Diarrhoea

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Signs and Symptoms

In addition to diarrhoea, there may be:

  • Fever
  • Abdominal pain
  • Vomiting
  • Dehydration (mild or severe)
    • No dehydration: The patient does not show enough signs to classify as moderate or severe dehydration
    • Some dehydration: The patient has two or more of the following signs:
      • Restlessness
      • Irritability
      • Sunken eyes
      • Dry mouth and tongue
      • Absence of tears
      • Thirsty, drinks eagerly
    • Severe dehydration: The patient is classified as having severe dehydration if there are two or more of the following signs:
      • Lethargic or unconscious; floppy
      • Absence of tears
      • Very dry mouth and tongue
      • Very thirsty, drinks poorly or unable to drink
      • Pinched skin goes back very slowly
      • Absent radial pulse
      • Low blood pressure.

Investigations

Investigations are necessary if the diarrhoea lasts more than one week, i.e.,

  • Stool microscopy
  • Culture and drug susceptibility

Treatment

  1. Fluid replacement

Fluid therapy (See the section on Cholera)

  1. Drugs

In chronic diarrhoea where the cause has not been found:

  • Loperamide 4mg Stat, then 2mg per loose stool (do not exceed 16mg in 24 hours)

NB: Any infective causes should be treated according to antimicrobial sensitivity 

Persistent/ Chronic Diarrhoea

Causes include:

  • Infections such as giardia, cryptosporidium, lsospora belli and microsporidia in AIDS patient.
  • Colonic lesions such as carcinoma, Crohn's disease and ulcerative colitis
  • Coeliac disease, Tropical sprue, Chronic pancreatitis
  • Pseudo membranous colitis
  • Thyrotoxicosis
  • Diabetes

Signs and Symptoms

  • Diarrhoea, bloody diarrhoea or steatorrhoea
  • Abdominal pain
  • Weight loss
  • Anaemia

NB: Persistent and chronic diarrhoea may be associated with vomiting

Investigations:

  • Stool microscopy, culture and sensitivity
  • Special tests may be needed for certain parasites such as cryptosporidium, isospora and microsporidia
  • Rectal/jejunal biopsy
  • Barium enema
  • Full blood count

Treatment: Treat infective causes 

  1. Fluid therapy – Oral fluid use should be stressed except for patients presenting with severe dehydration in whom intravenous fluids should be However, even with severe dehydration, oral fluids should be given concurrently. Fluid management is as for cholera
  2. Antidiarrheal agents
    • Loperamide 4mg start then 2mg every after loose stool
    • Nitazoxanide 500 mg tablets three times a day with food for 3 days

Treat specific causes such as:

  • Giardia – Metronidazole 400mg 8 hourly orally for 7 days
  • Cycloisospora Belli – Co-trimoxazole 960mg four times daily orally for 10 Give Pyrimethamine for sulpha-allergic patients. Recurrences tend to occur. In case of recurrence, refer to the experts.
  • Cryptosporidia – Nitazoxanide 500 mg tablets three times a day with food for 3 Combination antiretroviral therapy (cART) with immune reconstitution is the main line of management.