1. Approach to diarrhea/Dysentery
cholera/AGE/food poisoning
Girdiasis / amoebiasis/ viral
diarrhorea / other causes
Very common presenting problem

2. epidemiology
• Most common in developing country
• High- morbidity and mortality-DIRTY URBAN
AREAS
• Public health concern and problem
• Mostly danger in children with malnutrition/
AIDS/ patient with DM
• EASY DIAGNOSIS- SYMPTOMATICALLY
• TRETMENT MOSLY- EFFECTIVE- SYMPTOMATICALLY
• EFFECTIVE EMPERICAL TREATMENT- MOSLY-
ANTIBIOTICS/ ANTI-AMOEBIC/ ANTI- HELMENTHICS
• NEEDS- PROPER-PREVENTIVE MEASURE-

3. diarrhea
• Normal output of stool 200 gm/ 24 hour
• Diarrhea- passing of stool more than 200 gm /24 hour
Various mechanisms of diarrhea
 Osmotic-diarrhea
 Malabsorption/maldigetion/too fatty food--celiac disease,
pancreatic insufficiency,drugs( alcohol,neomycin,colchicine)
 Inflammation- AGE/DYSENTERY
 Secretory-FATTY ACID /BILE ACIDS/TOXINS/ ULCERATIVE COLITIS
 Altered motility-IBS

4. Osmotic diarrhea
• Excess amount of poorly absorable substance
like- magnesium sulphate ,lactulose, lactose
,magnesium hydroxide,polyethylene glycol.
• These substances retaines more water-
causes- osmotic diarrhea

5. Definition of diarrhea
• “Passage of loose ,liquid or watery stool 3 or more episode with history of recent
change in consistency and character of stool.”
• Acute diarrhea- lasts for few days to 1 week. AGE/ CHOLERA/ FOOD
POISONING/ BACTERIAL AND AMOEBIC DYSENTARY
• Chronic diarrhea:-generally lasts more than 3 weeks—common causes-
AIDS, IBS, CHRONIC BACTERIAL INF. TB ABDOMEN, MALABSORPTION, CHROHN’S
DISEASE, CA- COLON.CEOLIAC DISEASE
• Diarrhea reflects increased water content of the stool, whether due to impaired
water absorption and/or active water secretion by the bowel.
• In severe infectious diarrhea, the number of stools may reach 20 or more per day,
with defecation occurring every 20 or 30 minutes. In this situation, the total daily
volume of stool may exceed two liters, with resultant volume depletion and
hypokalemia.
• Most patients with acute diarrhea have three to seven movements per day with
total stool volume less than one liter per day.

6. Definition of dysentery
• Dysentery is an inflammatory disorder of the intestine,
especially of the colon, that results in
severe diarrhea containing blood and mucus in
the feces with fever, abdominal pain,and rectal tenesmus (a
feeling of incomplete defecation), caused by any kind
ofinfection.
• It is a type of gastroenteritis.

7. dysentery
Bacillary dysentery-diarrhea,loose, mucous bloody
stool /fever, pain abdomen- stool--- plenty of pus
cells and RBCs– Rx- antibiotis-COTRIMOXAZOLE/
cipro/oflo/ levofloxacin,
Amoebic dysentery- E. histolytica- ( abdomen pain,
loose,mucoid stool at late stage- blood mixed
mucoid stool)- d/d- bacterial dysentery/
ulcerative colitis.- diagnosis- stool-re/me,
treatment-metronidazole/ tinidazole/ ornidazole

8. pathogenesis
• Each specific pathogen has its own mechanism or pathogenesis, but in
general the result is damage to the intestinal lining, leading to the local or
systemic inflammatory immune response. This can cause elevated
temperature, painful spasms of the intestinal muscles (cramping), swelling
due to water leaking from capillaries of the intestine (edema), and further
tissue damage by the body's immune cells and the chemicals,
called cytokines, they release to fight the infection. The result can be
impaired nutrient absorption, excessive water and mineral loss through
the stools due to breakdown of the control mechanisms in the intestinal
tissue that normally remove water from the stools, and in severe cases the
entry of pathogenic organisms into the bloodstream.
• Some microorganisms – for example, bacteria of the genus Shigella –
secrete substances known as cytotoxins, which kill and damage intestinal
tissue on contact. Viruses directly attack the intestinal cells, taking over
their metabolic machinery to make copies of themselves, which leads to
cell death.

