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Acute Diarrhoea. Definition Increased frequency and water content of stools than is normal for the individual Usually: > 3 stools per day Descriptive Watery, mucoid, dysenteric Pathogenetic: Infective, non-infective. Acute Infective Diarrhoea. Epidemiology and predisposition Aetiology

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Acute Diarrhoea

  • Definition

    Increased frequency and water content of stools than is normal for the individual

    Usually: > 3 stools per day

  • Descriptive

    Watery, mucoid, dysenteric

  • Pathogenetic:

    Infective, non-infective


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Acute Infective Diarrhoea

  • Epidemiology and predisposition

  • Aetiology

    Virus (commonest: Rotavirus)

    Bacteria - Invasive

    Enterotoxigenic

    Parasites

    Fungi


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Pathogenesis of DiarrhoeaDepends on pathogen

  • VIRUS DIARRHOEA (eg Rotavirus)

    Effect on villus structure and function

    Enzyme damage

    Significant effect on digestion and absorption

    Secretion-absorption imbalance


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Pathogenesis of Bacterial Diarrhoea

  • without mucosal injury

    mediated by:

    Enterotoxins

    Adhesins

  • with mucosal injury

    mediated by:

    Adhesins

    Invasins

    Cytotoxins


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Paediatric DiarrhoeaEmerging issues

Food borne organisms of increasing importance with contamination of stored/transported food

Campylobacter Poultry, meat

Salmonella Poultry, Dairy Produce

Yersinia Meat

Bacillus cereus Reheated cereals

Vibrio parahaemolyticus Fish products

Unhygienic handling of food

Esch coli 0157 mince meat

Staph aureus


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Mechanisms of acute diarrhoea

  • Osmotic

    eg Lactose intolerance

  • Secretory

    eg Cholera

  • Mixed secretory-osmotic

    eg Rotavirus

  • Mucosal inflammation

    eg Invasive bacteria

  • Motility disturbance


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Effects of Diarrhoea

  • Dehydration

  • Biochemical disturbances

    Sodium, Potassium

    Metabolic acidosis

    Blood glucose

    Uraemia

    • Convulsions

    • Severe gut damage : ileus, NEC, PLE


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Clinical patterns

  • Some associated features depend on pathogen:

    Rotavirus

    Invasive bacteria

    Toxigenic bacteria

  • Fever, abdominal pain, early or late vomiting, other symptoms


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Management of diarrhoea

  • Replace the fluids and electrolytes which are lost

  • Drug therapy has very little place

    Antibiotic

    Antisecretory

    Antimotility

  • Nutritional management

  • Follow-up to ensure recovery


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Chronic diarrhoea

Diarrhoea can be categorized as:

  • Acute: less than 7 - 10 days

  • Persistent: More than 7 - 10 days

  • Chronic: More than 14 - 21 days

    (Persistent diarrhoea often a prolonged course of acute insult - different management)


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Chronic diarrhoea

  • With failure to thrive and excessive stool water losses

    Small intestinal mucosal injury

  • With failure to thrive but without excessive stool water losses

    Malabsorption syndromes

  • Without failure to thrive

    Motility disorder


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Small intestinal mucosal injury

  • Initiating acute insult - infection

  • Contributing malnutrition, young age, feeding problem

  • Acute diarrhoea does not stop

  • Leads to malnutrition

  • Aggravation by unmodified food

  • Immunological consequences

  • Contributes big percentage of deaths from diarrhoeal disease


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Diarrhoea in symptomatic HIV infection

  • Chronic diarrhoea: AIDS-defining condition

  • Severe mucosal damage with multiple defects of digestion and absorption

  • Associated infections

  • Intestinal super-infection with cryptosporidium, salmonella, opportunists

  • Protein-losing enteropathy can mask hyperglobulinaemia


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Lactose intolerance

  • Development of symptoms following lactose exposure due to lactase deficiency

  • Luminal fermentation of undigested lactose

  • Acid diarrhoea with lactose in stools

  • Diagnosed:

    History, low stool pH, positive reducing sugars

  • Relative lactase deficiency at birth improves with time

    Needs feed change only with failure to thrive


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Lactose intolerance

  • Congenital deficiency very rare

    Watery, acid diarrhoea from birth

  • Genetic primary adult lactase deficiency very common in Africa

  • Acquired deficiency common in severe gastroenteritis, malnutrition

  • Usually self-limiting without treatment

  • Feed change with persistent high stool water output


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Fat malabsorption

  • Diagnosis : stool microscopy, quantitative

  • Pancreatic deficiency (eg cystic fibrosis)

    Increased appetite cf intestinal disease

    Greasy floating stools, foul-smelling

    Treated with enzyme replacement

  • Bile salt deficiency (chronic liver disease)

  • Bile salt deconjugation

    Bacterial overgrowth in gut disease

    Treated with “bowel cocktail”


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Food allergy

  • Not equivalent to food intolerance

  • Requires exposure and sensitization before symptoms develop

    GIT and/or skin, nose, resp. symptoms

  • Not common 1 - 4% of children, most < 2yr

  • Careful diagnosis

    Atopic family history, allergy tests,

    food elimination and challenge

  • Beware nutritional adequacy of elimination diets


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Food intolerance

Symptoms after ingestion of food, the word does not indicate the pathology. Can be:

  • Allergic or immunological

    Allergic enteropathy

  • Biochemical - enzyme deficiencies

    Lactose intolerance

  • Chemical

    Laxative, salicylate


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Coeliac disease

  • Gluten-induced enteropathy : gliadin fraction of wheat protein

  • Symptoms after exposure to wheat

  • Genetic factors : HLA-B8

  • Auto-immune disorder

  • Villous atrophy with malabsorption

  • Resultant malnutrition

  • Anti-Endomysium, -gliadin IgA, jejunal biopsies

  • Total wheat product exclusion lifelong


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Motility disorders

Irritable bowel syndrome, Toddler diarrhoea

  • Between 6 months and 4 years

  • Normal growth and weight gain

  • Intermittent episodes, not at night

  • Stools get progressively more loose through the day, may contain undigested vegetables

  • Family history of “spastic colon”

  • Reassurance most important


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