1. Diarrhea Dr. Adnan Hamawandi Professor of Pediatrics

2. Consequences of diarrhea Dehydration Three types are considered Isotonic dehydration 70-80% 1. There is balanced deficit of water and sodium. 2. Serum sodium concentration is normal 130-150meq./L. 3. Serum osmolality is normal. 4. Hypovolemia occurs as a substantial loss of ECF.

3. Consequences Hypertonic dehydration: 1. There is deficit of water and sodium but the deficit of water is greater. 2. Serum sodium concentration is elevated > 150meq./L. 3. Serum osmolality is elevated >295mosmol/L. 4. Thirst is sever and out of proportion to the degree of dehydration, the child is irritable and have a doughy feeling skin. Seizures can complicate the course.

4. Consequences Hypotonic dehydration: 1. There is deficit of water and sodium, but the deficit of sodium is greater. 2. Serum concentration is low < 130meq./L. 3. Serum osmolality is low <275mosmol/L. 4. The child is lethargic; infrequently there are seizures.

5. Consequences Metabolic acidosis During diarrhea large amounts of bicarbonate may be lost in the stools. If the kidneys continue to function normally much of the lost bicarbonate is replaced. However, when renal function deteriorate as happens with hypovolemic shock base deficit and metabolic acidosis develop rapidly.

6. Consequences Acidosis also result from excessive production of lactic acid when patients have hypovolemic shock. The features of metabolic acidosis include: 1. Reduced serum bicarbonate. 2. Arterial PH is reduced. 3. Breathing become deep and rapid. 4. There is increased vomiting.

7. Consequences Hypokalemia Owing to large losses of potassium in the feces, patients with diarrhea often develop potassium depletion. This can be dangerous in malnorished infants who are potassium deficient before diarrhea starts. Clinical signs: 1. General muscle weakness. 2. cardiac arrhythmias. 3. paralytic ileus.

8. Consequences Malnutrition Diarrhea is an important cause of malnutrition. This is because patients with diarrhea eat less and their ability to absorb nutrients is reduced; moreover, their nutrient requirements are increased as a result of the infection. Each episode of diarrhea can cause weight loss and growth flattering.

9. Clinical features No Dehydration: Fluid deficit < 5% body weight, although they lack distinct signs of dehydration, they should be given more fluid than usual to prevent signs of dehydration from developing. Some dehydration: Fluid deficit equal to 5 -10% of body weight

10. Clinical features 1. Increased thirst. 2. Irritability and restlessness. 3. Eyes are slightly sunken. 4. Mouth and tongue are somewhat dry. 5. Skin pinch goes back slowly. 6. Radial pulse is detectable but rapid. 7. Anterior fontanel in infants is more sunken than usual.

11. Clinical features Sever dehydration: Fluid deficit is >10% body weight 1. Lethargy, stupor or even coma. 2. Eyes are deeply sunken and without tears. 3. Mouth and tongue are very dry. 4. Breathing is rapid and deep. 5. Drink poorly or unable to drink.

12. Clinical features 6. A skin pinch flattens very slowly 7. Radial pulse is very rapid and weak or undetectable. 8. In infants the anterior fontanel is very sunken. 9. Blood pressure is low or undetectable. 10. The arms and legs are cool and moist and the nail beds may be cyanosed.

13. Clinical features Weigh the child: The body weight is important for: 1. Determining the degree of dehydration exactly when the weight before the illness is known. 2. Determining the amount of oral or IV fluid to be given in the treatment. 3. After rehydration weight should be plotted on growth chart for follow up.

14. Assessment of dehydration According to WHO recommendation Look at Condition well restless* lethargic or* and behavior alert irritable unconscious Eyes normal sunken very sunken Tears present absent absent Mouth moist dry very dry Thirst drinks drinks * drinks* normally eagerly poorly Feel skin turgor normal slow* very slow* Decide NO SOME SEVER * Key sign

15. Assessment of dehydration Additional signs No dehydration Some Severe Urine output Normal Decreased Decreased Skin color Normal Normal Pale or Mottled Extremities Warm Warm Cold Heart rate Normal Tachycardia Tachycardia Peripheral pulses Normal Normal Weak Capillary refill Normal Normal Prolonged Breathing Normal Tachypnea Tachypnea Blood pressure Normal Normal Hypotension

17. Investigations Usually no investigations are indicated. Stool culture is necessary if the child looks septic, if there is blood or mucus in the stools or the child is immunocompromized. Plasma electrolytes, urea, creatinine and glucose should be checked if IV fluids are required or there are features suggestive of hypernatremia.