Diarrheal Diseases

Introduction
Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness. Patients may use the term "diarrhea" to refer to increased frequency of bowel movements, increased stool liquidity, a sense of fecal urgency, or fecal incontinence

DEFINITION
Watery Diarrhea: 3 or more liquid or watery stools in 24 h Dysentery: Presence of blood and/or mucus in stools Persistent Diarrhea: Diarrhea lasting for 14 days or more

TYPES OF DIARRHEA

Diarrhea Watery diarrhea Rota virus diarrhea E. coli diarrhea Cholera Dysentery Shigellosis Amebiasis Persistent diarrhea Causes are mostly unknown

COMMON CAUSES OF DIARRHEA- BACTERIA

Vibrio cholera Shigella Escherichia coli Salmonella Campylobacter jejuni Yersinia enterocolitica Staphylococcus Vibrio parahemolyticus Clostridium difficile

COMMON CAUSES OF DIARRHEA- VIRUS

Rotavirus Adenoviruses Caliciviruses Astroviruses Norwalk agents and Norwalk-like viruses

COMMON CAUSES OF DIARRHEA- PARASITE

Entameba histolytica Giardia lamblia Cryptosporidium Isospora

COMMON CAUSES OF DIARRHEA-OTHERS

Metabolic disease Hyperthyroidism Diabetes mellitus Pancreatic insufficiency Food allergy Lactose intolerance Antibiotics Irritable bowel syndrome

TRANSMISSION
Most of the diarrheal agents are transmitted by the fecal-oral route Some viruses (such as rotavirus) can be transmitted through air Nosocommial transmission is possible Shigella (the bacteria causing dysentery) is mainly transmitted person-to-person

SEASONALITY
Disease Cholera Common season 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

TYPES OF 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.

TYPES OF SHIGELLA
The major serotypes of Shigella that cause diarrhea are: Dysenteriae type 1 or Shigella shiga Shigella flexneri Shigella sonnei Shigella boydii

TYPES OF 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: CHOLERA

Rice-watery stool Marked dehydration Projectile vomiting No fever or abdominal pain Muscle cramps Hypovolemic shock Scanty urine

CLINICAL FEATURE: E. COLI DIARRHEA

Watery stools Vomiting is common Dehydration moderate to severe Fever often of moderate grade Mild abdominal pain

CLINICAL FEATURE: 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: 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

CLINICAL FEATURE: AMEBIASIS

Offensive and bulky stools containing mostly mucus and sometimes blood Lower abdominal cramp Mild grade fever No dehydration

LABORATORY DIAGNOSIS
Stool microscopy Dark field microscopy of stool for cholera Stool cultures ELISA for rotavirus Immunoassays, bioassays or DNA probe tests to identify E. coli strains

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.)

Tongue Skin Mild normal normal Dehydration Moderate Severe dry very dry, furred slow very slow retraction retraction rapid very rapid

Breathing normal

ASSESSMENT OF DEHYDRATION (contd.)

Mild normal Dehydration Moderate Severe rapid and feeble or low imperceptible volume dark scanty 6 - 9% 10% or more

Pulse

Urine Weight loss

normal < 5%

TREATMENT
Rehydration replace the loss of fluid and electrolytes Antibiotics according to the type of pathogens Start food as soon as possible

COMPOSITION OF ORS
Ingredient Sodium chloride Trisodium citrate or Sodium bicarbonate Potassium chloride Glucose Amount (g/liter) 3.5 2.9 or 2.5 1.5 20.0

AMOUNT OF SALT LOSS DURING DIARRHEA

Diarrhea Cholera (child) Cholera (adult) E. coli Rota virus Salt (mmol/L) Na K Cl HCO3 88 30 86 32 135 15 100 45 53 37 37 24 38 22 18 6

ANTIMICROBIAL AGENTS
Type of diarrhea Cholera Antimicrobial agent Tetracycline, Doxycycline, Ciprofloxacine Pivmecillinam (Selexid), Nalidixic acid, Ciprofloxacin, Ceftriaxone Metronidazole

Shigellosis

Amebiasis

Antidiarrheal Agents
Loperamide is the preferred drug in a dosage of 4 mg initially, followed by 2 mg after each loose stool (maximum:16 mg/24 h Bismuth subsalicylate (Pepto-Bismol), two tablets or 30 mL four times daily, reduces symptoms in patients with traveler's diarrhea by virtue of its antiinflammatory and antibacterial properties Anticholinergic agents are contraindicated in acute diarrhea

Key measures to treat diarrhoea include the following:

Rehydration: with oral rehydration salts (ORS) solution. Zinc supplements: zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume. Rehydration: with intravenous fluids in case of severe dehydration or shock. Nutrient-rich foods: the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods including breast milk during an episode, and by giving a nutritious diet including exclusive breastfeeding for the first six months of life to children when they are well.

Consulting a health professional

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.

 Safe drinking water and food Boil it, cook it, peel it, or forget it. " Hand washing Proper sanitation access to safe drinking-water; use of improved sanitation; hand washing with soap; exclusive breastfeeding for the first six months of life; good personal and food hygiene; health education about how infections spread; and rotavirus vaccination.

PREVENTION