Acute and chronic Diarrhea/food

poisoning/traveller diarrhea/water
and electrolyte imbalance.
By
Dr Williams E.A
Introductions
 Definitions
• An increase in frequency, volume and often
urgency of the passage of stool and decrease in
stool consistency.

• Objectively: is an increase in stool mass to

greater than 200gram per day.

• Watery Diarrhea: 3 or more liquid or watery

stools in 24 hrs
• Acute diarrhea: diarrhea within 14days.

• Persistent diarrhea: diarrhea lasting between

2 to 4weeks.

• Chronic diarrhea: last more than 4weeks.

• Dysentery: Presence of blood and/or mucus in

stools
• Acute diarrhea disease remain a major global
public health problem and account for about 2
million or more deaths annually.

• Most death occur in infants, young children

and elderly.

• Is 2nd to respiratory tract infection as a cause

of time lost from work.
• Worldwide, diarrheal diseases are the 3rd
leading cause of mortality and morbidity
(exceeded only by lower respiratory infections
and cardiovascular diseases).

• Diarrhea is a leading cause of malnutrition in

children (<5 years).
 SEASONALITY

Disease Common season

Cholera Winter
Rotavirus diarrhea Winter
Shigellosis Dry summer
 PERSON-AT-RISK

• Cholera: 2 years and above, uncommon in very

young infants
• Shigellosis: more common in young children aged
below 5 years
• Rotavirus diarrhea: more common in young infants
and children aged 1-2 years
• E. coli diarrhea: can occur at any age

• Amebiasis: more common among adults

 HOST RISK FACTORS FOR DIARRHEA

• Malnutrition (up to 70% increased risk)

• Micronutrient deficiency (e.g. vitamin A and zinc)

• Low gastric acid/hypochlorhydria (H. pylori)

• Reduced gastric acid acidity (e.g. associated with some

medications)

• Compromised cell-mediated immune capacity/response

• Genetic profile (e.g., blood group O increases susceptibility

to V. cholerae)
Aetio-pathogenesis
 Pathophysiology of Diarrhea

• Adult ingest about 2liters of fluid per day.

• An additional 7liters is of endogenous source,
from salivary, gastric, pancreatic, biliary and
enteric sources.
• A healthy small intestine will absorb 7.5 liters,
more in the duodenum and jejunum.
• Colon absorbs about 1.3 liters, remaining
0.2liters is in the stool contributing to stool
mass of < 200gram/day.
• The maximum absorptive capacity of the small
intestine is abt 12L and that of colon 4 – 6L.

Major Mechanism of Diarrhea

• Enhanced mucosal secretion: cholera, toxigenic
E. coli, VIP secretory tumor.
• Impaired epithelial absorptive and digestive
• Increased permeability of the epithelial
barrier.
• Decreased absorptive surface: rotavirus,
giadiasis, norovirus enteritis.
• Altered motility
• Increased intraluminal osmolarity: ingestion of
poorly absorbed or non-absorb agent,
laxatives,
 IMPACT OF DIARRHEAL AGENTS ON GUT

 Directly pathogenic organism

Production of toxin by specific organisms

Disruption of gut mucosa and gut function

Overcome commensal (good) gut organisms

Inflammation of gut mucosa

COMMON CAUSES OF DIARRHEA
BACTERIA
– Vibrio cholera
– Shigella
– Escherichia coli
– Salmonella
– Campylobacter jejuni
– Yersinia enterocolitica
– Staphylococcus
– Vibrio parahemolyticus
– Clostridium difficile
 Viruses

– Rotavirus
– Norwalk virus
– Norovirus
 Parasite/Protozoa
• Entameba histolytica

• Giardia lamblia

• Cryptosporidium

• Isospora

• Cyclospora cayetanensis
 OTHERS
• Metabolic disease
Hyperthyroidism
Diabetes mellitus
Pancreatic insufficiency
• Food related
Carbohydrate intolerance (lactose)
Allergy
Additives
sorbitol
• Medications : Antibiotics, laxative, antacid, NSAID,
nutritional supplement, colchicine.
• Irritable bowel syndrome
• Inflammatory bowel disease
• Celiac disease
 Major causes of acute diarrhea

• Viral infection
• Bacteria infection
• Parasitic infection
• Medication
• Food poisoning/related
• Abrupt onset of chronic diarrhea
 Major causes of chronic diarrhea

• Inflammatory bowel disease

• Irritable bowel syndrome

• Food intolerance

• Diverticulitis

• Malabsorption syndrome

• Immunosuppression
Clinical findings
 Symptoms and signs

• History and physical examination are crucial and provide

information as the nature, underlying cause, and
severity of the diarrhea.
• Things to explore in the hx:

- travel hx

- recent meals (type, preparation, (fully

cooked, rare, raw), source of food (home,

restaurant or street vendors)

- occurrence of a similar illness among recent

contacts like family members.

