Definition, Treatment and Management of Diarrhea

Introduction

 Diarrheal diseases are a collection of diseases caused by multiple viral, bacterial, and parasitic organisms that share the common symptom of diarrhea. The diarrheal diseases cholera, rotavirus, shigellosis, and typhoid are also profiled separately, but we have grouped them together with other forms of infectious diarrhea in this profile to discuss general diarrhea treatments. Irrespective of the underlying cause of the diarrhea symptoms, diarrheal diseases can lead to severe dehydration or even death when left untreated. Diarrheal diseases affect people of all ages throughout the world.

Definition

 Diarrhea, is as the passage of three or more loose or liquid stools per day

Causes

Diarrheal disease can be caused by a variety of pathogens including viruses, bacteria, and parasites. The relative frequency of each of these organisms as the cause of diarrhea varies significantly geographically.

Bacterial	Viral	Parasitic
Campylobacter Cholera ETEC Shigellosis Typhoid	Rotavirus            Calciviruses           Noroviruses       (e.g. Norwalk virus)	Amoebic dysentery (e.g Entamoeba hystolicai)   Cryptosporidium Giardia

Pathogenesis

 Infectious organisms that cause diarrhea are primarily transmitted by the oral-fecal route, such as when fecal matter contaminates food or water or from person-to-person contact in situations with poor hygiene. Diarrhea is caused by poor absorption of fluids in the large intestine or from increased secretion of water into the small intestine, resulting in excess fluid in the stool.

Sign and symptoms

The signs and symptoms occur 2- 3 days after invasion of microorganism

·         Fever is low or absent

·         The disease develop in three stages

• Acute watery diarrhea - caused by secretion of a toxin that disrupts the balance of electrolytes in the intestine resulting in excess water secretion.
• Acute bloody diarrhea - primarily caused by bacteria that invade the intestinal lining resulting in damage.
• Persistent diarrhea – diarrhea episode that lasts for more than 14 days commonly seen in children with poor nutrition and a history of diarrheal disease.

 Management

Clinical picture

Ø  Stage one

·         Profuse watery stool

·         Soon fecal matter disappears followed by clear fluid with mucous and rice water appearance stool

·         Vomiting at first food but later rice water vomitus

·         Severe cramps in the abdomen develops due to loss of salt

Ø  Stage two

·         Collapse due to dehydration

·         The body becomes cold, dry skin and inelastic

·         Blood pressure is low or unrecordable

·         Anuria and shock

Ø  Stage three

·         Diarrhea decreases

·         General condition improves

·         Isolate the patient in a temporary unit

·         Give intravenous fluid (Ringers lactate) in order to restore hydration (treat dehydration according classification of dehydration (Care of Diarrhea Diseases)

·         If possible take rectal swab

 Give drugs:

·         Doxycycline 300mg as a single dose

·         Erythromycin500mg tds for 7 days

·         Treat patient in cholera bed with the central hole through which continuous stool can pass into the bucket containing disinfectant

·         Send information to the district authority

·          Keep accurate record of all cases, their progress and report to the district authority every day

·         Nurse the patients as other sick patients

·         Adhere to standard precautions in infection prevention and control when caring cholera patients

Prevention and Control Measures of Fecal Oral Diseases (Diarrhea)

Prevention of fecal oral diseases depends on breaking the fecal oral transmission cycle

Ø  The following are general prevention and control measures of fecal oral diseases

·         Improve methods of stool disposal – Use of properly constructed latrines

·         Hand washing facilities should be provided outside toilets

·         Fly control by proper refuse disposal, feces disposal and covering latrines

·         Proper cooking and handling of food

·         Protection of water sources

·         Boiling of drinking water

·         Wash hands after attending to toilet, before food preparation and before eating

·         Food handlers should be routinely screened and treated if necessary

·         Proper washing of fruits before eating

·         Find out the source of the diseases and transmission

·         Early diagnosis and proper treatment

·         Admit diarrhea cases in a special unit

·         Give prophylaxis (doxycycline 300mg) to all members or contacts of the patients

·         Conduct continuous monitoring of all aspects of the disease including collecting of the disease morbidity and mortality rates

·         Burial of diarrhea cases should be supervised by medical personnel

·         Report to the District Medical Officer (DMO) if there is an outbreak of cholera

·         Working with the village government in tracing cholera cases and assisting in educating the community

Health education to the community on:

·         Proper use of latrine by all household members in a clean manner

·         Importance of boiling drinking water

·         Importance of hand washing after attending toilet, before food preparation and before eating

·         Protecting food and eating utensils from flies

·         Food hygiene and eating food while hot

·         Cleaning the surroundings to destroy flies breeding places

·         Mode of spread of cholera and its prevention

UNICEF and WHO recommend a seven point plan to improve diarrheal disease control, focusing on:

1. Fluid replacement to prevent dehydration
2. Zinc treatment
3. Rotavirus and measles vaccinations
4. Promotion of early and exclusive breastfeeding and vitamin A supplementation
5. Promotion of hand washing with soap
6. Improved water supply quantity and quality, including treatment and safe storage of household water
7. Community-wide sanitation promotion 

Complications

·         Dehydration and electrolytes imbalance

·         Malnutrition

·         Shock

·         Death

Summary

Acute diarrhea is a common problem worldwide, with high morbidity and mortality in high-risk groups, such as the very young, older adults, and immune compromised individuals. Diagnostic studies are warranted for patients with fever or bloody diarrhea, or if the affected individual is immune compromised. Prevention of dehydration is the most important therapeutic intervention for the management of individuals with acute diarrhea. Oral hydration is preferred in most cases.

References

WHO Diarrhea Disease Fact Sheet.

WHO and UNICEF (2009) Diarrhea: Why children are still dying and what can be done.

Allender, J, Spradley, B. (2001). Community health nursing: Concepts and practice fifth edition. New York Baltimore: Lippincott Philadelphia.

 Basavanthappa B, (2006) Community health nursing second edition New Delhi: Jaypee brothers

Byrne,M, Bennett,F (1986). Community Nursing in develping countries: A manual for the community nurse second edition. Great Britain: Oxford University

Heymann D. (2008). Control of communicable diseases manual nineteenth edition. Washington DC: WHO

 Ngatia, P, Tiberry,P, Oirere,B, Rabar,B, Waithaka.M. (2008) Community health third edition. Nairobi: AMREF