9. GENERAL APPROACH
• CLINICAL AND EDIDEMIOLOGICAL HISTOTRY
• CLINICAL ASSESSMENTS- assessment of dehydration- dry
tongue, skin turgor, shrunken eye, amount of urine output,
blood pressure measurement, capillary filling test.
• Investigations– stool r/e, stool c/s, blood for- CBC,
ELECTROLYTE, UREA CREATININE, MALARIA PARASITE.
• MANAMENT- isolation- regardeless of cause of dirrhea,
fluid and electrolyte replacement, antibiotics,anti-amoebic,
anti-helmenthics, anti-emetics, anti-pyretics,anti-viral anti-
fungal,anti-histamine, anti- motility agent,

10. Acute diarrhea
• Very common presenting problem-in clinical practice / in
community.
• One of the most important public health problem
• The mod-of transmission- fecal-oral route.
• Common causes are- bacterial toxins,infection, viral ,
protozoal infections and parasitic infestations.
• Other causes may be non- infectious agents.
• Principle of treatment=fli Clostridium perfringens Multiplies
in food Produces toxins in SI after contaminated food is
eaten ud and electrolyte replacement, rest, avoid
contamination, antiboitics/ anti-diarrheal, anti-emetics,
anti-spasmodics, anti-hiatamine.

11. Causes
• Infectious- most- common-bacterial/protozoal
• Non-infectious- toxins/drugs
• Psychological- anxiety
• Self-Induced- laxatives

12. Noninfectious diarrhea
• Drugs- other drugs
• Antibiotic associated diarrhea-kills normal flora
• Food allergies
• Gastrointestinal diseases such as inflammatory bowel disease
• Other disease states such as thyrotoxicosis and the carcinoid
syndrome.
• Ischemic colitis –
– acute lower abdominal pain preceding watery, then bloody diarrhea;
– acute inflammatory changes in the sigmoid or left colon while sparing
the rectum
• Toxins –
– organophosphate insecticides
– amanita and other mushrooms;
– arsenic

13. Infectious-diarrhea
• Food poisoning-staphylococcal, shigellosis ,
salmonellosis
• Acute gastro-enteritis
• Cholera
• Travelers' diarrhea
• Giardiasis
• Amoebiasis
• Viral diarrhea
• Helminthiasis
• Antibiotic associated diarrhea-

14. RISK PERSONELS
1. Travelers - enterotoxigenic or enteroaggregative
Escherichia coli, Campylobacter, Shigella, Giardia
2. Consumers of certain foods -
– Salmonella, Campylobacter, or Shigella from chicken
– enterohemorrhagic E. coli (O157:H7) from undercooked
hamburger
– Bacillus cereus from fried rice or other reheated food
– Staphylococcus aureus or Salmonella from mayonnaise or
creams
– Salmonella from eggs
– Listeria from uncooked foods or soft cheeses
– Vibrio species, Salmonella, or acute hepatitis A from
seafood, especially if raw.

15. RISK PERSONELS
3. Immunodeficient persons
– primary immunodeficiency (e.g., IgA deficiency, common variable
hypogammaglobulinemia, chronic granulomatous disease)
– secondary immunodeficiency states (e.g., AIDS, senescence,
pharmacologic suppression)
4. Daycare attendees and their family members
5. Institutionalized persons- HEALTH CARE PERSONS

16. Infectious diarrhoea may be associated with
systemic manifestations
– Reiter's syndrome - arthritis, urethritis, and
conjunctivitis may accompany or follow infections
by Salmonella, Campylobacter, Shigella, and
Yersinia.
– Hemolytic-uremic syndrome - enterohemorrhagic
E. coli (O157:H7) and Shigella

17. Common bacteria causing diarrhea
• E.coli
• Compalobacter jejunu
• Shigella (DYSENTERAI, SONNEI)
• Salmonella
• VIBRIO CHOLERA
• VIBRIO-PARAHEMOLYTICUS(SEA FOODS)
• BASILUS CEREUS
• YARSINIS

