DID YOU KNOW 1, 9
According to the World Health Organization (WHO) and UNICEF, there are about two billion cases of diarrhoeal disease worldwide every year, and 1.5 million children younger than 5 years of age perish from diarrhoea each
year, mostly in developing countries. This amounts to 18% of all the deaths of children under the age of five and means that more than 4000 children are dying every day as a result of diarrhoeal diseases.
WHAT IS DIARRHOEA 1, 3-5
Diarrhoea is both a symptom and a sign. As a symptom, diarrhoea is most often described as a decrease in stool consistency and an increase in stool volume marked frequency, urgency and faecal incontinence. As a sign, diarrhoea is characterised by an abnormal increase in stool water secretion.
CAUSES 1, 5, 6
DIAGNOSIS 1, 2, 7, 10, 11
- The duration of diarrhoea is of significant clinical importance: Most acute diarrhoeas (< 2 weeks) are caused by microbial pathogens and typically resolve independent of intervention. Chronic diarrhoea (lasting more than 2 weeks) is unlikely to be infectious.
- The presence of blood in the stools suggest inflammation, neoplasm, ischaemia, or infection.
- Large-volume diarrhoea suggests small bowel or proximal colonic disease, and frequent small stools with associated urgency suggests left-sided colonic and/or rectal disease.
- Current and recent medications (e.g. antibiotics, antacids and nutritional supplements) and alcohol intake should be reviewed.
- The social history should include travel, source of drinking water (treated city water or well water), consumption of raw milk in rural populations, exposure to farm animals and sexual practices.
- Familial occurrence of celiac disease, inflammatory bowel disease, or multiple endocrine neoplasia syndromes should be considered.
- Physical examination in acute diarrhoea is helpful in determining severity of disease and hydration status.
SYMPTOMS 1, 10
Acute diarrhoea has < 2 weeks duration and is most commonly caused by invasive or non-invasive pathogens and their enterotoxins.
Acute noninflammatory diarrhoea
- Watery, non-bloody
- Usually mild, self-limited
- Caused by a virus or non-invasive bacteria
- Diagnostic evaluation is limited to patients with diarrhoea that is severe or persists beyond 7 days
Acute inflammatory diarrhoea
- Blood or pus, fever
- Usually caused by an invasive or toxin-producing bacterium
- Diagnostic evaluation requires routine stool bacterial cultures in all and testing as clinically indicated for Clostridium difficile toxin, ova and parasites.
Diarrhoea may be caused by bacteria or parasites found in food and water.
TREATMENT 5, 8-12
In over 90% of patients with acute non-inflammatory diarrhoea, the illness is mild and self-limited, responding within 5 days to simple diet and rehydration therapy or antidiarrhoeal agents; diagnostic investigation is unnecessary.
If diarrhoea worsens or persists for more than 7 days, stool should be sent for faecal leukocyte or lactoferrin determination, ovum and parasite evaluation, and bacterial culture.
Diet and dietary supplements – Most mild diarrhoea will not lead to dehydration provided the patient takes adequate oral fluids containing carbohydrates and electrolytes. Patients find it more comfortable to rest the bowel by avoiding high-fibre foods, fats, milk products, caffeine, and alcohol.
Frequent feedings of tea, “flat” carbonated beverages, and soft, easily digested foods (eg, soups, crackers, bananas, apple sauce, rice, toast) are encouraged.
There are some dietary supplements very useful in diarrhoea – Kaolin/pectin is an adsorbent and protectant combination. It works by absorbing excess fluid and reducing intestinal movement.
Absorbents like diosmectite that coat the entire mucose lining and absorb toxins, bacteria, viruses.
Absorbants – Absorb toxins, bacteria, viruses (Smecta). Diosmectite (Smecta) coats entire mucosa lining and absorb toxins, viruses and bacteria efficiently.
Anti-Motility – Loperamide
Kaolin/Pectin Conbin – Gastropect/Pectrolyte
Rehydration – In more severe diarrhoea, dehydration can occur quickly, especially in children, the frail and the elderly. Oral rehydration with fluids (containing glucose, Na+, K+, Cl–, and bicarbonate or citrate) is preferred. Alternatively, oral electrolyte solutions are readily available. Intravenous fluids (lactated Ringer injection) may be necessary in patients with severe dehydration.