- drug hx esp. antibiotics

- sexual hx = homosexual/anal sex

- predisposing conditions like

immunosuppression.

- character of the stool ( volume, frequency,

mucus, blood stain)

• Character of stool also provide clues to the part of GIT
that is involved.

• Large volume with little urgency, no tenesmus and

moderate increased frequency = small intestine and
proximal colon.

• Frequent, small volume dysentery stool containing

blood and mucus associated with urgency and
tenesmus = distal colon and rectum.
• On physical examination:

- fever

- hypotension

- orthostasis

- tachycardia

- poor skin turgor

 Laboratory findings

• Stool evaluations:

- fecal leukocytes

- stool leucocyte markers; lactoferin or

calprotectin

- stool exam for oval, cyst and parasites

- stool testing for C. difficile toxin

- Dark field microscopy of stool for cholera
- Stool cultures
- ELISA for rotavirus
- Immunoassays, bioassays or DNA probe
tests to identify E. coli strains
• Endoscopy and biopsy

• Abdominal imaging studies; not required in

uncomplicated cases.
• Blood culture

• Full blood count

• Serum electrolyte, urea & creatinine

Treatment
General principles of treatment of acute diarrhea

are:
• Treatment of dehydration (replace fluid loss).

• Antidiarrheal medications

• Empiric antibiotic therapy

• Specific antibiotic therapy: for specific pathogens

that cause acute infection.
• Commence oral intake as soon as possible.
 Treatment of dehydration

• Oral rehydration therapy is enough in most cases of

acute diarrhea.

• In milder cases, juices, broth, and water along with

salted crackers usually suffice. If dehydration is more
severe, ORS should be use.

• Intravenous hydration

• Monitoring and correction of electrolyte imbalance.

 ASSESSMENT OF DEHYDRATION

Dehydration
Mild Moderate Severe
Appearance irritable, irritable, lethargy,
thirsty very coma, or
thirsty unconscious
Anterior normal depressed markedly
Fontanelle depressed
Eyes normal sunken sunken
 ASSESSMENT OF DEHYDRATION (contd.)

Dehydration
Mild Moderate Severe
Tongue normal dry very dry,
furred
Skin normal slow very slow
retraction retraction
Breathing normal rapid very rapid
ASSESSMENT OF DEHYDRATION (contd.)
 WHO recommended ORT formula per liter of
water.

• 2.6 g sodium chloride

• 2.5 g sodium bicarbonate or 2.9 trisodium
citrate
• 1.5 g potassium chloride
• 13.5 g glucose or 27 g sucrose
 COMPOSITION OF ORS

Ingredient Amount (g/liter)

Sodium chloride 3.5
Trisodium citrate or 2.9 or
Sodium bicarbonate 2.5
Potassium chloride 1.5
Glucose 20.0
AMOUNT OF SALT LOSS DURING DIARRHEA

Diarrhea Salt (mmol/L)

Na K Cl HCO3
Cholera 88 30 86 32
(child)
Cholera 135 15 100 45
(adult)
E. coli 53 37 24 18
Rota 37 38 22 6
virus
Indications of intravenous hydration in diarrhea
disease.

• Massive diarrhea

• Severe dehydration esp in infants, young

children and elderly.
• Unable to tolerate orally due nausea and
vomiting or co-morbidities.
• Shock
 Fluid for intravenous hydration

• Isotonic infusions are recommended:

- hartman solution
- normal saline (.9% saline)
- 5% dextrose solution dissolved in water.
- ringer’s lactate solution.
 Composition IV fusions
Fluid Na Cl K Lactate Ca Glucose Osmol
mmol/l mmol/l mmol/l mmol/l mmol/l g/l mOsm/l

Normal 135 - 145 100 - 110 3.5 – 5.0 0.5 – 2.2 2.2 – 2.6 100 - 275 - 300
plasma 140

Normal 154 154 0 0 0 0 300

saline

Hartman 131 111 5 29 2 0 280

solution

Ringer’s 130 109 4 28 1.5 0 274

lactate

5% D/w 0 0 0 0 0 50 278
 Antidiarrheal medications

• Generally antimotility (Antidiarrheal) agents is not

required in acute diarrhea.
• Can be used with caution to provide symptomatic
relief.
• Use of antimotility agent may prolong the course of
some enteric infections, by prolonging the time
required to clear causative organism and toxins in the
gut.
Antimotility should be avoided in acute diarrhea
if:

• Fever

• Dysentery

• Toxic megacolon

• Colonic distention

Antimotility agents include: loperamide, bismuth

subsalicylate, diphenoxylate
 Empirical antibiotic use in acute diarrhea

• Antibiotics are over utilized in acute diarrhea.

