Physiologic Basis of Oral Rehydration*

Norma H. Abejar, M.D;**

(* Presented at the 13th Annual Convention and International Symposium on Infectious Diseases of the Philippine Society for Microbiology and Infectious Diseases, Westin Philippine Plaza Hotel, December 2-3, 1990; ** Medical Specialist II and Head, National Rehydration Treatment and Training Center, San Lazaro Hospital, Manila)

ABSTRACT
One of the major breakthroughs in the field of diarrheal diseases research has been the discovery that dehydration in cases of acute diarrhea of all etiologies and in all age groups can be safely and effectively treated by a simple method of oral rehydration using a glucose-electrolyte solution. For an optimum intestinal absorption of orally administered water and electrolyte solution, it must fulfill certain physiologic criteria. The World Health Organization recommended oral rehydration solution (ORS) satisfies physiologic criteria. ORS has been extensively used worldwide with remarkable results in the prevention and treatment of dehydration, the main complication of diarrheal illness. ORS' appropriate use in the hospital wards and in out patient departments can reduce diarrheal care fatality rates, diarrheal disease hospitalization rates, and cost of diarrhea treatment. [Phil J Microbiol Infect Dis 1990; 19(2):54-56] Key words: Oral rehydration, diarrhea. ORS

In the Philippines, diarrheal disease is a major public health problem. Over the past 20 years, it has consistently ranked second to fourth among the le ading causes of morbidity and mortality and also a significant contributor to malnutrition. A field survey conducted jointly by the Department of Health, World Health Organization, United States Agency for International Development (USAID) and UNICEF involving a nationwide example of 11,000 children showed that chi1dren under five years of age, on the average, experience 2.8 diarrhea episodes per child per year. This means that a total of up to 25 million diarrhea episodes occur each year among children five years old and below. The survey also showed that diarrhea mortality among children of this same age group is 9 per thousand. Diarrhea does not kill but the resulting dehydration due to loss of electrolytes and fluids is the fatal factor that threatens life. The only way to treat dehydration is through fluid therapy to replace vital fluids lost. For so many years up to 1960s, fluid therapy was equated with intravenous administration of electrolytes and fluids into the body. Administration efficacy was noteworthy but has proved to be less than ideal because the facilities required for intravenous therapy, as well as the price of the solution are beyond the reach of many people especially in the developing countries. The struggle to come up with a more effective medication that is relevant and accessible to the population has evolved using the approach called oral rehydration therapy. Many scientists call this method as the most important medical advance of the century in terms of public health. Developing countries that lack medical facilities and medical services can have a home-based remedy that is scientifically valid and supported by physicians to provide a simple yet a life saving oral medication that mothers can administer. It prevents mild dehydration from worsening due to diarrhea thus obviating need for IV therapy and hospitalization. Numerous clinical studies in patients have provided conclusive evidence that fluid and electrolyte losses due to acute diarrhea and cholera can be adequately replaced orally by using glucose-electrolyte solution of optimal concentration. For optimum absorption of orally administered rehydration formula, there are certain physiologic conditions to be met: 1. The solution should be isosmotic to plasma. Total osmolarity should be similar to or less than that of plasma. 2. Glucose concentration should be about 20 grams (11 mmol) per liter. With this concentration, a maximum sodium and water absorption can be achieved. Higher concentrations

lead to osmotic diarrhea (this is the reason why one must discourage mixing of ORS with juice or soft-drinks). Lower concentrations lead to ineffective absorption and rehydration. Sucrose or table sugar can substitute for glucose. To obtain the same recommended concentration, as glucose, sucrose concentration (40 G/L) should be twice that of glucose. 3. Sodium concentration should be sufficient to correct existing deficits and replace ongoing losses of salt. The nearer the sodium concentration to plasma is, the faster and, higher is net absorption; 90 mmol/L sodium concentration proved optimum to correct existing deficits and replace on-going losses of salt. 4. Potassium concentration should be about 20 mmol/L. It should be higher than that of plasma to induce absorption. The potassium loss during diarrhea is of the same magnitude as that of sodium but sodium replacement is more urgent because potassium body stores are several times larger. 5. Molecular ratio of the glucose to sodium concentrations in the solution must approximate 1: 4 to 1: 1.4. 6. Citrate concentration of 10 mmol/L or a bicarbonate concentration of 30 mmol/L is an optimal concentration to correct base deficit acidosis due to diarrheal dehydration. The use of trisodium citrate dihydrate is preferred because it does not readily react with glucose or sucrose and has a longer shelf life. Oral therapy is based on the fact that the normal small bowel actively absorbs glucose and that sodium is carried with it in about equimolar ratio. Thus, in the normal intestine there is considerably greater net absorption of an isotonic salt solution with glucose than of one without glucose (Figure 1). During acute watery diarrhea, the absorption of sodium (without glucose) is impaired. An isotonic solution taken by mouth simply augments stool volume by passing through the gut unabsorbed; glucose absorption by the small bowel, however remains largely intact and the net absorption of water and electrolytes (including potassium and bicarbonate/trisodium citrate) from isotonic glucose-salt solutions can equal or exceed simultaneous stool losses even when the loss is rapid, as in cholera (Figure 2). When glucose is not available, other sugars, especially those that yield glucose when broken down in the gut may be useful for enhancing salt and water absorption. If their breakdown were incomplete, however, their effect would be reduced. A glucose-salt solution containing 40 g sucrose per liter has been almost as effective as the glucose-salt solution for treating patients with severe cholera and other diarrheal diseases. For the successful implementation of oral therapy in local health centers, hospitals and even in homes, the method employed must be uniform, simple and the use of ORS solution based on single formula. Figure 3 shows the composition of a widel tested and effective glucose-electrolyte y solution, which is approximately isotonic with plasma; it contains sodium and glucose in an approximately equimolar ratio; and sufficient potassium and bicarbonate/citrate to replace a major portion of stool losses. The sodium concentration is sufficient to correct an initial isotonic deficit and to replace continuing stool losses when the rate of loss is moderate or severe. Normal renal function is essential so that any excess of salt or water may be excreted. In patients with mild diarrhea the stool concentration is often lower than that in the oral solution; the water provided in continued oral feedings also meets the water requirement of such patients. The WHO-ORS (ORESOL) Formulation answers the ideal recommended ranges shown in Figure 4. It meets the optimum sodium concentration of 90 mmol/L to satisfy rapid rehydration needs. During maintenance, one could alternate with equal amount of plain water to obtain an effective sodium concentration of 45 mmol/L and to replace on-going sodium losses. This WHOORS then, is adequate for both rehydration and maintenance needs for adults, children, infants and neonates with diarrhea of diverse etiology. Net loss of water and salts is not determined by stool sodium alone but by concomitant losses from skin, urine and respiration. Several controlled

studies confirmed that 90 mmol ORS corrected acidosis and dehydration earlier, weight gain was better and duration of rehydration was shorter without any evidence of hypernatremia.

In conclusion, the use of a single formulation throughout the national health system for treating dehydration from diarrheas of all causes in all ages, both for rehydration and for maintenance facilitates the delivery of oral rehydration therapy more effectively. The National Rehydration Treatment and Training Center at San Lazaro Hospital with its facilities had been collaborating with the National Control of Diarrheal Disease Program of the Department of Health by implementing oral rehydration therapy, proper use of IV fluids and antimicrobials in the treatment of acute diarrhea. REFERENCES
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