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Ovid: Oxford Handbook of Tropical Medicine

Editors: Eddleston, Michael; Pierini, Stephen; Wilkinson, Robert; Davidson, Robert Title: Oxford Handbook of Tropical Medicine, 2nd Edition Copyright ©2005 Oxford University Press (Copyright 2005 by M. Eddleston, S. Pierini, R. Wilkinson, and R. Davidson) > Table of Contents > Chapter 2 > Chapter 2D – Diarrhoeal diseases > Introduction Introduction Diarrhoea is defined as the passage of abnormally loose or fluid stools more frequently than normal. Normal bowel habit varies greatly from person to person, but recent onset of 3 or more liquid or loose stools per day is considered abnormal. Infective diarrhoea is the second highest cause of death due to inection in the world, with ~3–4 million fatalities each year. 80% of deaths are in children under 2 yrs, specifically during and shortly after the introduction of complementary foods between 6–12 months. Breastfeeding, especially exclusive breastfeeding, confers significant protection against intestinal infections. Repeated attacks of diarrhoea initiate a vicious cycle of malnutrition, reduced immunity, and more intestinal infections. An accurate history is vital for all cases of diarrhoea, since it will give clues to the aetiology and severity of disease. Include in the past medical history any similar episodes and any current medication. The treatment of most diarrhoeal episodes depends on treating and preventing dehydration regardless of the aetiology of the infection. Antimicrobials are only recommended for dysentery and cholera, and for severe episodes with laboratory diagnosis in certain vulnerable groups (see below). Symptomatic antidiarrhoeal agents should be avoided in young children. Some key questions to be asked

  • How long has the diarrhoea been present?
  • Is (or was) there fever or other systemic symptoms?
  • What is the stool like — specifically is there blood (bright red or dark) and/or mucus?
  • How frequent are the motions?
  • Is there any abdominal pain — where?
  • Is there a sense of tenesmus (incomplete emptying following defecation)?
  • Has the patient vomited — how much, when, what?
  • Has the patient been in contact with anyone with similar symptoms?
  • Have they eaten or drunk anything unusual prior to the onset of symptoms?
  • Is anyone else in the family ill?
  • Is there a history of recent travel? Where?
  • Has the patient been exposed to malaria?

In examining the patient, one should look for signs of dehydration and malnutrition, as well as for clues to determine the disease aetiology. P.119
Classification of diarrhoea It is useful to subdivide diarrhoeal diseases according to presence or not of blood in the stool, since the causative agents are largely different, but be aware that both shigellosis and Campylobacter infections may present as acute watery diarrhoea. Here we shall divide the diseases into acute diarrhoea with blood (dysentery) and acute diarrhoea without blood. Diarrhoea that continues more than 14 days is considered persistent or chronic and additional pathological conditions need to be considered and this condition is accorded a separate section. Antimicrobial drugs In the majority of cases, symptoms of diarrhoea improve with treatment of dehydration alone, without the need for antibiotics. In certain circumstances, however, antimicrobial drugs may be beneficial. These include:

  • Bloody diarrhoea (dysentery) that does not improve after 3 days of rehydration treatment. If a specific cause is found it should be treated appropriately (see relevant section below). If no cause can be found, an antimicrobial effective against Shigella should be used in the first instance.
  • Cholera with severe dehydration: any suspected case of cholera should be treated with an effective antimicrobial and control agencies notified.
  • Laboratory-proven symptomatic cases of G. intestinalis infection that do not improve after 3 days of ORS therapy should be treated with an antimicrobial.
  • Laboratory-proven enteropathogenic E. Coli infections respond to antibiotics and should be used in vulnerable hosts such as young babies.
  • Traveller’s diarrhoea in adults: duration is reduced when treated with an antibiotic such as ciprofloxacin.

Investigations For general assessment in a hospital setting or if diarrhoea continues beyond 2–3 days include Hb, FBC, U&E, and glucose. However, most uncomplicated cases of diarrhoea can be managed without any laboratory tests. Stool culture and microscopy are often requested but few centres can offer diagnostic tests for all enteropathogens; mixed infections are common; single-stool cultures are insufficient for some pathogens; and results will often come back too late to influence management. Apart from investigation of outbreaks, surveillance, and research purposes, stool culture in uncomplicated cases should be limited to the exclusion of those pathogens for which antibiotic treatment is indicated (e.g. parasites, Shigella species, and Vibrio cholerae). If appropriate, do a blood film for malaria.

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