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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
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
Acute Infective Diarrhoea
  • Epidemiology and predisposition
  • Aetiology

Virus (commonest: Rotavirus)

Bacteria - Invasive

Enterotoxigenic

Parasites

Fungi

pathogenesis of diarrhoea depends on pathogen
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

pathogenesis of bacterial diarrhoea
Pathogenesis of Bacterial Diarrhoea
  • without mucosal injury

mediated by:

Enterotoxins

Adhesins

  • with mucosal injury

mediated by:

Adhesins

Invasins

Cytotoxins

paediatric diarrhoea emerging issues
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

mechanisms of acute diarrhoea
Mechanisms of acute diarrhoea
  • Osmotic

eg Lactose intolerance

  • Secretory

eg Cholera

  • Mixed secretory-osmotic

eg Rotavirus

  • Mucosal inflammation

eg Invasive bacteria

  • Motility disturbance
effects of diarrhoea
Effects of Diarrhoea
  • Dehydration
  • Biochemical disturbances

Sodium, Potassium

Metabolic acidosis

Blood glucose

Uraemia

    • Convulsions
    • Severe gut damage : ileus, NEC, PLE
clinical patterns
Clinical patterns
  • Some associated features depend on pathogen:

Rotavirus

Invasive bacteria

Toxigenic bacteria

  • Fever, abdominal pain, early or late vomiting, other symptoms
management of diarrhoea
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
chronic diarrhoea
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)

chronic diarrhoea11
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

small intestinal mucosal injury
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
diarrhoea in symptomatic hiv infection
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
lactose intolerance
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

lactose intolerance15
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
fat malabsorption
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”

food allergy
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
food intolerance
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

coeliac disease
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
motility disorders
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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