• Most episode of acute diarrhea are self-

limited and clear within 2 – 4days.

• Antibiotics should be avoided in bloody stools,

abdominal pain with little or no fever until
EHEC has been ruled out.
 Indication to empirical antibiotics

• Fever

• Shock

• Extremes of age

• Dysentery

• Immunosuppression

• Traveler’s diarrhea

• Severe diarrhea lasting > 1 week

 ANTIMICROBIAL AGENTS

Type of diarrhea Antimicrobial agent

Cholera Tetracycline,
Doxycycline,
Ciprofloxacine
Shigellosis Pivmecillinam
(Selexid), Nalidixic
acid, Ciprofloxacin,
Ceftriaxone
Amebiasis Metronidazole
Specific diarrhea
 Types of Diarrhea
• Osmotic
• Secretory

• In Practice: Watery

Fatty
Bloody
 Osmotic Diarrhea

• Unmeasured osmotic substances hold water in

lumen of colon.

• Improves with FASTING or elimination.

• Fecal Osmolar Gradient will be >125.

• If lactose intolerant, low stool pH.

• Can be watery or fatty stool.
• KEY here is history of lactose intolerance or
laxatives.
• Laxatives like PEG, Lactulose, or Magnesium salts

• Fructose in our diet

• Lactose ( if lactase deficient)

• Sorbitol, Mannitol ( sugar free gums, drinks)

 OSMOTIC DIARRHEA

Low pH
Stool Analysis
Carbohydrate
FOG>125 malabsorption

Dietary review
High Mg output
Breath H2 test
Inadvertent ingestion
(lactose)
Laxative abuse
Lactase assay
 Secretory Diarrhea

1. Amount of fluid input exceeds absorption

2. Not affected by fasting and can continue at
night
3. Related to excess secretion or inadequate
absorption
4. Related to abnormal GI motility
5. Stool Na and Cl will be high and FOG<50
6. Can be Fatty, Watery, Bloody, Mixed
 Secretory Causes

Fatty Watery
Bloody IBS
Chronic
IBD Neuroendocrine
pancreatitis
Infection Infection
EPI
Radiation IBD
Celiac SIBO
Ischemia
SIBO Microscopic
Cancer
Cirrhosis Celiac
Cholestasis DM
Non-osmotic laxative
Bile Salt Depletion
Short Gut
Villous adenoma
Alcohol (sugar)
 SECRETORY DIARRHEA

4. Cholestyramine
1. Exclude 2. Exclude
3. Selective testing trial for
Infection Structural disease
bile acid diarrhea

Bacterial pathogens Plasma peptides

"Standard" Small bowel Gastrin
Aeromonas radiographs Calcitonin
Plesiomonas
VIP
Somatostatin

Other pathogens
"Standard" Sigmoidoscopy or
colonoscopy/biopsy Urine
Ova & parasites
Coccidia 5-HIAA
Microsporidia Histamine
Giardia antigen

CT scan of abdomen
Other tests
TSH
ACTH stimulation
Serum protein
Small bowel bx electrophoresis
Immunoglobulins
and
aspirate for quantitative
culture
 Fecal osmolar gradient (FOG)

• FOG= 290 – 2 {fecal Na + K} mmol/l

• If <50 secretory

• If > 125 osmotic

• If between 50-125 overlap osmotic/secretory

 Infection

• Clostridium difficile produces enterotoxins

which kill enterocytes

• Cholera type infections induces cGMP ion-

transporters to increase Chloride secretion
• Viral CMV, HIV, and HSV affect colon if
immunocompromised
 Altered Surface Area diarrhea

1. Ileal resection: reduces bile salt absorption

2. Ileocecal resection: altered bacterial

concentrations reach small bowel

3. Surgical scar/strictures: cause stasis

4. Celiac disease: reduces SI surface absorption

5. Inflammation: increased cytokines leads to increased

wall-thickening with leakage and decreased
absorption
 Dysregulation
(diarrhea from gut dysregulation)

1. diabetic autonomic dysfunction

2. post-vagotomy

3. sympathectomy

4. scleroderma, associated SI diverticulosis

5. hyperthyroidism
 Steatorrhea

Decreased fat solubilization: inadequate bile salts micelles.

