ACUTE DIARRHOEA AND DYSENTRY

Introduction

Today, diarrhoea is one of the most common problem in the young children. Worldwide about 4-5
million deaths occur as a result of diarrhoeal disease every year. Under five morbidity and mortality,
rate is high due to diarrhoea.

Definition

It is defined as passage of liquid or watery stools which usually passed more than 3 times in a day (24
hours), resulting in excessive loss of fluids and electrolytes in stools and cause dehydration.

(a) Acute diarrhoea refers to a diarrhoea that begins acutely and terminates within a week or
so, only a small proportion of cases passing to the 2nd week or beyond.
(b) Chronic diarrhoea refers to diarrhoea beyond 2 weeks.
(c) Persistent diarrhoea episodes of acute diarrhoea.
(d) Diarrhoea along with vomiting known as gastroenteritis.

Dysentry: When there is a passage of blood and mucus or pus in stools, the condition is called as
dysentry. It is usually associated with abdominal colic, tenesmus and fever.

Etiology

Breast feed babies are protected against development of diarrhoea, breast milk is free from
contamination and it contains several protective agents.

The causes for diarrhoea are:

I- Unhygienic conditions and practices in bottle fed babies and feeding practices during
weaning.
The causative organism for diarrhoea includes –
Virus – Rotavirus, Enterovirus, Influenza virus etc.
Bacteria – E.coli, Shigella, Salmonelle, Staphylococcus, vibrio cholera etc.
Parasites – Entaemoeba histolytica, Giardia lamblia Malaria etc.
Fungi – Candida albicans.
Parental – Upper respiratory infection, Otitis Media, Tonsillitis, Pneumonia, Urinary tract
infection.
II- Dietetic/Nutritional: Overfeeding, starvation, food allergy, food poisoning, imbalanced
diet, deficiency of diasacharides.
 III- Drugs – Antibiotics.
IV- Other non specific causes.
Other predisposing factors for diarrhoea diseases are age, season, artificial feeding and
other factor peculiar to infants and children population.

Pathophysiology

Due to any cause of diarrhoea increases the frequency of stools. This infection of both stomach and
intestine leads to gastro-enterities. Because of hyper paristalisis enormous amount of water is lost
from the body. Along with this Na+, K+ HCO-3 etc. ions are also lost. With vomiting is gastro enteritis
anorexia may be present and may reduce oral intake of fluids and absorption of nutrients. These
events produce dehydration. The blood plasma first affected by fluid loss, but this is replaced by
intestinal fluids. If the loss is rapid is causes peripheral blood loss or fall in blood pressure. It results
finally in shock (cold extremities, rapid pulse). Later, it cause dehydration and weight loss.

Clinical Features

The clinical features may vary from mild to moderate and moderate to severe cases.

(A) Mild
- Onset – 2 to 5 motions.
- Consistency – Loose, green, offensive and contain mucus and milk curds.
- Volume – May be small or large.
- Attacks – May subside with 1-2 days with or without dehydration.
(B) Moderate:
- Number of motion: 10 or more.
- Symptom: Fever, irritability, anorexia & vomiting.
- Mild dehydration: 3 to 5% is associated.
(C) Severe:
- Too many loose stools.
- Severe vomiting.
- No oral intake (only parenteral).
- Moderate to severe dehydration (5 to 10% moderate) (> 10% severe).

Manifestations seen in CNS 110 to severe dehydration are prominent. Early irritability, apathy,
may progress restlessness, cloudiness of consciousness, delirium and stupor, lethargy and coma
etc. Sometimes convulsions & polycythemia (viscosity of blood) can be cause of serious
complications.

Diagnostic evaluations

(1) Stool examination – It includes frequency amount, colour of stools, odour, and microscopic
examination.
(2) Serum pH.
(3) Blood urea nitrogen levels.

Do the proper physical assessment – Weight, Estimation of urine output, Examination of stools,
Stool culture and estimation of electrolytes.

