DEHYDRATION | APPROACH TO DIARRHEA

FLUID THERAPY:

1. Maintenance Therapy: for the first 10kg 100

ml\kg\day, for the second 10kg 50 ml\kg\day, for each
additional kg 20 ml\kg\day [HOLLIDAY-SEGAR METHOD
not suitable for neonates <14days]. We give 0.45% NS.
2. Deficit Repletion:
a. Calculated assessment:%dehydration= [(pre-illness wt -
illness wt)\ pre-illness wt] x 100%
b. Clinical assessment [see next table]. 1% dehydration=
10ml\kg.
3. Emergency: 20 ml\kg IV of NS bolus. We repeat the bolus
until clinical improvement.

DIARRHEA:

- Acute if <2 wks, persistent if 2–4 weeks, chronic if >4 wks.

1. Acute:
 90% infectious, 10% medications, toxic ingestions, ischemia, and other
conditions.
 Causative agents are divided into 5 categories:
 Travelers:
- Latin America, Africa, and Asia: Enterotoxoginic , entroaggresive E. Coli,
Campylobacter, Shigella, Aeromonas, norovirus, Coronavirus, and
Salmonella.
- Russia, Campers, backpackers, and swimmers in wilderness area:
Giardia.
- Cruise ships: norovirus.
 Consumers of certain foods:
- Chicken: Salmonella, Campylobacter, or Shigella.
- Undercooked hamburger: enterohemorrhagic E. coli (O157:H7).
- Fried rice or other reheated food: Bacillus cereus.
- Mayonnaise or creams: Staphylococcus aureus or Salmonella.
- Eggs: Salmonella.
- Uncooked foods or soft cheeses: Listeria.
- Seafood [especially if raw]: Vibrio species,
Salmonella, or acute hepatitis A
 Immunodeficient persons:
- AIDS: Mycobacterium species, viruses
[cytomegalovirus, adenovirus, herpes
simplex], parasites [(Cryptosporidium,
Isospora belli, Microsporida, and Blastocystis
hominis].
- Hemochromatosis: Vibrio species and Yersinia
[avoid raw fish]
 Daycare attendees:
- Shigella, Giardia, Cryptosporidium and
rotavirus
 Institutionalized persons: C. difficile.
 Management:
- Indications for evaluation include: profuse diarrhea with dehydration,
grossly bloody stools, fever ≥38.5°C, duration >48hrs w\o
improvement, recent antibiotic use, new community outbreaks,
associated severe abdominal pain in patients >50 years, and elderly
(≥70 years) or immunocompromised patients.
- Work up:
 Cultures for bacterial and viral pathogens.
 Direct inspection for ova and parasites.
 Immunoassays for certain bacterial toxins [C. difficile], viral
antigens [rotavirus] and protozoal antigens [Giardia, E. histolytica]
- Persistent diarrhea is commonly due to Giardia, others [C. difficile
(especially if antibiotics had been administered), E. histolytica,
Cryptosporidium, Campylobacter].
- If stool studies are unrevealing flexible sigmoidoscopy with
biopsies and upper endoscopy with duodenal aspirates and biopsies.
- Treatment:
 Fluid and electrolyte replacement: ORS or IVF [especially infants,
elderly and if cannot tolerate oral]
 Antimotility and antisecretory agents: moderately severe
nonfebrile and nonbloody diarrhea [avoid w\ febrile dysentery].
 Antibiotics:
 Rx empirically; febrile dysentery [ciprofloxacin (500 mg bid for 3–5 d)], suspected giardiasis [metronidazole (250 mg qid
for 7 d)].
 Immunocompromised, mechanical heart valves, recent vascular grafts, elderly  Antibiotic coverage is indicated,
whether or not a causative organism is discovered.
 Antibiotic prophylaxis is only indicated for certain patients traveling to high-risk countries [ciprofloxacin or rifaximin].