1. Intestinal stasis: SIBO and lower duodenal pH

2. CP/ ZES: pancrease enzyme insufficiency or enzyme

deactivation by HCL

3. Cholestasis decreases bile salt secretion

4. Cholecystectomy: increases BS secretion

5. Ileal resection leads to BS depletion or malabsorption

 FATTY DIARRHEA

1. Exclude
Structural Disease

Small bowel biopsy Small Bowel

and aspirate for radiographs CT Scan of abdomen
quantitative culture

2. Exclude
pancreatic exocrine
insufficiency

Stool chymotrypsin
Bentiromide test Secretin test
activity
Length of Ileal resection determines if fatty or
watery
1. < 100cm resected : compensated with reduced BS
returned to Liver. Unabsorbed BS pull water through
colon wall into lumen get watery diarrhea. OK to use
cholestyramine.

2. > 100cm resected: decompensated with no BS return to

liver leading to reduced BS secretion; decreased micelle
formation. May not be OK to use cholestyramine. Will get
mixed fatty/watery diarrhea. Tx with low fat diet.
 INFLAMMATORY
DIARRHEA

Exclude Exclude
Structural Disease Infection

Bacterial pathogens
Small bowel "Standard"
Radiographs Aeromonas
Plesiomonas Tuberculosis

Sigmoidoscopy or Other Pathogens

colonoscopy/bx Parasite
Viruses

CT scan of abdomen

Small bowel biopsy

 VIBRIO CHOLERA

• Two major biotypes of Vibrio cholera that cause

diarrhea are:
 Classical

 ElTor

• Two common serotypes of Vibrio cholera that cause

diarrhea are:
 Inaba

 Ogawa
 Vibrio cholerae O139

• Vibrio cholerae in O-group 139 was first

isolated in 1992 and by 1993 had been found
throughout the Indian subcontinent. This
epidemic expansion probably resulted from a
single source after a lateral gene transfer (LGT)
event that changed the serotype of an
epidemic V. cholerae O1 El Tor strain to O139.
 Vibrio vulnificus

• The organism Vibrio vulnificus causes wound

infections, gastroenteritis or a serious syndrome
known as "primary septicema."
• V. vulnificus infections are either transmitted to
humans through open wounds in contact with
seawater or through consumption of certain
improperly cooked or raw shellfish.
• This bacterium has been isolated from water,
sediment, plankton and shellfish (oysters, clams and
crabs) located in the Gulf of Mexico, the Atlantic
Coast as far north as Cape Cod and the entire U.S.
West Coast.
• Cases of illness have also been associated with
brackish lakes in New Mexico and Oklahoma.
 CLINICAL FEATURE: CHOLERA

• Rice-watery stool

• Marked dehydration

• Projectile vomiting

• No fever or abdominal pain

• Muscle cramps

• Hypovolemic shock

• Scanty urine
 SHIGELLA

• The major serotypes of Shigella that cause

diarrhea are:
Dysenteriae type 1 or Shigella shiga

Shigella flexneri

Shigella sonnei

Shigella boydii
 CLINICAL FEATURE:
SHIGELLOSIS

• Frequent passage of scanty amount of stools,

mostly mixed with blood and mucus
• Moderate to high grade fever

• Severe abdominal cramps

• Tenesmus– pain around anus during defecation

• Usually no dehydration
 Nontyphoidal salmonellosis

• 1.4 million infections annually

• Commonly cause foodborne enterocolitis

• Occurs from ingestion of fecal contaminated,

incompletely cooked foods.
• Direct person to person spread, spread from pets, esp
reptiles
• Outbreak from contaminated water has been described.
• Salmonella typhimurium and S. enteritidis are the most
common causes.
• Salmonella are acid sensitive thus larger inoculum is
required.
• Risk factor:

- hypoacidity
- recent use of antibiotics
- extremes of age
- immunosuppression.
• Salmonella adhere to and invade the intestinal
epithelium, and are ingested by macrophages in which
virulent form can survive and disseminate to distant
site.
• Incubation period of 12 to 72hours

• Clinical features: vomiting, nausea, fever, abd cramp,

diarrhea
• Self-limited course.
 E. COLI

• Six major types of Escherichia coli cause diarrhea:

 Enterotoxigenic E. coli (ETEC)

 Enteroinvasive E. coli (EIEC)

 Enteropathogenic E. coli (EPEC)

 Enterohemorrhagic E. coli (E. coli O157:H7)

 Enteroaggregative E. coli (EAggEC)

 Diffuse adherent E. coli (DAEC)

