Management of diarrhoea :-

Nikhil Bansal Roll

no. 067

2006 batch

Introduction in brief :-

• More than 5 million children under the age of 5 years die every year due to diarrhoea .

• In India, more than 1 million children get killed by this miserable disease known as diarrhoea .

Pathogen % of cases

Viruses Rotavirus 15 to 25%

Bacteria Enterotoxigenic Escherichia coli 10 to 20%

shigella 5 to 15%

Campylobacter jeijuni 10 to 15%

Vibrio cholerae 5 to 10%

salmonella 1 to 5%

Protozoans Cryptosporidium 5 to 15%

No pathogen

found- 20 to 30%

Pathogens frequently identified in treatment centres in children

Principles of management:-

Therapeutic measures may be grouped into :-• Rehydration(treatment of fluid

loss,shock & acidosis)• Maintenance of nutrition• Drug therapy

Rehydration :-

i) Intravenous rehydration –

Given when fluid loss>10% of the body weight OR 10 ml/kg/hr

Dhaka fluid :-

NaCl : 85 mM = 5g

KCl : 13mM = 1g

NaHCO3 : 48 = 4g

In 1 litre of water or glucose solution

• Ringer lactate by WHO :-Na : 130 mMCl : 109 mMK : 4 mMLactate : 28 mM

Volume equivalent to 10% of the body weight should be infused over 2 to 4 hrs

ii) Oral rehydration:-

Given if the fluid loss is just mild (7.5 to 10% of the body weight)

Rationale of ORS composition :-

• Oral rehydration possible only if glucose is added with salt helping glucose coupled sodium absorption

General principles:-

1. Isotonic or somewhat hypotonic(200 to 310 mOsm/L)

2. The molar ratio should not exceed 110mM

3. Enough potassium(15-25mM) & bicarbonates(8-12mM) must be provided

WHO recommends:-

• Na 90mM

• K 20mM

• Cl 80mM

• Citrate 10mM

• Glucose 110mM

(Total osmolarity of 310mOsm/L)

New formula of WHO–ORS:-

• Introduced in 2002 with low sodium & low glucose formulated by WHO

• Both sodium & glucose tend to increase the stool volume in higher concentrations & hence they must be reduced

• Ideally the total osmolarity should be 245mOsm/L

• Nacl : 75mM

• K : 20mM

• Trisod. Citrate : 65mM

• Citrate : 10mM

• Glucose : 75 Mm

(total osmolarity is 245mOsm/L)

Administration of ORS:-

• At ½ - 1 hr intervals• Initially body weight equivalent is given in

2-4 hours(5ml/kg/hr)• Intragastric drip is used in case of childrenSuper ORS:-Main aim is to reduce the stool volume other

than the rehydration taskAmino acids helping in sodium cotransport

are included viz. alanine & glycine

Maintenance of nutrition :-

Fasting decreases brush border disaccharide enzymes & reduce absorption of salt,water & nutrients

Nutruents like buffalo milk,boiled potato,rice,chicken soup,banana etc

Drug therapy:-

Choice of drug for pregnant women in dehydration – anti diarrhoeals like diphenoxylate-atropine,loperamide.

Oral rehydration salts is used as an alternative

Choice of drug for children in dehydration -

Pathogen

Drug given

Enterotoxigenic Escherichia coli

shigella

Campylobacter jeijuni

Vibrio cholerae

salmonella

Entamoeba histolytica

L.giardia

Nalidixic acid,cotromoxazole,ampicillin

Nalidixic acid , cotromoxazole, ampicillin,inj. gentamicin

Erythromycin, furazolidin,chloramphenicol,gentamycinFurazolidin,cotrimoxazole,tetracycline,erythromycin

Metronidazole,tinidazole,secnidazole

Metronidazole,tinidazole,secnidazole

Ampicillin,chloramphenicol