Diarrhoea

Description

Passage of three or more loose/watery stool or one voluminous loose/watery stool per day.

Causes

Infectious

• Bacterial infections: Commonly, Vibrio cholerae, Salmonella species, Shigella, and Escherichia coli (E. coli), Campylobacter pylori
• Viral infections: rotavirus, novovirus, adenovirus, Norwalk virus, astrovirus
• Parasites: Giardia lamblia, Entamoeba histolytica, Cryptosporidium
• Systemic infections associated with diarrhoea include: influenza, measles, fever, HIV, malaria, pneumonia, urinary tract infection, meningitis, and sepsis.

        N.B. Diarrhoea may be watery or bloody (dysentery)

Non-infectious causes

• Food poisoning
• Drugs: Antibiotics, anti-hypertensive, cancer drugs, and antacids containing magnesium
• Intestinal diseases: Inflammatory bowel disease and coeliac disease
• Food intolerance: Lactose
• Food allergy: Cow’s milk, Soya

N.B: Some of the above causes may lead to persistent/chronic diarrhoea.

Signs and Symptoms

• Watery or loose stools ± bloody stools
• Abdominal cramps
• Tenesmus
• Urgency
• Abdominal pain
• May be associated with vomiting and fever, poor appetite and dehydration

Accurate clinical assessment of dehydration is very important!!

Investigations

• FBC, ESR
• Stool m/c/s for bloody and PDD
• U&E, Creatinine
• Abdominal x-ray
• Barium enema/meal

N.B: Other investigations will depend on the underlying/systemic conditions identified such as RDT/MPS

Assessment of hydration status

Table 50:Assessment of hydration status

Divided into four components to guide clinical management:

1. Classification of the type of diarrhoeal illness
2. Assessment of hydration status
3. Assessment of nutritional status
4. Assessment of co-morbid conditions

Classification of levels of dehydration; using a combination of two to three physical signs reliably predict dehydration.

Treatment

Fluid management

• Intravenous fluids are required ONLY in the following cases (in all others, ORS should be preferred):
  • Resuscitation from shock
  • Dehydration with severe acidosis and prolonged capillary refill
  • Severe abdominal distension and ileus
  • An altered level of consciousness
  • Resistant vomiting despite appropriate oral fluid administration
  • Deterioration or lack of improvement after 4 hours of adequate oral
    • Check vital
    • Assess and grade hydration
    • If in shock, refer to protocol on
    • Depending on level dehydration, give fluids as outlined below:

Table 51:Fluid management

Zinc supplementation

• Give zinc supplement for 10 to 14
• Infants below 6months of age 10mg daily
• Children 6months and above 20mg daily

Nutritional Status:

• Children presenting with diarrhoea should be assessed for malnutrition according to WHO
• Children with acute diarrhoea and malnutrition are at increased risk for developing fluid overload and heart

failure during rehydration.

• The risk of serious bacterial infection is also
• Such children require an individualized approach to rehydration and nutritional

Description

Passage of three or more loose/watery stool or one voluminous loose/watery stool per day.

Causes
Infectious
• Bacterial infections: Commonly, Vibrio cholerae, Salmonella species, Shigella, and Escherichia coli (E.
coli), Campylobacter pylori
• Viral infections: rotavirus, novovirus, adenovirus, Norwalk virus, astrovirus
• Parasites: Giardia lamblia, Entamoeba histolytica, Cryptosporidium
• Systemic infections associated with diarrhoea include: influenza, measles, fever, HIV, malaria, pneumonia, urinary tract infection, meningitis, and sepsis.

N.B. Diarrhoea may be watery or bloody (dysentery)

Non-infectious causes
• Food poisoning
• Drugs: Antibiotics, anti-hypertensive, cancer drugs, and antacids containing magnesium
• Intestinal diseases: Inflammatory bowel disease and coeliac disease
• Food intolerance: Lactose
• Food allergy: Cow’s milk, Soya
N.B: Some of the above causes may lead to persistent/chronic diarrhoea.

Signs and Symptoms

• Watery or loose stools ± bloody stools
• Abdominal cramps
• Tenesmus
• Urgency
• Abdominal pain
• May be associated with vomiting and fever, poor appetite and dehydration

Accurate clinical assessment of dehydration is very important!!