18. COMMON VIRUS CAUSING DIARRHEA
• ROTA VIRUS
• ASTRO VIRUS
• ADENO VIRUS
• CORONA VIRUS
• ENTERO-VIRUS

19. OTHER COMMON INFECTIOUS AGENTS
OTHER THAN BACTERIA AND VIRUS
• E.HYSTOLYTICA,GIARDIA LUMBRIA(protozoal)
• TRIGHURIASIS ,ROUND WORM( helminthes)
• FUNGAL- (CRYPTOSPORIDIUM , CANDIDA)
• OTHER HELMINTHS- H. NANA

20. Viral diarrhea
• Causes Acute Diarrhoea:
• Common Causes of Acute Diarrhoea Infection
– highly contagious Viral gastroenteritis
Rotavirus Usually cause explosive, watery
diarrhoea Typically last only 48-72hrs Usually
no blood and pus in stool

21. Bacterial diarrhea
cholera
• Caused by vibrio-cholera- survives 2 weeks in fresh water and 8 weeks in salt water
• Causes- Acute watery diarrhea
• Clinical features-severe watery diarrhea(rice-water ) without colic ,with vomiting , intense
dehydration with muscular cramps ,low out put urine and features of shock.
• Epidemic in many part of worlds- India, Africa
• Transmission-feco-oral-route- contaminated foods/waters
• Diagnosis- hx of epidemic outbreak, stool test-dark field microscopy-shows –shooting star –motility
of v. cholerae.
• Other Ix- electrolyte, urea /creatinine, stool culture, blood CBC,
• Should notify– epidemiology department
• Management-
• fluid and electrolyte REPLACEMENT, ASSESSMENT OF DEHYDRATION
• ORS, IV FLUIDS ( RINGER LACTATE-BEST/ NORMAL SALINE)-5-6 LITER/24 HOUR-TOTAL 50 LITRES-
OVER-5- 7 DAYS
• TETRACYCLINE CAP , OXY TETRACYCLINE INJ.
• CIPROFLOXACIN 1 GRAM, DOXYCYCLINE 3OO MG SINGLE DOSE- MAY HELP .
• PREVENTION- strict- maintaining of personal hygiene and sanitation, cholera vaccine, health
education, proper waste disposal , avoid contamination, clean drinking water.

22. Food poisoning/ acute gastroenteritis
• Acute -Gastro-enteritis- food poisoning, other infectious agents/toxins
• Food Poisoning Brief illness cause by toxins produced by bacteria Cause
abdominal pain, vomiting , secrete high amount of water – diarrhoea
Some bacteria produce toxins in food before intake or in intestine after
food is eaten Symptoms usually appear within several . Hours
• Staphylococcus aureus- common cause Produces toxins in food before it is
eaten Usually food contaminated left unrefrigerated overnight
• Clostridium perfringens Multiplies in food Produces toxins in SI after
contaminated food is eaten
• c/f– profuse vomiting, Fever the diarrhea with discomfort in abdomen-
bood cbc- leucocytosis
• Tratment= antiemetics/ fliud and electrolytes/ iv fluids/ antboitic-
ciprofloxacin or ofloxacin + metronidazole or tinidazole

24. INVESTIGATIONS
• Stool R/E, M/E
• Stool culture
• Serologic Ix- for certain toxins, virus, parasites
• Blood CBC, electrolyte, urea, creatinine,RBS
• IF STOOL-REPORT- NORMAL and diarrhea persistent
• Sigmoidosopy, colonoscopy,usg, CT/MRI- TO SEE CD
/UC, OR SURGICAL –DISODERS-DIVERCULITIS, SCHEMIC
BOWEL DISEASE,PARTIAL OBSTRUCTION
• HIV-SCREENING
• TB-antibody, serum deaminase
• If all are normal- IBS.

25. INTEGRATED MANAGEMENT
1.Counseling about the nature of disease and course
To patient and patient party- very important- part.
2. Proper assessment of dehydration and Isolation of the
patient/ concern for epidemic outbreaks
3. Maintain – infection prevention-
4. Fluid replacement-judicial in children, with other
comorbidities- heart disease BP. Children.
5. Combine antibiotics– cipro/oflo+ metronidazole/tinidazole
+ albendazole
6. Adjunctive –codiene/ ondacetrone, h2 blockers.
Antispasmodics, anti-histamine- avomine,antimotility-
(loperamide)
. If necessary- anti-viral/ anti-fungal- agent