Diarrhea is defined as increased frequency of defection (more than 3 per day) with excessive or abnormally loose consistency. Stool weights more than 200g/day are sometimes used to define diarrhoea but in the absence of abnormal consistency, weight alone is not an ideal indicator as bowel weight is influenced by high fiber intake.

Most diarrhea are mild and resolve in a few days. Sometimes, it can be severe and prolonged leading to loss of fluid and electrolytes (sodium, chloride, potassium, and bicarbonate) causing dehydration. Dehydration, if not treated on time, can lead to kidney failure and even death.

There are five types of diarrhoea defined by mechanism

• Osmotic diarrhoea – due to large amount of poorly absorbed solutes in the bowel lumen that inhibit normal water and electrolytes absorption
• Secretory diarrhoea – due to increased secretion of water and electrolytes in the bowel loop because of abnormal ion transport
• Exudative or Inflammatory – due to disruption of mucosal barrier in in the bowel lumen secondary to infection
• Steatorrhoea – due to pancreatic insufficiency or bile acid deficiency. Presence of excess fat in the in feces, stool have oily appearance and foul smelling
• Motility related diarrhoea – due to impaired motility in the bowel lumen

Diarrhoea can be defined as acute or chronic depending upon the duration of symptoms. Acute diarrhoea lasts less than 4 weeks whereas chronic diarrhoea lasts more than 4 weeks.

Causes

Infections are common cause of diarrheal disease in underdeveloped countries like Nepal.

• