Diarrhoea:Know the basics

 #Diarrhoea

(Part l)

Let talk about Diarrhoea!!!

#Diarrhoea  

 

What is it?

About 10 litre fluid enters in the dudenum off which all but 1.5 litre absorbed in the small intestine.And further absorption occurs in colon.Eventually less than 200ml passed through feces.Sometimes Diarrhoea is defined as passed of more than 200-300gm stool in 24 hours but measuring of stool is rarely needed except in chronic Diarrhoea.

    According to Physician's working definition" Passage of stool more than 3 times or more in 24 hours or increased liquidity of stool defined as Diarrhoea"

Types:

   Mainly 2 types

    ১)Acute Diarrhoea

    ২) Chronic Diarrhoea

 ACUTE DIARRHOEA:

       Starts suddenly and persists less than two weeks.

 It may be two types according to etiology

     1)Acute Inflammatory

     2)Acute Non Inflammatory

Acute Inflammatory Diarrhoea:

    Criteria:

       a) Usually caused by Invasive or Toxic producing organism 

       b)Fever

       c) Blood in stool(Dysentry)

       d) As these organic invade colon do less water is excreted and total amount does not exceed 1 litre Ina day.

        e) cramping pain in left side lower quadrant of abdomen,Urgency,Tenesmus

        f) fecal leukocyte in stool examination

 What are the causes?

     Viral: Cytomegalovirus.This Virus causes  intestnal ulceration which causes bloody diarrhoea in immunocompromised and  HIV infected patients.

          

  Protozoa:  Entomoeba histolytica

Bacterial:

   1. Cytotoxin producing:

          Enterohaemorrhagic E. coli 0157:HD(EHEC), it is a Shiga toxin producing bacteria can spread eating contaminated meat.

         Vibrio parahaemolyticus

          Clostridium difficile: Diarrhoea can persists more than two weeks.

  2. Invasive:

        Shigella

        Campylobacter jejuni

        Salmonella

        Entetinvasive E. coli

       Aeromonas

       Plesiomonas

       Yersenia enterocolitica

       Clamydia

       Neisseria gonnorhoeae

       Listeria monocytogens

Acute non-inflammatory Diarrhoea:

   Criteria:

         a) watery, voluminous

         b) non bloody

         c) Mild,self-limiting

         d) usually caused by  Non invasive virus ( vide infra)

          e) No fecal leukocyte as no mucosal invasion

           f) Usually not persists more than 7 days.If persists then further evaluation needed.

Causes:

    Usually viral such as;

           Norovirus,astrovirus,adenovirus

           Rotavirus,sapovirus

‌Protozoal:

           Giardia lamblia

           Cryptosporidium

           Cyclospora

Bacterial:

      1.Preformed enterotoxin production:

            Staphylococcus aureus

            Bacilus cereus

            Clostridium perfringens

     

      2.Enterotoxin priduction:

            Enteroxigenic E. coli

            Vibrio cholera,

            Vibrio vulnificus

Evaluation and management:

   A. If an adult having diarrhoea more than 7 days then search for,

         a)‌Fever, abdominal pain, dehydration,bloody diarrhoea,frequency more than 6 in 24 hours.

               

         b)‌Immunocompromised:

AIDS,transplantation

         c) Age more than 70 years

If a,b,c negative then, 

         *Symptomatic treatment

         *Give Antidiarrhoeal agent: 

 Loperamide, bismuth subsalicylate but stop if worsened or not improved that is diarrhoea persists 7-10 days.

B. If any one described in a,b,c present then send stool for,

1)Fecal leukocytes

2)Stool culture

3) If admitted in hospital recently or  history of Antibiotic use then C.difficile assay 

4)Ova ও parasite test if

           *Diarrhoea more than 10days

           *History of travel in Endemic area

           *HIV  infection or a men having history of sex with another men

Also in section B patients should receive emperical antibiotic when culture report is awaiting if 

      

          *Fecal leukocyte positive 

          * Bloody diarrhoea,fever, abdominal pain

          *‌Dehydration or passage of 8 stools per 24 hours

          *Immunocompromised 

          *If hospitalisation needed

When to be admitted?

   1)If severe dehydration and patient needs to give IV fluid and patient is unable to intake much fluid

   2) Bloody diarrhoea which is worsening

   3) Severe abdominal pain

   4) Sepsis or sign of  severe infection  : Temperature 39.5 degree Celsius or more,Leukocytosis,rash

  5 ) Age more than 70 years with severe diarrhoea

  6) Signs of Haemolytic uremic syndrome such as Acute kidney injury, thrombocytopenia, hemolytic anemia

‌Treatment:

    Diet):

           *High fibre,fat,milk products,caffeine should be avoided

           *More carbohydrates and Electrolytes containing and easily  digestible food should be taken such banana,soup,toust,rice etc.

           *More liquid food

   

     Rehydration :

           *If mild to moderate dehydration then oral rehydration solution.Amount may be 50-200ml/kg/hour which depends on level of dehydration.

           * If severe dehydration then IV saline

     ৩) Antidiarrhoeal agent:

           *Previously it is discussed when to use it but shouldn't use in High fever,bloody diarrhoea,systemic toxicity

          *This type of drug should be stopped if condition worsening or no improvement.

      ৪)Antibiotic Therapy:

         *It is discussed that when  emperical antibiotic should be used.(vide supra)

         * Drug of choice for emperical therapy is Fluriquinolones  such as Ciprofloxacin 500mg,ofloxacin 200mg,Levofloxacin 500mg daily

          *Alternative drugs are Trimethoprim-Sulfamethoxazole 160/800 twice daily,Dxycycline 100mg twice daily

          * If Non inflammatory traveler's diarrhoea then  Rifaximin 200mg 3 times daily ,Azithromycine 1000mg single dose or  500mg twice daily

          *Specific Antimicrobial treatment: according to Culture.But in  nontyphoid Salmonella,Campylobactor,STEC,Aerominas,Yersinia etc, Antibiotic is not necessary unless in severe case. 

Antibiotic should be used in Shigellosis,cholera,extraintestinal salmonellosis,Listeriosis,C.duffile

Thanks for reading