Diarrhea

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Diarrhea

• Dr. Adnan Hamawandi
• Professor of Pediatrics

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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.

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Consequences

• Hypertonic dehydration
• 1. There is deficit of water and sodium but
  the deficit of water is greater.
• 2. Serum sodium concentration is elevated gt
  150meq./L. 3. Serum osmolality is elevated
  gt295mosmol/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.

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Consequences

• Hypotonic dehydration
• 1. There is deficit of water and sodium, but
  the deficit of sodium is greater.
• 2. Serum concentration is low lt 130meq./L.
• 3. Serum osmolality is low lt275mosmol/L.
• 4. The child is lethargic infrequently there
  are seizures.

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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.

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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.

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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.

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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.

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Clinical features

• No Dehydration
• Fluid deficit lt 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

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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.

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Clinical features

• Sever dehydration
• Fluid deficit is gt10 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.

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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.

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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.

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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

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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

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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.