- Sunken eyes and cheeks
- Fast heartbeat
- Decreased skin turgor
Probiotics – Probiotics are live micro-organisms (in most cases, bacteria) that are similar to beneficial micro-organisms found in the human gut. They are also called “friendly bacteria” or “good bacteria.” Probiotics are available to consumers mainly in the form of dietary supplements and foods.
Antibiotic Therapy (ex: Kantrexil) – Empiric antibiotic treatment of all patients with acute diarrhoea is not indicated. Even patients with inflammatory diarrhoea caused by invasive pathogens usually have symptoms that will resolve within several days without antimicrobials. Empiric treatment may be considered in patients with non–hospital-acquired diarrhoea with moderate to severe fever, tenesmus, or bloody stools, or the presence of fecal lactoferrin while the stool bacterial culture is incubating, provided that infection with E coli O157 is not suspected.
The oral drugs of choice for empiric treatment are the fluoroquinolones (eg, ciprofloxacin 500 mg, ofloxacin 400 mg, or norfloxacin 400 mg, twice daily, or levofloxacin 500 mg once daily) for 5–7 days. Alternatives include trimethoprim-sulfamethoxazole, 160/800 mg twice daily; or doxycycline, 100 mg twice daily.
|Secretory||Large-volume, watery diarrhoea; no gas or pus; no solute gap; little or no response to fasting||Cholera; vasoactive intestinal peptide-secreting tumour; bile salt enteropathy; fatty acid-induced diarrhoea|
|Osmotic||Watery stool, no blood or pus; Improves with fasting; stool may contain fat globules or meat fibres and may have an increased solute gap||Lactose intolerance;
|Inflammatory||Small frequent stools with blood and pus; fever||Ulcerative colitis; amebiasis|
|Variable||Bowel resection; enteric fistula|
|Variable; malabsorption||Hyperthyroidism; irritable bowel syndrome|
1.Ammoury RF and Ghishan FK. Chapter 82-Pathophysiology of Diarrhea and its Clinical Implications. Physiology of the Gastrointestinal Tract(FifthEdition).2012;Volume2:2183-2197.
2.GuarinoA et al. Chronic diarrhoea in children(Review).Best Practice & Research Clinical Gastroenterology.2012;26(5):649-661.
3. MurrayJAandRubio-TapiaA. Diarrhoea due to small bowel diseases (Review). Best Practice & Research Clinical Gastroenterology.2012; 26(5):581-600.
4. Dupont C at al.Oral DiosmectiteReduces Stool Output and Diarrhea Duration in Children With Acute Watery Diarrhea. Clinical Gastroenterology and Hepatology.2009;7(4):456-462.
5.Whyte LA and Jenkins HR. Pathophysiology of diarrhea(Review).Paediatrics and Child Health.2012;22(10):
6. Blondon H et al.Secretory diarrhea with high faecal potassium concentrations:A new mechanism of diarrhea associated with colonic pseudo-obstruction? Report of five patients. Gastroentérologie Clinique et Biologique. 2008; 32(4): 401-404.
7.AntikainenJ et al. A Quantitative Polymerase Chain Reaction Assay for Rapid Detection of 9 Pathogens Directly From Stools of Travelers With Diarrhea. Clinical Gastroenterology and Hepatology. 2013; 11:1-8.
8. Dupont HL et al. Treatment of Travelers’ Diarrhea:RandomizedTrial Comparing Rifaximin,Rifaximin Plus Loperamide,and LoperamideAlone.Clinical Gastroenterology and Hepatology.2007;5(4):451-456.
9.KentAJandBanksMR.PharmacologicalManagementofDiarrhoea(Review).Gastroenterology Clinics of North America. 2010; 39(3): 495-507.
10. NHS: Diarrhoea – information prescription [Internet]. London. National Health System; 2012 Nov 28.Available from: http://www.nhs.uk/Conditions/Diarrhoea/Pages/Treatment.aspx.
11.RCN:The management of diarrhoea in adults [Internet]. London. Royal College of Nursing; 2013 Mar.Available from: https://www.rcn.org.uk/professional-development/publications/pub-004371.
12.WHO/UNICEFJointStatement:ClinicalmanagementofAcuteDiarrhoea[Internet].Geneva. 2004 May.Available from:http://www.who.int/maternal_child_adolescent/documents/who_fch_cah_04_7/en/.13. Lorrot M,Vasseur M. Physiopathologie de la diarrhee a rotavirus. Journal de Pediatrie et de Puericulture. 2007; 20(8): 330-336. 14. Built by Doctors Ltd. Letter of authorisation.WilmingtonDE.2013Oct.