Diarrhea

Question 1

Diarrhea

Answer 1

• increase in frequency and decrease in consistency of stools
  (faecal discharge) for a given individual compared to their normal bowel movement pattern

Question 2

Classification of diarrhea

Answer 2

Classified by duration of episodes

• Acute diarrhea e.g. infectious :- < 14 days’ duration
• Persistent diarrhea :- > 14 days but < 30 days’ duration
• Chronic diarrhea e.g. /t diabetes:- > 30 days’ duration

Question 3

Etiology of diarrhea

Answer 3

1. Infections:
   - Viral e.g. Rotavirus, Hepatitis A
   - Bacterial, e.g., E.coli, Salmonella, Shigella
   - Parasitic, e.g., Cryptosporidium, Histolytics, Giardia
2. Medical conditions :
   • Gastrointestinal diseases
   • Irritable Bowel Syndrome
   • Ulcerative Colitis
   • Crohn’s disease
   Non-gastrointestinal diseases
   • Diabetes mellitus
3. Medications :
   • Antibiotics esp broad spectrum
   antibiotics
   • Cholinergic medicines
   • Long term use of Proton Pump Inhibitors
   • H2-Receptor Blockers
   • Digoxin – toxicity
   • Mannitol

Question 4

Pathophysiology of diarrhea

Answer 4

• Water and electrolyte disruption
• ↑ in gastric/intestinal motility
• ↑ luminal osmolality
• ↑ in hydrostatic pressure of the tissue

Question 5

Risk factors for diarrhea

Answer 5

• Day care center
• Long-term care – for the elderly
• Travelling

Question 6

Diagnosis of diarrhoea

Answer 6

• Based on clinical presentation
• Stool specimen examination evaluation and analysis
• Endoscopy
• Biopsy
• Radiological studies

Question 7

Clinical presentation

Answer 7

• Acute diarrhoea – self-limiting (72 hours)
• Frequent bowel movement

Abrupt onset of:
• Nausea and vomiting (N/V)
• Abdominal pains
• Headache (HA)
• Fever, chills
• Malaise

Pain:
• Periumbilical, w/ cramps and bowel sound (R quadrant)
indicative of small intestines involvement
• Gripping and aching pain with tenesmus, straining and
ineffective painful passing of stool)
Indicative of large intestines involvement

Question 8

Sign of dehydration

Answer 8

Adults
• Dry mouth and skin
• Weakness
• Dizziness
• Oliguria, little urine, dark
colored urine
• Fatigue
• Tenting of skin when pinched

Children
• Dry mouth/tongue
• Irritability
• Crying with no tears
• Fever (temperature ≥ 39°C)
• Sunken fontanelle,
• Sunken eyes
• Loss of skin tugour

Question 9

Goal of treatment

Answer 9

• Manage diet
• Abort the symptoms of diarrhea
• Prevent future episodes of diarrhea
• Prevent complications of diarrhea
• Prevent water and electrolyte loss and dehydration
• Prevent acid-base imbalance
• Treat curable underlying disorder
• Remove the causative agent

Question 10

Non-pharmacological treatment of dehydration

Answer 10

• Prevention = is key
• Hand-washing regularly
• Vaccination against Rotavirus
• Proper cooked food while traveling

Question 11

Pharmacological treatment of dehydration

Answer 11

• Intravenous fluid (severe dehydration)
• Oral Rehydration Solution
• Homemade
• Commercial e.g. WHO recommended
• Oral supplemental Zinc tablet for children (↓ severity and duration
of acute diarrhoea)

Question 12

Pharmacological treatment of Diarrhea

Answer 12

• Anti-motility agents e.g. Loperamide Imodium (OTC or Prescription)
– Avoid in children
– Avoid in bloody diarrhea or if fever present

• Opioids e.g. codeine, loperamide

• Adsorbents e.g. kaolin-pectin

• Antisecretory medicines e.g. racecadotril

• Toxin binders e.g. cholestyramine

• Antibiotics e.g. Fluoroquinolones, azithromycin
– If bloody diarrhea, abdominal pain, fever
– If recently travelled

• Probiotics e.g. Lactinobacilli spp

Question 13

Therapeutic outcomes

Answer 13

• Monitor for resolution of key signs and symptoms
• No of stools per day => ↓ no. of stools/bowel movement
• Consistency of the stools => ↑ consistency of stool and ↓ volume of
stools
• Resolution of dehydration
• Resolution of constitutional symptoms (such as fever, abdominal pains,
loss of appetite, dehydration, hypotension, hematochezia) within 24
hours to 72 hours.
• Improvement of appetite
• Improvement of vital signs e.g. ↑BP if patient had hypotension, Temp
• Body weight
• Monitor laboratory tests results
• Serum electrolytes – to normalise
• Full blood count (FBC) including WBC, RBC
• Culture and sensitivity (if applicable)