
Endstage renal failure
Drinking sea water in attempt to treat dehydration
 Complications
The major complications: dehydration and hypovolemic
shock.
Electrolyte imbalance :Hyponatremia is common;
hypernatremia is less common.
Metabolic acidosis: results from losses of bicarbonate in stool.
 Lactic acidosis: results from shock
Hyperphosphatemia : retention of phosphate due to transient
prerenal-renal insufficiency[severe dehydration]
Seizures: may occur with high fever, especially with Shigella.
Intestinal abscesses: - with Shigella
.
Intestinal perforation-Salmonella infections, especially typhoid
fever, leading to
Esophageal tears : Severe vomiting associated with gastroenteritis.
Deaths: resulting from diarrhea reflect the principal problem of
disruption of fluid and electrolyte homeostasis, which leads to
dehydration, electrolyte imbalance, vascular instability, and shock
 References
1. WHO website.
2. General Paediatric Protocols ,Arthur Davison
Children’s Hospital.1st Edition
3. Gary D H,Stephen J M.Pathophysiology of Diseases,an
introduction to clinical medicine.7th edition.McGraw
Hill Education
 THANK FOR YOUR
ATTENTION!!!!!!!!!!!!