Infective Diarrhoea

UNIT 1
Introduction
• Diarrhoea is defined as the passage of 3 or more loose or liquid stools per day (or more frequent
passage than is normal for the individual)
• Diarrhoea is NOT the frequent passing of formed tools nor is it the passing of loose, pasty stools by
breastfed babies.
• Diarrhoea is usually a symptom of an infection in the intestinal tract which can be caused by a
variety of bacterial viral and parasitic organisms.
• The infection is spread through contaminated food or drinking water, or from person to person as a
result of poor hygiene.

WHO-2024
Bristol Stool Chart
Clinical Workup of Diarrhoea

HISTORY: INVESTIGATIONS:
1. Stool characteristics 1. Where Appropriate: Stool, Blood and Imaging
2. Onset & Duration
3. Associated symptoms
4. Recent Travel

EXAMINATION: Possible Findings ASSESSMENT

1. Vital Signs 1. Classify Diarrhoea: Likeliest Aetiology and
Pathophysiology
2. Peripheral Signs
2. Exclude Red Flags & Severe Presentations
3. Abdominal Examination
4. Neurological Examination
History: Stool
Characteristics
• Watery diarrhoea: Often associated with
viral infections (e.g., norovirus, rotavirus).
•
• Bloody diarrhoea: More likely to be
bacterial (e.g., Shigella, Salmonella,
Camgpylobacter, or E. coli). Can be
associated with inflammatory changes.
•
• Mucus in stool: Typically seen with
bacterial infections, particularly with
invasive organisms like Shigella or
Campylobacter.
History: Onset &
Duration
• Acute diarrhoea: Generally
lasts less than 14 days,
which is highly suggestive of
infectious etiologies.
• Chronic diarrhoea: Lasts
longer than 14 days, which
may suggest persistent or
parasitic infections or non-
infectious etiologies
History: Associated Symptoms
• Abdominal Pain: Frequently observed with bacterial and parasitic infections, especially in cases involving Salmonella,
Shigella, or Campylobacter. Often more severe with invasive organisms or when there is colonic involvement.
• Nausea and Vomiting: Common in viral infections (e.g., norovirus, rotavirus), but may also be present in bacterial
infections like Staphylococcus aureus or Bacillus cereus.
• Fever: Mild to moderate fever is common in bacterial and parasitic infections (e.g., Shigella, Salmonella, Entamoeba
histolytica). High fever is often seen in invasive infections or with systemic involvement.
• Dehydration: Dehydration is a major concern with infective diarrhoea due to fluid loss.
Symptoms include:
• Dry mouth
• Reduced urine output
• Dizziness, hypotension
• Tachycardia
• Sunken eyes
• Skin tenting
• Severe dehydration may lead to hypovolemic shock in extreme cases
Possible Examination Findings: Vital Signs
• Fever → Suggests bacterial/parasitic infections (Shigella, Salmonella, Entamoeba histolytica).
• Tachycardia, Hypotension, Tachypnea → Signs of dehydration or sepsis.
• Fever + Bradycardia (Relative Bradycardia) → Consider Salmonella typhi (enteric fever).
Possible Examination Findings:
Peripheral Signs
Hydration Status:
• Mild dehydration (3–5% fluid loss) → Dry mucous
membranes, increased thirst.
• Moderate dehydration (6–9% fluid loss) → Sunken eyes,
reduced skin turgor, oliguria.
• Severe dehydration (>10% fluid loss) → Lethargy, weak
pulses, hypotension, cool extremities.
• Capillary Refill Time (>2 sec in moderate, >4 sec in severe
dehydration).
• Sunken fontanelles in infants.
Abdominal Examination
Inspection:
• Abdominal distension → Toxic megacolon (C. difficile colitis, severe Shigella).
• Visible peristalsis → Severe dehydration/malnutrition.
Auscultation:
• Hyperactive bowel sounds → Early infectious diarrhea (osmotic or secretory).
• Hypoactive/absent bowel sounds → Severe dehydration or paralytic ileus.
Palpation:
• Diffuse tenderness → Viral gastroenteritis.
• Localized tenderness (RLQ pain) → Consider ileocecal involvement (Yersinia, Salmonella, Entamoeba histolytica).
• Severe tenderness + Guarding/Rebound tenderness → Peritonitis (bowel perforation or toxic megacolon).