Investigations

• FBC, ESR
• Stool m/c/s for bloody and PDD
• U&E, Creatinine
• Abdominal x-ray
• Barium enema/meal
N.B: Other investigations will depend on the underlying/systemic conditions identified such as RDT/MPS

Assessment of hydration status

Table 50:Assessment of hydration status

Divided into four components to guide clinical management:
i. Classification of the type of diarrhoeal illness
ii. Assessment of hydration status
iii. Assessment of nutritional status
iv. Assessment of co-morbid conditions

Classification of levels of dehydration; using a combination of two to three physical signs reliably predict dehydration

Treatment

Fluid management

• Intravenous fluids are required ONLY in the following cases (in all others, ORS should be preferred):
  • Resuscitation from shock
  • Dehydration with severe acidosis and prolonged capillary refill
  • Severe abdominal distension and ileus
  • An altered level of consciousness
  • Resistant vomiting despite appropriate oral fluid administration
  • Deterioration or lack of improvement after 4 hours of adequate oral
    • Check vital
    • Assess and grade hydration
    • If in shock, refer to protocol on
    • Depending on level dehydration, give fluids as outlined below:

Table 51:Fluid management

Zinc supplementation

• Give zinc supplement for 10 to 14
• Infants below 6months of age 10mg daily
• Children 6months and above 20mg daily

Nutritional Status:

• Children presenting with diarrhoea should be assessed for malnutrition according to WHO standards.
• Children with acute diarrhoea and malnutrition are at increased risk for developing fluid overload and heart failure during rehydration.
• The risk of serious bacterial infection is also increased.
• Such children require an individualized approach to rehydration and nutritional care.

Continued feeding is very important during episodes of diarrhoea!! Give appropriate feedAvoid juices, carbonated drinks and cereal based ready to drink over the counter preparations.N.B: Diarrhoea is a major risk factor for malnutrition which is associated with high mortality and deficits in
physical and cognitive development.

Drugs
• Antibiotics are NOT indicated for most children with acute watery diarrhoea; dysentery and suspected
cholera are important exceptions.
• Children with acute diarrhoea should NOT receive antimotility agents or antiemetics.

N.B: Antimotility agents (loperamide, diphenoxylate-atropine, and tincture of opium) prolong some bacterial infections and may cause fatal paralytic ileus in children.

Description

Passage of 3 or more watery stools within 24hrs lasting for more than 14 days. Dehydration, malnutrition, and infections are major contributors to development of persistent diarrhoea. The many causes of PD can be divided into four principle pathophysiologic mechanisms: osmotic, secretory, dysmotility associated, and inflammatory

Signs and Symptoms

• Liquid stools often passed after eating, may be explosive.
• Occasionally stool may contain visible blood.
• Weight loss often evident and signs of malnutrition often present
• Signs of dehydrations
• Features of Extra-intestinal infections: e.g. Pneumonia, UTI

Causes of Persistent Diarrhoea

Table 52:Causes of Persistent Diarrhoea

Treatment

• Appropriate fluids to prevent and treat
• A nutritious diet to promote weight BEWARE of foods worsen diarrhoea.
• If Severe Acute Malnutrition is present, treat according to SAM
• Supplementary vitamins and minerals, including zinc for 10-14
• Antimicrobials to treat diagnosed infection

Description

WHO defines severe acute malnutrition in children 6 - 59 months old by a very low weight for heigh/
weight for length < -3SD with or without clinical signs of bilateral pitting oedema as well as mid upper arm
circumference <11.5cm.

Identifying and assessing the children with severe malnutrition

• Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a weight-for-height/length <–3 Z-score of the WHO growth SSstandards, or have bilateral oedema, should be immediately admitted to a programme for the management of severe acute malnutrition.

Criteria for inpatient or outpatient care

• Children who are identified to have severe acute malnutrition should first be assessed with a full clinical examination to confirm whether they have medical complications and whether they have an appetite. Children who have appetite (pass the appetite test) and are clinically well and alert should be treated as outpatients despite having SAM

Children who have medical complications, severe oedema (+++), or poor appetite (fail the appetitetest), or present with one or more Integrated Management of Childhood Illness (IMCI) danger signs should be treated as inpatients.

Identifying and assessing the children with severe malnutrition

• Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a weight-for-height/length <–3 Z-score of the WHO growth standards, or have bilateral oedema, should be immediately admitted to a programme for the management of severe acute malnutrition.

Investigations

• Blood Sugar and Haemoglobin Immediately on admission
• Full blood count, ESR
• Malaria slide (thick and thin smear)
• Blood culture
• Urinalysis
• Urine m/c/s
• Gastric lavage for AFB
• Lumbar puncture if indicated.
• Chest x-ray
• Routine counselling and testing (RVT)
• Reducing substances if passing watery, urine like stool (ask mother remove nappy and put patient on plastic)

Treatment

Assess for emergency and danger signs and manage promptly. Manage patients based on 10 steps as recommended by WHO

Time frame for management of a child with complicated severe acute malnutrition

Table 53:Time frame for management of a child with complicated severe acute malnutrition (refer to guidelines link)

Signs and Symptoms

In addition to diarrhoea, there may be:
• Fever
• Abdominal pain
• Vomiting
• Dehydration (mild or severe)

o     No dehydration: The patient does not show enough signs to classify as moderate or severe dehydration.