 CLINICAL FEATURE OF E. COLI DIARRHEA

• Watery stools

• Vomiting is common

• Dehydration moderate to severe

• Fever– often of moderate grade

• Mild abdominal pain

• Bloody dysentery depend on the serotype mostly

invasive ones.
 CLINICAL FEATURE OF ROTAVIRUS DIARRHEA

• Insidious onset

• Prodromal symptoms, including fever, cough, and

vomiting precede diarrhea
• Stools are watery or semi-liquid; the color is greenish
or yellowish– typically looks like yoghurt mixed in water
• Mild to moderate dehydration

• Fever– moderate grade

 CLINICAL FEATURE OF AMEBIASIS

• Offensive and bulky stools containing mostly

mucus and sometimes blood
• Lower abdominal cramp

• Mild grade fever

• No dehydration
 Bacillius cereus

• Gram positive spore forming bacillius.

• Produce 2 distinct types of food poisoning.

• Some strains produce heat stable toxin in vitro that

induces vomiting.

• Other strains produce heat labile enterotoxin that cause

diarrhea.

• The vegetative form of the organism are destroyed when

rice is boiled, but the spores survives
• If the rice is not refrigerated the spore germinate and
produce toxin which is not deactivated by flash frying
of fried rice.
• Incubation period is 2 to 3hours after ingestion of toxin

• Xteristically; diarrheal types presents with stooling, abd

cramp, while vomiting type give more of nausea and
vomiting with mild diarrhea.
• Illness is self limited < 8hours
 Giardiasis

• Cause by giardia lamblia, a protozoa

• Most common cuase of traveler’s diarrhea

• Has both endemic and epidemic outbreaks

• Causes mucosal inflammation and architectural

changes
• Most cases recovery spontaneously without
treatment within 3 – 4weeks.
• Symptoms:

- Diarrhea

- Flatulence

- Abd cramps

- Epigastric pain

- Nausea & vomiting

- Malabsorpton with steatorrhea

- Weight loss
• Stool sample should be atleast 3 times.

• Cysts and trophozoites may be seen in diarrhea

stool.
• Only cysts are usually observed in formed stools.

• Rx: metronidazole
 Traveler’s diarrhea

• Increased popularity of tourism to developing nations,

traveler’s diarrhea affects literally millions of people
each year.
• Definition: passage of 3 or more loose to watery stool
within few hours to 10days of arrival of travelers.
• Incidence correlate with the level of sanitation at the
traveler’s destination
• Risk factors to traveler’s diarrhea include:

- poor sanitation.

- immunosuppression.

- hypochlorhydria (cause by drugs and

stomach surgery).

Common causes of traveler’s diarrhea:

- ETEC

- EAEC

- campylobacter
 - salmonella

- shigella

- invasive E. coli

- rotavirus and norovirus

- giadia and cryptosporidia.

Treatment: same with general diarrhea management.

 COMPLICATIONS: WATERY DIARRHEA

• Dehydration

• Electrolyte imbalances

• Tetany

• Convulsions

• Hypoglycemia

• Renal failure
 COMPLICATIONS: DYSENTERY

• Electrolyte imbalances

• Convulsions

• Hemolytic uremic syndrome (HUS)

• Leukemoid reaction

• Toxic megacolon

• Protein losing enteropathy

• Arthritis

• Perforation
 VACCINES

• An oral cholera vaccine is available, which gives

immunity to 50-60% of those who take the vaccine,
and this immunity lasts only a few months.
• No vaccines are available against shigellosis

• A vaccine against rotavirus diarrhea has been

withdrawn recently from the market.
 PREVENTION

• Safe drinking water and food

“Boil it, cook it, peel it, or forget it. "

• Hand washing
• Proper sanitation
 Steps to Reduce Waterborne Diseases

• Safe disposal of human waste (latrines)

• Hand washing

• Education about sanitation

• Piped, treated water

• Food safety
 COMMUNITY STRATEGIES TO REDUCE DIARRHEA

 Promotion of breast feeding and better weaning practices

• Safe water provision and waste disposal

• Promotion of hand washing

• Measles vaccination

• Cholera vaccination in high risk areas

• Zinc and vitamin A supplementation

• Rotavirus vaccination: Rota Teq, Rotarix

 OTHER PREVENTIVE STRATEGIES?

 Vitamin –A prophylaxis

 Improved Nutrition

 Immunization

- Measles immunization
 ROTA VIRUS VACCINE
Two live oral attenuated rotavirus vaccines were licensed

in 2006. Now there are three.

Monovalent human rotavirus vaccine (Rotarix).

The pentavalent bovine- Human reassortant vaccine

(Rota Teq)
They Provide 75-80% protection against rotavirus diarrhoea

and 90-100% protection against rotavirus disease.

Thank you for listening