lOMoARcPSD|46396551

Persistent-diarrhoea

Medicine (University of the Witwatersrand, Johannesburg)

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PERSISTENT DIARRHOEA

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DEFINITION

• Prolongation of acute diarrhoea / dysentery for more

than 14 days

• Generally associated with weight loss.

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PROTRACTED DIARRHOEA

• Prolongation of acute diarrhoea or dysentery >14

days – Persistent Diarrhoea
• Persistent diarrhoea – associated weight loss &
extreme malnutrition – Protracted Diarrhoea

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CAUSE OF PERSISTENT DIARRHOEA

• Persistent infection with one or more enteric

pathogens
• Secondary malabsorption of carbohydrates & fat.
• Intestinal parasitosis.
• Dietary protein allergy/intolerance.

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PATHOLOGY

• Damage to the absorptive mucosal surface of small

intestine
• Delay in repair of the damaged epithelium (Normal
<5 days)
• Carbohydrate, fat and protein mal ‐ absorption
ensues as consequence
• Direct absorption of macromolecules leads to
protein allergy.

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PATHOLOGY CONT..

• Mild form
– Several motions
– No significant weight loss
– No significant dehydration

• Moderate form
– Several motions
– Marginal weight loss
– Without dehydration
– Non tolerance to
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• Severe form
– Dehydration with several motions
– Weight loss
– Non tolerance to milk & cereals
– Secondary infection often coexists

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DIAGNOSIS

• Assess dehydration.

• Assess malnutrition.

• Stool ‐ R/E, Culture, Reducing sugar

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MANAGEMENT

• Mild form ‐ Try low milk formula feeds.

• Moderate form ‐ Do not try milk, permit cereal based feeds.

• Severe form
– Phase I: Resuscitation < 24 hours
– Phase II: Partial parenteral nutrition (1‐4 days), IV fluids,
colloid, antimicrobials, electrolyte balance
– Phase III: Nutritional rehabilitation with calorie dense, > 5
days, lactose free formulae
If fails ‐ Chicken/egg white, glucose, oil ‐ feed
If fails ‐ Total parenteral nutrition

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INDICATIONS FOR ANTIMICROBIALS

• Presence of gross blood in stool/Dysentery

• Associated systemic infection.
• Severe malnutrition.
• Cholera

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VITAMIN AND MINERAL SUPPLEMENTATION

• Twice the RDA of vitamins and minerals.

• Special attention for Vit. A and Zn.
• In malnutrition :
– Magnesium sulphate IM
– Potassium oral.

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PREVENTION

• Promotion of breast feeding.

• Active management of acute diarrhoea.
• Appropriate dietetic management.
• Judicious administration of drugs.

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CHRONIC DIARRHOEA
Definition

• Diarrhoea of more than 2 weeks duration.

OR

• 3 attacks during last 3 months, without specific

congenital, biochemical or metabolic disorders.

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COMMON CAUSES OF
CHRONIC DIARRHOEA

• Post gastroenteritis malabsorption syndrome.

• Protein‐energy malnutrition.
• Cow’s milk /soy protein intolerance.
• Primary/Secondary disaccharidase deficiencies.
• Cystic fibrosis.
• Intestinal parasites – Giardia, EH, Cryptosporidia.
• Excessive consumption of carbonated fluids.
• Intestinal infection – Enteropathogens, M.tuberculosis.
• Tropical sprue.
• Inflammatory bowel disease –
• Crohn’s disease, Ulcerative colitis.
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EVALUATION OF PATIENTS WITH

CHRONIC DIARRHOEA

PHASE – I
• Clinical History.
• Nutrition assessment.
• Stool exam – pH, reducing substances,
leukocyte count, fat, ova, parasites.
• Stool culture.
• Stool for Clostridium difficile toxin.
• Blood studies – CBC, ESR, Electrolytes, Urea,
Creatinine

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EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA

– Contd..

PHASE ‐ II
• Sweat chloride.
• 72 hours stool fat estimation.
• Stool electrolytes, Osmolarity.
• Stool for phenolphthalein, magnesium sulphate,
phosphate.
• Breath H2 test.

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EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA

– Contd.

PHASE ‐ III
• Endoscopic studies.
• Small bowel Biopsy.
• Sigmoidoscopy or colonoscopy with biopsies.
• Barium studies.

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EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA

– Contd.

PHASE ‐ IV
• Hormonal studies
– Vasoactive intestinal polypeptide.
– Gastrin.
– Secretin.
– 5‐hydroxyindoleacetic assay.

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THERAPY

• Depends upon the cause.

• Secondary carbohydrate intolerance – by
reduction of the sugar load.
• Lactase for digestion of lactose.
• Post gastroenteritis malabsorption – Needs
predigested formula.
• Specific diseases to be treated.

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DYSENTERY

• It is a Syndrome of Bloody diarrhoea with visible red

blood, fever, abdominal cramps, rectal pain &
tenesmus, mucoid stool.

• Does not include :‐

– Blood streaks on formed stool.
– Microscopic red blood cell in stool.
– Melena.

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CAUSES OF DYSENTERY

• Shigella
• Entero‐ invasive & Entero‐ hemorrhagic E.coli
(EIEC&EHEC)
• Salmonella
• Campylobacter jejuni
• Entamoeba histolytica

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PATHOGENESIS

• Spread by feco‐oral contamination.

• Bacterial invasion of colonic epithelium.
• Results in inflammatory colitis.
• Recto sigmoid area maximally affected.
• Host defense
– Copious mucoid secretion
– Epithelial regeneration.
• Shigella causes disease with 10 to 100 organisms

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CLINICAL SPECTRUM

• Watery diarrhoea to fatal dysentery.

• Incubation period – 12 hours to 1 week.
• High fever.
• Abdominal cramps.
• Vomiting
• Abdominal tenderness & rectal tenderness.
• Blood & mucus in the stool.
• Tenesmus and straining.
• Rectal Prolapse.
• Self limiting course in most bacterial infection in 10 days.
• Bacteremia is uncommon.

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COMPLICATIONS

• Seizures – Mostly with Shigella‐ shig(Type –I)

• Dyselectrolytemia & dehydration
• Rectal prolapse
• Malnutrition – Protein losing enteropathy.
• Hemolytic Uremic Syndrome.
• Non suppurative arthritis.

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DIAGNOSIS

• Stool Examination – for leukocytes, RBCs,

trophozoites of EH
• Stool Culture
• Peripheral blood smear – Leukocytosis with more
band cells.
• Blood culture in toxic, malnourished & very young
infants.
• Electrolytes in severe dehydration.

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ANTIMICROBIALS IN DYSENTRY

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ANTIMICROBIALS THAT SHOULD NOT BE USED FOR

SHIGELLOSIS

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HIGH RISK FACTORS IN DYSENTRY

WITH
HIGHER MORTALITY RATE
• Infants < 1 year
• Non breast fed babies.
• Dehydration
• Malnutrition
• H/o Convulsion or measles
• Infants

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THERAPY FOR AMOEBIC DYSENTRY

• Diloxanide furoate – 20mg/kg/day in 3 divided doses

X 10 days
• Metronidazole – 35 – 50mg/kg/day in three divided
doses X 10 days

Alternative
• Paromomycin ‐ 25‐30 mg/kg/day in 3 divided doses X
5 to 10 days.
• Dehydroemetine hydrochloride – 1.0 to 1.5
mg/kg/day IM X 5 days
• For severe cases two oral medicines can be
combined.

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CONTROL

• Prevention of feco‐oral transmission.

• Breast feeding
• Hand washing before handling food.

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Thank You

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