Post on 23-Aug-2014
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DIARRHOEA
CHETAN RASTOGIM.Pharm Pharmacology Ist Year
HIPER Lucknow
Introduction
Diarrhoea is defined as passage of unusually loose
or watery stools usually at least three times in a 24
hour period. (WHO)
For adults stool weight >200 g/d can generally be
considered diarrhoeal. Passage of even one large watery stool in young
child is diarrhoea. Frequent passage of normal stool is no diarrhoea.
Types & Causes Based on Clinical Syndrome
Diarrhoea
Persistent
Multiple cause
Dysentery
Bacillary Amoebic
Watery
Cholera E. coli Rotavirus
Diarrhoea: types, etiology, pathogenesis
Acute (up to 1-2 weeks)Food poisoning (due for microbs or not)Bacterial infections: E.coli, Shigella, Salmonella, Campylobacter, Yersinia Viral infections: RotavirusProtozoan infections: Entamoeba, Giardia lamblia Drugs:antibiotics (Сl.deficile)laxativesantacids (Mg)anticholinesterase drugscolchicinpreparations with Auquinidinecardiac glycosides
Chronic (> 4 weeks)
Osmotic diarrhoea (osmotic laxatives and lactose)
Secretory diarrhoea (bacterial toxins, hormones, fatty and bile acids, laxatives)
Inflammatory diarrhoea (infections, inflammatory bowl diseases, celiacia, lymphoma, iscemia)
Hypermotoric diarrhoea (irritated bowl syndrome)
TRANSMISSION• Most of the diarrheal agents are transmitted by the fecal-oral
route• Cholera: water-borne disease; transmitted through water
contaminated with feces.• Some viruses (such as rotavirus) can be transmitted through
air• Nosocommial transmission is possible• Shigellosis (blood dysentery) is mainly transmitted person-to-
person• Shigellosis is a water-washed disease; transmitted more
when there is scarcity of water
Pathophysiological Mechanismssecretory diarrhea (increased intestinal
secretion)
infections (cholera toxin, E-coli, salmonella, staphylococcal)
Hormonal (Gut Hormones, ZES, VIP), cancer (calcitonin, Prostaglandins)
miscellaneous (laxatives abuse, villous adenoma of the rectum)
agentsAdenylate
cyclasecAMP system
secretory diarrhea
activate NaCl
• secretory diarrhea (increased intestinal secretion)
• Osmotic diarrhea• Decreased intestinal surface area and/or
intestinal absorption• Inflammatary diarrhea• Rapid transit of intestinal contents
(shortened transit time)
• secretory diarrhea (increased intestinal secretion)
• Osmotic diarrhea
• Decreased intestinal surface area and/or intestinal
absorption
• Inflammatary diarrhea
• Rapid transit of intestinal contents (shortened transit
time)
Pathophysiological Mechanisms
Symptoms Accompany Diarrhoea1. Dehydration
Diarrhea can cause dehydration. Loss of electrolytes through dehydration affects
the amount of water in the body, muscle activity, and other important
functions.
Signs of dehydration in adults include:
• thirst
• less frequent urination than usual
• dark-colored urine
• dry skin
• fatigue
• dizziness
• light-headedness
Signs of dehydration in infants and young children include:• dry mouth and tongue• no tears when crying• no wet diapers for 3 hours or more• sunken eyes, cheeks, or soft spot in the skull• high fever• listlessness or irritability
SIGNS OF DEHYDRATION
2. Functional bowel disorders: Diarrhea can be a symptom of irritable bowel
syndrome.
3. Intestinal diseases: Inflammatory bowel disease, ulcerative colitis, Crohn’s
disease, and celiac disease often lead to diarrhea.
4. Food intolerances and sensitivities: Some people have difficulty digesting
certain ingredients, such as lactose, the sugar found in milk and milk
products. Some people may have diarrhea if they eat certain types of
sugar substitutes in excessive quantities.
5. Reaction to medicines: Antibiotics, cancer drugs, and antacids containing
magnesium can all cause diarrhea.
LABORATORY DIAGNOSIS
• Stool microscopy
• Dark field microscopy of stool for cholera
• Stool cultures
• ELISA for rotavirus
• Immunoassays, bioassays or DNA probe tests
to identify E. coli strains
ASSESSMENT OF DEHYDRATION
Dehydration Mild Moderate Severe
Appearance irritable, thirsty
irritable, very thirsty
lethargy, coma, or unconscious
Anterior Fontanelle
normal depressed markedly depressed
Eyes normal sunken sunken
ASSESSMENT OF DEHYDRATION (contd.)
DehydrationMild Moderate Severe
Tongue normal dry very dry,furred
Skin normal slowretraction
very slowretraction
Breathing normal rapid very rapid
ASSESSMENT OF DEHYDRATION (contd.)
DehydrationMild Moderate Severe
Pulse normal rapid andlowvolume
feeble orimperceptible
Urine normal dark scanty
Weightloss
< 5% 6 - 9% 10% or more
DIARRHOEA: PREVENTION AND CONTROL
When should adults with diarrhea see a health care provider?
Adults with any of the following symptomsshould see a health care provider:• signs of dehydration• diarrhea for more than 24 hours• a fever of 102 degrees or higher• stools containing blood or pus• stools that are black and tarry
When should children with diarrhea see a health careprovider?
Children with any of the following symptomsshould see a health care provider:• signs of dehydration• diarrhea for more than 24 hours• a fever of 102 degrees or higher• stools containing blood or pus• stools that are black and tarry
DIARRHOEAFLUID DEFICIT CLINICAL SIGNS TREATMENT
SEVEREDEHYDRATION
greater than 10percent of their body weight
• Lethargic or unconscious• Sunken eyes• Skin pinch goes back
very Slowly (longer than 2 seconds)
WHO Treatment Plan C
SOMEDEHYDRATION
5 to 10 percent of their body weight
Two of the following signs:• Restless, irritable• Sunken eyes• Skin pinch goes back
slowly (skin stays up even for a brief instant)
WHO Treatment Plan B
NODEHYDRATION
Less than 5 percent of their body weight
• No sign to classify as some or severe dehydration
• Skin pinch goes back immediately.
WHO Treatment Plan A
WHO Treatment Plan C• Severe dehydration require immediate IV
infusion, nasogastric or oral fluid replacement according to WHO treatment guidelines
• Give 100 ml/kg IV fluids.
Age 30 ml/kg 70 ml/kg
Infant 100 ml/kg In 6 hrs First hour Next 5 hrs
Older children 100 ml/kg In 3 hrs First 30 mins Next 2.5 hrs
• Ringer's lactate solution is the preferred commercially
available solution.
• If IV infusion is not possible, urgent referral to the
hospital for IV treatment is recommended.
• When referral takes more than 30 minutes, fluids
should be given by nasogastric tube.
• If none of these are possible and the child can drink,
ORS must be given by mouth.
WHO Treatment Plan B• Some dehydration• The approximate amount of ORS required is
75 ml/kg; during first four hours, the mother slowly gives the recommended amount of ORS by spoonfuls or sips.
• After four hours, the child is reassessed and reclassified for dehydration, and feeding should begin
• If dehydration persists- the same amount of ORS may be repeated for another 4 hours.
