Diarrhoea

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ACUTE DIARRHOEAPassage of 3 or more watery stools per day for less than 14 days.

Clinical Features

SIGNS AND SYMPTOMS

  • Watery diarrhea +/- abdominal pain

INVESTIGATIONS

  • Full Blood Count
  • Stool analysis
  • Urea, Electrolytes + Creatinine

Treatment 

NON-PHARMACOLOGICAL

  • Hygiene; washing hands regularly
  • Avoid taking foods that seem spoiled/contaminated
  • Take a lot water when passing loose stool to rehydrate
  • Seek medical intervention when passing loose stool more than three times a day as well as when passing blood stool
  • Take a solution of sugar and salt to retain lost minerals salts (more especially for children)
  • Eat heated foods
  • Drink boiled or chlorine treated water

PHARMACOLOGICAL

  • Doxycycline 300mg PO STAT
  • Mild dehydration/not vomiting: Give ORS
  • Moderate/severe dehydration/ vomiting/hypovolaemia: IV fluids
    • preferably Ringer’s Lactate
    • use Normal Saline if Ringer’s Lactate unavailable
  • Dysentery (fever/bloody stools/systemically unwell): Ciprofloxacin 500mg 12 hourly PO x 5 days

 

CHRONIC DIARRHOEA

Passage of loose stools > 3 times/day for > 4 weeks. Common presentation in HIV/AIDS patients.

Clinical Features

SIGNS AND SYMPTOMS

  • Diarrhea +/- abdominal pain

INVESTIGATIONS

  • Full blood count
  • Stool analysis
  • HIV test
  • Urea, creatinine and electrolytes

Treatment 

please refer to the acute diarrhoea section

Adults:

  • Replace fluids and electrolytes
    • Oral rehydration solution
  • If severe dehydration/hypovolaemia:
    • IV fluids, preferably Ringer’s Lactate treat underlying cause.
  • If HIV positive
    • ensure patient is on effective ART
    • Empiric treatment
    • Cotrimoxazole 1920mg PO 12 hourly for 14 days (to treat Isospora)
      • If no improvement on Cotrimoxazole, Metronidazole 2g po 24 hourly for 5 days (to treat Giardia).
      • If no improvement on Metronidazole, Albendazole 400mg every 12 hourly PO for 14 days (to treat Microsporidia)
    • Anti-motility agents
      • Loperamide 4mg initially then 2mg after each loose stool (maximum 16mg per day)
      • Alternative: Codeine Phosphate 30mg 8 hourly PO for 5 days

Avoid anti-motility agents in colitis/bloody diarrhoea – may precipitate toxic mega colon.

ACUTE GASTROENTERITIS IN CHILDREN

  • Passage of more than 3 loose stools in a day.

Causes 

  • Infection: majority are caused by viruses, bacteria, parasites, toxins, drugs
  • Malabsorption: e.g. lactose intolerance and Food Protein Induced Entero-Colitis Syndrome (FPIES)

Clinical Features

SIGNS AND SYMPTOMS

  • Shock
  • Vomiting
  • Diarrhoea
  • Failure to thrive
  • Abdominal pain

INVESTIGATIONS

  • Stool microscopy and culture
  • Random blood glucose
  • Blood gas
  • Urea, electrolytes, and creatinine
  • FBC

Treatment

  • Assess nutritional status. If malnourished, refer to malnutrition protocol
  • Assess dehydration and treat accordingly

Classification

Signs and Symptoms

Treatment

Severe Dehydration

Two or more of the following signs:

·       Lethargy/unconsciousness

·       Sunken Eyes

·       Unable to drink/drinks poorly.

·       Skin pinch goes back very slowly (≥2seconds)

PLAN C

Some Dehydration

Two or more of the following signs:

·       Restlessness/irritability

·       Sunken eyes

·       Drinks eagerly/thirsty

·       Skin pinch goes back slowly

PLAN B

No Dehydration

·       Not enough signs to classify as some or severe dehydration

PLAN A
  • Plan C: see severe dehydration protocol
  • Plan B: give 75ml/kg ORS over 4 hours
  • Plan A give ORS 5ml/kg after each loose stool.
  • Continue breastfeeding or give extra fluid.
  • Correct electrolyte imbalances.
  • Zinc 10mg PO 24 hourly < 6 months and 20mg if > 6months old for 10 days.
  • ONLY give antibiotics if bloody diarrhoea or if child is toxic.
  • Ciprofloxacin 10mg/kg PO 12 hourly for 5-7 days or Ceftriaxone 25 mg -50mg/kg IV 24 hourly for 5 days if not tolerating orally.

DO NOT give antiemetic’s or anti-motility drugs in children.

Complications 

  • Acute Kidney injury
  • Electrolyte imbalance
  • Haemolytic Uraemic Syndrome (HUS)

REFERRAL

Persistent diarrhea not responding to treatment

 

DYSPEPSIAMeal related non-specific abdominal discomfort and pain.

Clinical Features

SIGNS AND SYMPTOMS

  • Heart burn or epigastric burning pain

INVESTIGATIONS

  • Only refer for gastroscopy if not improving on anti-acid treatment

Treatment

NON-PHARMACOLOGICAL TREATMENT

  • Advise patient to avoid hot spices, alcohol, smoking, tobacco, carbonated drinks, NSAIDs and Aspirin
  • Eating foods rich in proteins to promote healing
  • encourage patient to take regular meal
  • Do not eat something heavy after staying long time without eating something

PHARMACOLOGICAL

  • Chew 2 magnesium trisilicate tablets 6 hourly or more frequently as required for 7 days.

Alternatively:

Omeprazole 20mg at night for 4 weeks or

Ranitidine 300mg at night or 150mg 12 hourly for 4 weeks or

Cimetidine 400mg 12 hourly or 800mg at night for 4 weeks