• Some dehydration: The patient has two or more of the following signs:
  • Restlessness
  • Irritability
  • Sunken eyes
  • Dry mouth and tongue
  • Absence of tears
  • Thirsty, drinks eagerly
• Severe dehydration: The patient is classified as having severe dehydration if there are two or more of the following signs:

• Lethargic or unconscious; floppy
• Absence of tears
• Very dry mouth and tongue
• Very thirsty, drinks poorly or unable to drink
• Pinched skin goes back very slowly
• Absent radial pulse
• Low blood pressure.

Investigations

Investigations are necessary if the diarrhoea lasts more than one week, i.e.,

• Stool microscopy
• Culture and drug susceptibility

Treatment

1. Fluid replacement

Fluid therapy (See the section on Cholera) (show page)

2. Drugs

In chronic diarrhoea where the cause has not been found:

• Loperamide 4mg Stat, then 2mg per loose stool (do not exceed 16mg in 24 hours)

NB: Any infective causes should be treated according to antimicrobial sensitivity 

Description - as in childrenCauses include:

• Infections such as giardia, cryptosporidium, lsospora belli and microsporidia in AIDS patient.
• Colonic lesions such as carcinoma, Crohn's disease and ulcerative colitis
• Coeliac disease, Tropical sprue, Chronic pancreatitis
• Pseudo membranous colitis
• Thyrotoxicosis
• Diabetes

Signs and Symptoms

• Diarrhoea, bloody diarrhoea or steatorrhoea
• Abdominal pain
• Weight loss
• Anaemia

NB: Persistent and chronic diarrhoea may be associated with vomiting

Investigations:

• Stool microscopy, culture and sensitivity
• Special tests may be needed for certain parasites such as cryptosporidium, isospora and microsporidia
• Rectal/jejunal biopsy
• Barium enema
• Full blood count

Treatment: Treat infective causes 

1. Fluid therapy – Oral fluid use should be stressed except for patients presenting with severe dehydration in whom intravenous fluids should be However, even with severe dehydration, oral fluids should be given concurrently. Fluid management is as for cholera (See the section for fluid replacement in children)
2. Antidiarrheal agents
   • Loperamide 4mg start then 2mg every after loose stool
   • Nitazoxanide 500 mg tablets three times a day with food for 3

Treat specific causes such as:

• Giardia – Metronidazole 400mg 8 hourly orally for 7 days
• Cycloisospora Belli – Co-trimoxazole 960mg four times daily orally for 10 Give Pyrimethamine for sulpha-allergic patients. Recurrences tend to occur. In case of recurrence, refer to the experts.
• Cryptosporidia – Nitazoxanide 500 mg tablets three times a day with food for 3 Combination antiretroviral therapy (cART) with immune reconstitution is the main line of management.

Description

Peptic ulcer disease (PUD), the end result of inflammation caused by an imbalance between cytoprotective and

cytotoxic factors in the stomach and duodenum, manifests with varying degrees of gastritis or frank ulceration.

The pathogenesis of peptic ulcer disease is multifactorial, but the final common pathway for the development of ulcers is the action of acid and pepsin-laden contents of the stomach on the gastric and duodenal mucosa and the inability of mucosal defense mechanisms to allay those effects.

Gastric ulcers are generally located on the lesser curvature of the stomach, and 90% of duodenal ulcers are found in the duodenal bulb.

The common causes of peptic ulcers include H pylori, medication use, and stress-related gastric injury. Less common causes include ingestion of corrosive substances, hypersecretory states (Zollinger-Ellison syndrome), IBD, systemic mastocytosis, chronic renal failure, and hyperparathyroidism.

Signs and Symptoms

• Vary with the age of the
• Hematemesis or melena is reported in up to half of the patients with peptic ulcer
• Epigastric pain and nausea, especially in school going
• Dyspepsia, epigastric abdominal pain or fullness is seen in older
• Infants and younger children usually present with feeding difficulty, vomiting, crying episodes, hematemesis, or melena.
• In the neonatal period, gastric perforation can be the initial presentation.

Investigations

• Esophagogastroduodenoscopy is the method of choice.
• Safely performed in all ages by experienced paediatric Endoscopy allows the direct visualization of esophagus, stomach, and duodenum.
• Biopsy specimens may be obtained from the stomach for histopathology, culture or rapid urease testing for pylori.
• Endoscopy also provides the opportunity for hemostatic therapy including injection and the use of a heater probe or electrocoagulation if necessary.
• Other investigations include faecal-H. pylori antigen test and urea breath test.
• *Blood-H. pylori antigen test and abdominal ultrasound are less informative hence a diagnosis should not be based solely on these.

Treatment

PUD treatment includes eradication of H. pylori and gastric acid suppression using triple therapy comprising of 2 antibiotics and a proton pump inhibitor (PPI). Examples of triple therapy regimens are shown in the table below.

Table 55:Triple therapy regimens