If the child is breastfed, breast-feeding should continue
WHO Treatment Plan A• Plan A focuses on the three rules of home
treatment: – Give extra fluids, – Continue feeding, and – Advise the caretaker when to return to the
health facility
if the child develops blood in the stool, drinks poorly, becomes sicker, or is not better in 48 hours
ORAL REHYDRATION SALT(ORS)
It is a balanced mixture of glucose and electrolytes
Almost all deaths from diarrhoea can be prevented by ORS
MECHANISM OF ACTION
Sodium promotes absorption of water from the intestine
Glucose promotes the absorption of sodium and water
from the intestine
Composition grams/Litre
Glucose, anhydrous 13.5
Trisodium citrate, dihydrate 2.9
Sodium chloride 2.6
Potassium chloride 1.5
Total weight 20.5
Composition mmol/Litre
Glucose 75
Sodium 75
Chloride 65
Potassium 20
Citrate 10
Total osmolarity 245
WHO ORS
RICE BASED ORS• Tastes better and provides more calories than the glucose-
based ORS • Culturally acceptable,• Reduces stool volume (by about 40 %)• Shortens the duration of diarrhea in both cholera and other
severe diarrheal diseases.• Starches other than rice, including wheat flour and maize,
have also been shown to reduce stool volume in patients with cholera.
• Reduce diarrhea by adding more substrate to the gut lumen without increasing osmolality, thus providing additional glucose molecules for glucose-mediated absorption.
REHYDRATION THERAPYAmount of ORS to be given in first 4 hrs
Age < 4 months
4 -12 months
12m- 2 yrs 2-6 yrs
Wt (kg) < 6 6 - < 10 10 - <12 12 - 19
ORS(ml) 200-400 400-700 700-900 900-1400
Glass(No.) 1 - 2 2 - 3 3 – 4 4 - 7
Rate & Quantities of I/V infusion for severe dehydration
Age 30 ml/kg 70 ml/kg 100 ml/kg
Infant First hour Next 5 hrs 6 hrs
Older children
First 30 mins Next 2.5 hrs 3 hrs
ZINC THERAPY
• 10 mg/day orally for 14 days in children <6 months of age
• 20 mg/day orally for 14 days in children ≥6 months of age
• It is used as adjunct therapy (in all cases of diarrhoea) that decreases the duration and severity of the episode and the likelihood of subsequent infections on the 2-3 months following treatment.
Role of Probiotics
Probiotics means "for life" and is currently used to
name bacteria associated with beneficial
effects for humans and animals.
Coined in 1960 to name substances
which promoted the growth of other
organisms.
Effect of probiotics in diarrhoea- The strongest evidence of a beneficial effect
has been for the following probiotics - Lactobacillus rhamnosus GG and Bifidobacterium lactis BB-12
These probiotics are effective for both treatment and prevention of acute diarrhoea caused mainly by rotavirus in children
Antibiotic associated diarrhoea has also been found to respond when probiotics have been used as prophylaxis and also for therapy
POTENTIAL USES OF PROBIOTICS
Diarrhoea Helicobacter pylori infection Inflammatory bowel disease Cancers To increase Immunity Allergy Heart disease Urogenital tract infections
FEEDING IN DIARRHOEA
Children should continue to be fed during diarrhoea.
Milk should not be diluted with water during any phase of
acute diarrhoea.
Milk can also be given as milk cereal mixture e.g. dalia,
milk-rice mixture.
This technique reduces the lactose load & preserving
energy density.
To make foods-energy dense some of preparation are:- - Khichri with oil - Rice with curd & sugar- Mashed banana with milk or curd - Mashed potatoes with oil.
Breast feeding should be continued uninterrupted even during rehydration with ORS.
FEEDING IN DIARRHOEA
Rota virus vaccination Rotashield vaccine -1999 Withdrawn because of its association with intussuscption Two new oral, live attenuated rotavirus vaccines were
licensed in 2006 with very good safety and efficacy The first dose administered between ages 6-10 weeks . subsequent doses at intervals 4-10 weeks. Vaccination should not be initiated before 6weeks and after
12 weeks of age. All doses should be administered before 32 weeks.
Rota Rix vaccine Rota Teq vaccine
Oral, live attenuated Oral, live attenuated, pentavalent
vaccine. Contains 5 live reassortant rotaviruses
2 dose schedule 3 dose schedule
1st dose - 2 month of age at 2 month of age
2nd dose- 4 month 4 month of age…………………………. 6 month of age
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Antidiarrhoeal agents
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