Diarrhea A messy subject

Case A 1 year old girl is brought to clinic with 3 days of watery brown diarrhea and irritability. On exam the child is lethargic, afebrile, with sunken eyes and a weak pulse of 140/minute. Which of the following is the best management plan? Check CBC and stool tests for pathogens Check CBC and stool tests for pathogens Prescribe oral rehydration solution Prescribe oral rehydration solution Prescribe oral antibiotics Prescribe oral antibiotics Begin IV fluids and hospitalize Begin IV fluids and hospitalize

” “More than 70 per cent of almost 11 million child deaths every year are attributable to six causes: diarrhoea, malaria, neonatal infection, pneumonia, preterm delivery, or lack of oxygen at birth.” - Unicef

Deaths per year from diarrheal illness United States: 6,000 United States: 6,000 Developing world: 1.5 to 2 million (children < 5 years old) Developing world: 1.5 to 2 million (children < 5 years old) World Gastroenterology Organization (WGO) Practice Guideline Acute Diarrhea (March 2008)

WGO Practice Guideline – Acute Diarrhea March 2008 Classification

Acute diarrhea: clinical priorities Assess severity of illness and need for rehydration Assess severity of illness and need for rehydration Identify likely causes on the basis of history and exam Identify likely causes on the basis of history and exam

Exam: nutritional and volume status

Exam: volume status Adults and Children Adults and Children Tachycardia, postural hypotension Tachycardia, postural hypotension Jugular venous distension Jugular venous distension Mucous membranes Mucous membranes Children Children Sunken eyes, skin turgor Sunken eyes, skin turgor Sunken fontanelle Sunken fontanelle Irritable or lethargic Irritable or lethargic Drinking poorly Drinking poorly

WGO Practice Guideline – Acute Diarrhea March 2008

Kwashiorkor: lack of protein Marasmus: protein + calorie malnutrition Malnutrition is a major risk factor for diarrhea mortality

History suggests etiology Fever, bloody stool, tenesmus Fever, bloody stool, tenesmus Inflammation Inflammation Invasive and cytotoxin producing pathogens Invasive and cytotoxin producing pathogens Profuse watery stool Profuse watery stool Secretory diarrhea Secretory diarrhea Cholera, viral pathogens, giardia Cholera, viral pathogens, giardia Vomiting Vomiting Viral pathogens, ingested bacterial toxins Viral pathogens, ingested bacterial toxins

Lab tests Stool for ova and parasites Stool for ova and parasites Especially in severe or chronic diarrhea Especially in severe or chronic diarrhea Fecal leukocytes Fecal leukocytes Suggests colitis, invasive organism Suggests colitis, invasive organism CBC and electrolytes CBC and electrolytes Won’t alter acute Rx, unless there are signs of severe anemia Won’t alter acute Rx, unless there are signs of severe anemia Stool culture Stool culture Often not available or required Often not available or required Stool Sudan stain (fecal fat) Stool Sudan stain (fecal fat) In chronic diarrhea with weight loss In chronic diarrhea with weight loss

If the gut works, use it

WGO Practice Guideline – Acute Diarrhea March 2008 Oral rehydration saves lives

Oral rehydration solution (ORS) Rice-based ORS is superior to glucose-based ORS in patients with cholera WGO Practice Guideline – Acute Diarrhea March 2008

Rehydration of children WGO Practice Guideline – Acute Diarrhea March 2008

Rehydration of children WGO Practice Guideline – Acute Diarrhea March 2008

Medical therapy - children Admit to hospital if malnourished, severely dehydrated, age < 1 year, recent measles Admit to hospital if malnourished, severely dehydrated, age < 1 year, recent measles ORS if dehydrated; IV fluids (RL, NS) if severely dehydrated ORS if dehydrated; IV fluids (RL, NS) if severely dehydrated Re-feed as soon as rehydration is accomplished Re-feed as soon as rehydration is accomplished zinc 20 mg daily x 14 days zinc 20 mg daily x 14 days Antibiotics not usually indicated Antibiotics not usually indicated Give antibx for: Give antibx for: bloody diarrhea (shigella) bloody diarrhea (shigella) Suspicion of cholera Suspicion of cholera Giardiasis or amebiasis Giardiasis or amebiasis

Medical therapy - adults ORS or IV fluids (RL, NS) if severely dehydrated ORS or IV fluids (RL, NS) if severely dehydrated Bismuth or Loperamide (contraindicated if there is fever or bloody stool) Bismuth or Loperamide (contraindicated if there is fever or bloody stool) Antibiotics not usually indicated Antibiotics not usually indicated Give antibx for: Give antibx for: bloody diarrhea (shigella) bloody diarrhea (shigella) Suspicion of cholera Suspicion of cholera Giardiasis or amebiasis Giardiasis or amebiasis

Dysentery Bloody stools, often with fever Bloody stools, often with fever Shigella, enterohemorrhagic e coli (EHEC), other bacteria Shigella, enterohemorrhagic e coli (EHEC), other bacteria Amebiasis Amebiasis Antibiotics recommended for extremes of age, immunocompromised or malnourished patients, suspicion of sepsis or enteric fever Antibiotics recommended for extremes of age, immunocompromised or malnourished patients, suspicion of sepsis or enteric fever Antibiotic Rx may precipitate hemolytic-uremic syndrome, especially in children Antibiotic Rx may precipitate hemolytic-uremic syndrome, especially in children

WGO Practice Guideline – Acute Diarrhea March 2008 Bacteria resistance is common – learn local patterns

Chronic diarrhea - children Among infants in developing countries, 20% of acute diarrheal illnesses become chronic Among infants in developing countries, 20% of acute diarrheal illnesses become chronic Enteropathogenic e coli (EPEC) Enteropathogenic e coli (EPEC) Vicious cycle of diarrhea and malabsorption leading to death Vicious cycle of diarrhea and malabsorption leading to death Consider HIV Consider HIV Rx is largely nutritional: Rx is largely nutritional: Iso-osmolar carbohydrate porridge, via feeding tube if needed Iso-osmolar carbohydrate porridge, via feeding tube if needed MVI and zinc MVI and zinc Antibiotics for EPEC Antibiotics for EPEC

Chronic diarrheal syndromes - adults Campylobacter ileitis: chronic diarrhea, signs of inflammation Campylobacter ileitis: chronic diarrhea, signs of inflammation Giardia, ameoba Giardia, ameoba Wasting? Consider HIV, TB Wasting? Consider HIV, TB Fat in stool? Consider sprue, chronic pancreatitis Fat in stool? Consider sprue, chronic pancreatitis

Resources WGO Practice Guideline – Acute Diarrhea March 2008