Percussion:
• Tympanic sounds → Suggestive of increased gas (bacterial overgrowth or severe diarrhea).
• Dullness in the flanks → Ascites (seen in severe Entamoeba histolytica).
Neurological Examination
(when indicated)
• Altered Mental Status (Lethargy, Confusion, Coma) → Severe
dehydration or electrolyte imbalances (hypokalemia,
hyponatremia).
• Descending Flaccid Paralysis → Clostridium botulinum toxin.
• Seizures (Hyponatremia, Hypoglycemia, Shigella Neurotoxicity) →
Seen in pediatric cases.
Investigations
Stool
• Culture: The gold standard for identifying bacterial pathogens (e.g., Salmonella, Shigella, E. coli, etc)
• Microscopic Examination of Stool: To identify parasites, ova, or larvae (e.g., Giardia, Entamoeba
histolytica, Cryptosporidium, Strongyloides).
• Stool Antigen Tests: To detect specific pathogens, such as Clostridium difficile, Giardia, or Rotavirus.
• Polymerase Chain Reaction (PCR)
Blood Tests:
• Full blood count (FBC):To check for leukocytosis, indicating infection or inflammation.
• U&E and renal function tests: To assess for dehydration and electrolyte imbalances.
• C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR): To assess inflammation.
Imaging
• Endoscopy or Colonoscopy (if indicated): In chronic or severe cases, or if there is suspicion of invasive
disease or other gastrointestinal pathology (e.g., inflammatory bowel disease).
Putting it all together: Assessment
Assessment: Aetiology
Viral Causes (e.g., Norovirus, Rotavirus, Adenovirus):
• Onset: Sudden onset of watery diarrhoea, vomiting, and nausea.
• Associated Symptoms: Fever and malaise.
• Duration: Typically self-limiting, lasting 1-3 days.
• High Risk Groups: Children and the elderly, particularly with rotavirus.
Bacterial Causes (e.g., Salmonella, Shigella, E. coli, Campylobacter):
• Onset: May begin with crampy abdominal pain followed by diarrhoea.
• Bloody diarrhoea: Seen with invasive organisms like Shigella, enterohemorrhagic E. coli (O157:H7).
• Fever: Common in bacterial infections, especially in invasive forms
• Complications: Bacterial infections can lead to systemic involvement (e.g., sepsis, toxic megacolon,
hemolytic uremic syndrome in the case of E. coli).
Assessment: Aetiology
Parasitic Causes (e.g., Giardia, Entamoeba histolytica, Cryptosporidium):
• Onset: Insidious and prolonged course, typically more gradual than bacterial causes.
• Diarrhoea: Can be watery, but often more persistent and associated with weight loss.
• Associated Symptoms: Abdominal bloating, gas, and fatigue.
• Duration: Chronic if untreated, with recurrent episodes.
Protozoal Infections:
• Giardiasis: Frequently causes foul-smelling, greasy stools and bloating.
• Amebiasis: Causes bloody diarrhoea and may present with liver abscesses
Assessment: Pathophysiology
Assessment: Specific Pathogens
Management
A. Hydration
• Mild to moderate dehydration: Oral Rehydration Solution
• WHO ORS or homemade (8 teaspoons of sugar and ½ teaspoon of salt in 1 liter of clean, boiled
water)
• Severe dehydration or shock: IV fluids
• Ringer’s lactate or normal saline bolus
• Maintain fluid balance and replace ongoing losses
B. Dietary Advice
• Continue feeding (BRAT diet: bananas, rice, applesauce, toast)
• Avoid dairy, fatty foods, caffeine, alcohol
• Zinc supplementation (10–20 mg/day for 10–14 days) in children
Management
C. Antibiotics
• Not needed for most viral diarrhoea (self-limiting).
• Bacterial causes (e.g., Shigella, Salmonella, Campylobacter, E. coli, C. difficile):
• Ciprofloxacin 500 mg BD x 3–5 days (adults)
• Azithromycin 500 mg once daily for 3 days (travelers’ diarrhea)
• Metronidazole/Vancomycin for C. difficile infection
• Parasitic causes (e.g., Giardia, Entamoeba): Metronidazole 500 mg TDS x 7 days

D. Symptomatic Treatment
• Antipyretics: Paracetamol for fever
• Anti-motility agents (e.g., Loperamide): Avoid if bloody diarrhoea or suspected C. difficile.
• Probiotics: May help in antibiotic-associated diarrhoea.

