Approach to the patient of Approach to the patient of acute diarrheaacute diarrhea

DEFINATIONDEFINATION

Passage of 3—4 stools of Passage of 3—4 stools of consistency softer than normal consistency softer than normal per day,lasting less than 2 per day,lasting less than 2 weaks.weaks.

CAUSESCAUSES

INFECTIONS(90%)INFECTIONS(90%)

FOOD INTOLERANCEFOOD INTOLERANCE

DRUGS DRUGS

STRESSSTRESS

INFECTIOUS DIARRHEAINFECTIOUS DIARRHEA

INFLAMMATORYINFLAMMATORY

Shigella Shigella SalmonellaSalmonella CampylobacterCampylobacter Clostridium difficleClostridium difficle Entamoeba histolyticaEntamoeba histolytica CytomegalovirusCytomegalovirus

NON-INFLAMMATORYNON-INFLAMMATORY

Rota VirusRota Virus Norwalk Norwalk

E.ColiE.Coli V.CholeraV.Cholera StaphaureusStaphaureus Bacillus CereusBacillus Cereus

GiardiaGiardia

ShigellaShigella

salmonellasalmonella

Vibrio CholeraVibrio Cholera

HISTORYHISTORY

Ask about the onset,duration and Ask about the onset,duration and frequency of loose stoolsfrequency of loose stools

Any recent travellingAny recent travelling Exposure to unpurified waterExposure to unpurified water Any unusual food intakeAny unusual food intake Any history of drug intakeAny history of drug intake Similar illness in familySimilar illness in family

EXAMINATIONEXAMINATION

General appearanceGeneral appearance Mental statusMental status VITALSVITALS

Blood pressureBlood pressure

Pulse RatePulse Rate

TempratureTemprature

Resp.RateResp.Rate

LOOK FOR DEHYDRATIONLOOK FOR DEHYDRATION

ConfusedConfused Dry mouthDry mouth Inelastic SkinInelastic Skin LethargyLethargy Sunken EyesSunken Eyes Decrease UrinationDecrease Urination

SymptomSymptomss

MinimalMinimal ModerateModerate SevereSevere

Mental Mental statusstatus

AlertAlert RestlessRestless LethargicLethargic

ThirstThirst Normal drinkingNormal drinking Eager to Eager to drinkdrink

Unable to Unable to drinkdrink

PulsePulse NormalNormal DecreaseDecrease Weak ,ThrWeak ,Threadyeady

EyesEyes Normal Normal Slightly Slightly sunkensunken

Deeply Deeply sunkensunken

TongueTongue MoistMoist DryDry ParchedParched

Skin FoldSkin Fold Instant recoilInstant recoil Less than Less than 2 sec.2 sec.

More than More than 2 sec2 sec

ExtremitieExtremitiess

WarmWarm CoolCool Cold,cyanCold,cyanoticotic

CLUE TO THE ORGANISMCLUE TO THE ORGANISM

WATERWATER V.Cholera,Giardia,NorwalkV.Cholera,Giardia,Norwalk

POULTRYPOULTRY Salmonella,ShigellaSalmonella,Shigella

EGGSEGGS SalmonellaSalmonella

SHELFISH SHELFISH V.Cholera,SalmonellaV.Cholera,Salmonella

FOREIGN TRAVELFOREIGN TRAVEL E.Coli,Salmonella,Shigella,GiardiaE.Coli,Salmonella,Shigella,Giardia

ANTIBIOTICSANTIBIOTICS Clostridium difficleClostridium difficle

MANAGEMENTMANAGEMENT

Maintain IV line or pass CVP lineMaintain IV line or pass CVP line

Monitor vitalsMonitor vitals

Monitor urine outputMonitor urine output

Rehydrate the patientRehydrate the patient

Degree of Degree of dehydrationdehydration

RehydrationRehydration ReplacementReplacement

NutritionNutrition

MildMild Not ApplicableNot Applicable 120—240ml Ors 120—240ml Ors for each loose for each loose stoolstool

Normal soft Normal soft diet with diet with adequate adequate caloriescalories

ModerateModerate ORS 50—ORS 50—100ml body 100ml body wt over 4 wt over 4 hourshours

SAMESAME SAMESAME

SevereSevere R.Lactate or R.Lactate or N/S,@ N/S,@ 20ml/kg bolus 20ml/kg bolus until perfusion until perfusion improves,then improves,then 100ml/kg ORS 100ml/kg ORS over 4 hrs.over 4 hrs.