(1) Rehydration Therapy

Replacement of fluids to prevent the severe dehydration of child as early as possible.
a. Oral Rehydration Therapy
It is very effective treatment for mild dehydration and moderate dehydration. WHO ORS
or homemade electrolyte solution can be used for this. Cereal based solution such as
rice water electrolyte solution can be used for better tolerance and to provide greater
energy. Continuation of breast feeding is very important.
b. Intravenous fluid therapy
Intravenous fluid therapy should provided when child is not responded with ORS and
having severe dehydration. It is two types –
i) Deficit
ii) Maintenance therapy

i) Deficit therapy –
When between 5 to 10% weight loss. The fluids are to be administered to the
child to maintain fluid level.
ii) Maintenance therapy –
 When need of total fluid in 24 hours. 1/5 given rapidly as R.I., in 2.5 or 5%
glucose during the first 1 to 2 hours to the child.
 Continuation therapy – for rest 24 hours remaining 4/5 fluid (Half strength
K+ solution).
Always maintain therapy or fluids & electrolytes should continue over the
second 24 hours even if diarrhoea has stopped in very first 24 hours to
maintenance of fluid balance.
(2) Domiciliary Management
Diarrhoea is well controlled problem, in this replacement of fluid and electrolyte should be
maintained properly. Breast feeding, water and juices should be continue to child. Todays,
ORS is also available for replacement of electrolytes and fluids in the form of sachet of 6 gm
and 10 gm, which can be prepared easily.
Preparation of ORS at home
2 finger a thumb pinch table salt (2 gm)
+ 4 finger scoop of sugar (40 gm)
+ Few drops of lemon
+ 1 litre water
Other preparations uses are – Rice, kanji, barley water, water tea, lassi, butter milk or
chaach, moong dal soup, coconut water etc.
ORS preparation with sachets:
(i) 6 gm sachet – Reconstitute in 200 ml /1 glass water.
(ii) 30 gm sachet – Reconstitute in 1 litre of water.
(iii) ORS solution must be given to a diarrhoeal child regularly (5 minutes) with sips.
Ingredients of standardized World Health Organization (WHO) ORS:
Sodium chloride 3.5 gm
Sodium bicarbonate 2.5 gm
Potassium chloride 1.5 gm
Glucose 20.0 gm
Note: Sodium bicarbonate can be replaced by sodium citrate (2.9 gm), which
increase life of ORS, but it will increase the cost of ORS sachet. All above ingredients
should be dissolved in one litre (1000 ml) of water.
(3) Dietary Advice
- Don’t keep the child on starvation.
- Continue breast feeding.
- Provide undiluted milk for child taking formula feed.
- Give khichadi, egg white, boiled and mashed potatoes and banana.
- Avoid fresh fruit juices and canned cold drinks.
- Milk cereal mixture (dalia, sago, kheer).
(4) Drugs for diarrhoea
 Give antibiotics, when child has invasive diarrhoea with fever, mucus or blood in stools and
pus cells in stools, some antibiotics like co-trimoxazole, nalidixic acid or norfloxacin are
useful and consult with doctor regularly.
(5) Prevention of diarrhoea
- Provide continue breast feeding.
- Always give clean and safe water for drinking.
- Provide bottle feeding with hygienically.
- Avoid pacifiers.
- Maintain strict personal hygiene, hand wash before and after feeding.
- Always keep clean hands and toys of baby and cut the nails short.
- Proper disposal of stools of baby immediately.

Home care management

 Continue breast feeding.

 Use clean and safe water for drinking.
 Give khichadi, egg white, boiled and mashed potatoes and banana etc.
 Give small & frequent feeds.
 Maintain strict personal hygiene.
 Hand wash before and after feeding.
 Proper disposal of stools of baby immediately.
 Avoid use of canned cold drinks.
 Replace fluids & electrolyte with ORS.
 Give easy digestible food preparations such as rice, kanji, lassies, butter milk, dal soup,
coconut water etc.
 Prepare ORS at home if needed.
 Continue medication as per prescriptions.
 Regular follow-ups.