E. Monitoring & Prevention

• Prevent spread: Hand hygiene, safe food handling, proper sanitation.
• Vaccination: Rotavirus (children), cholera in endemic areas.
 Prevention and Public Health Measures
Personal Hygiene:
• Hand hygiene: Emphasize proper handwashing with soap and water, especially before eating and after using
the toilet.
• Safe food handling: Proper cooking of food, washing fruits and vegetables, and avoiding consumption of raw
or undercooked meat, seafood, or eggs.
• Safe drinking water: Ensure access to clean and safe drinking water.
Vaccination
• Rotavirus vaccination: Routine immunization of infants can prevent severe rotavirus gastroenteritis, a major
cause of childhood diarrhea.
• Typhoid vaccination: For populations at risk, such as travelers to endemic areas
Environmental Control:
• Water sanitation: Chlorination and filtration of drinking water to reduce the risk of waterborne diseases.
• Proper sanitation: Access to clean and hygienic toilets, and the safe disposal of human waste.
Health Interventions:
• Surveillance: Monitoring and reporting outbreaks of infectious diarrhea to track patterns and identify
affected areas.
• Education: Public health campaigns to raise awareness about the importance of hygiene, safe food
practices, and vaccination.
• Quarantine and isolation: In cases of highly contagious diseases (e.g., cholera or shigellosis),
implementing isolation and quarantine measures to prevent further spread.
• Antibiotic stewardship: In some cases, limiting unnecessary antibiotic use to prevent antimicrobial
resistance and reduce the impact of bacterial pathogens like C. difficile
Food Safety Regulations
• Regulation of food markets and food establishments: Enforcing hygiene and food safety standards in
food production and distribution channels to prevent contamination.
• Water Safety and Treatment: Promote the use of water treatment methods such as boiling, chlorination,
or filtration in communities with limited access to clean water.
References
1. World Health Organization (WHO). Diarrhoeal disease [Internet]. Geneva: WHO; 2024 [cited
2024 Mar 30]. Available from: [Link]
disease.
2. Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med. 2004;350(1):38-47.
3. Centers for Disease Control and Prevention (CDC). Infectious Diarrhea: Causes & Management
[Internet]. Atlanta: CDC; 2023 [cited 2024 Mar 30]. Available from:
[Link]
4. National Department of Health, South Africa. (2024). Primary Health Care Standard Treatment
Guidelines and Essential Medicines List: Chapter 2 – Gastro-intestinal Conditions with Supporting
NEMLC Report (Version 1.0). Retrieved from [Link]
content/uploads/2024/06/Primary-Healthcare-Chapter-2_Gastro-intestinal-conditions-with-
supporting-NEMLC-report_2020-4_Version1.0_24-[Link]
5. Ralston, S. H., Penman, I. D., Strachan, M. W. J., & Hobson, R. (Eds). Davidson’s principles and
practice of medicine (24th ed.)
References
1. Walker CL, Perin J, Katz J, et al. Diarrhea incidence in low- and middle-income countries in
children younger than 5 years: a systematic review. Lancet Infect Dis. 2013;13(9): 697-707.
2. Yared M, Gharehbaghi F, Wozniak S. Clinical evaluation and diagnostic work-up in infectious
diarrhea. J Clin Gastroenterol. 2014;48(4):297-305.
3. Finkelstein RA, Rowe B, Levine MM. Waterborne infections and diarrhea: epidemiology and
prevention. In: Ziegler A, editor. Textbook of Clinical Gastroenterology. 2nd ed. Elsevier; 2015. p.
567-586.
4. Simmonds N, Blatchford P. Infectious gastroenteritis: diagnosis and treatment. BMJ.
2016;354:i3340.
5. World Health Organization (WHO). Diarrhoeal [Link] at: [Link]
room/fact-sheets/detail/diarrhoeal-disease [Accessed April 2025].
Thank You!