SAME. By NG if SAME. By NG if unable to drinkunable to drink

SAMESAME

In Emergency rehydrate by givingIn Emergency rehydrate by giving

Normal saline or Ringer LactateNormal saline or Ringer Lactate

@ 50….200ml/kg/24hrs@ 50….200ml/kg/24hrs Fluids should be given according to Fluids should be given according to

hydration statushydration status Look for basal crepts…or cvp Look for basal crepts…or cvp

pressure .rpressure .r

Anti diarrhealAnti diarrheal

Can be used in mild – moderate Can be used in mild – moderate diarrheadiarrhea

Should not be used in inflammatory Should not be used in inflammatory diarrheadiarrhea

Loperamide 4mg initially,then 2mg Loperamide 4mg initially,then 2mg after each loose stoolafter each loose stool

ANTIBIOTICSANTIBIOTICS

In most of the cases not requiredIn most of the cases not required

Empirical therapy given in inflammatory Empirical therapy given in inflammatory casescases

Ciprofloxacin 500mg BDCiprofloxacin 500mg BD

Metronidazole 500 mg Tds if Giardia Metronidazole 500 mg Tds if Giardia suspectedsuspected

ADVISE FOR HOMEADVISE FOR HOME

Plenty of fluidsPlenty of fluids Specially ORS…1 sachet in 1 litre Specially ORS…1 sachet in 1 litre

boiled water(100..200ml after each boiled water(100..200ml after each stool )stool )

OROR Add 1tsp salt,8 tsp sugar.1tsp baking Add 1tsp salt,8 tsp sugar.1tsp baking

powder in 1 litre boiled water.powder in 1 litre boiled water. Take 1 or 2 banana alongwith it.Take 1 or 2 banana alongwith it.

DIETDIET

Soft dietSoft diet BANANABANANA RICERICE APPLE MASHAPPLE MASH TOASTTOAST

Avoid fats,milk,caffiene,alcohalAvoid fats,milk,caffiene,alcohal

PREVENTIONPREVENTION

Always wash hands after trip to the Always wash hands after trip to the toilettoilet

Make sure ,dairy products you use Make sure ,dairy products you use are pasteurizedare pasteurized

Avoid unnecessary antibiotics useAvoid unnecessary antibiotics use Eat freshly cooked mealEat freshly cooked meal Use boiled waterUse boiled water

MCQ’SMCQ’S

Salmonella and shigella cause..Salmonella and shigella cause..

1.Inflammatory diarrhea1.Inflammatory diarrhea 2.Non.Inflammatory diarrhea2.Non.Inflammatory diarrhea 3.Both3.Both 4.Non of the above4.Non of the above

Anti.diarrheals may be given in..Anti.diarrheals may be given in..

1.Salmonella1.Salmonella 2.Shigella2.Shigella 3.Staphaureus3.Staphaureus 4.Non of the above4.Non of the above

Antimicrobials are indicated in…Antimicrobials are indicated in…

1.Inflamatory diarrhea1.Inflamatory diarrhea 2.Non Inflammatory diarrhea2.Non Inflammatory diarrhea 3.Both3.Both

Water contains…Water contains…

1.V.Cholera1.V.Cholera 2.Giardia2.Giardia 3.Norwalk3.Norwalk 4.All4.All 5.None5.None

Diarrhea by C.difficle is due to.Diarrhea by C.difficle is due to.

1.Unpurified water1.Unpurified water 2.Use of antibiotics2.Use of antibiotics 3.Poultry3.Poultry 4.Shell fish4.Shell fish

Identify the Organism.Identify the Organism.

1.Salmonella1.Salmonella 2.Shigella2.Shigella 3.E.coli3.E.coli 4.Non of the above4.Non of the above

In Dehydration Heart rateIn Dehydration Heart rate .. ..

1.Increases1.Increases 2.Remains normal2.Remains normal 3.May be decreased3.May be decreased 4.Both 1&3 true.4.Both 1&3 true.

THANKSTHANKS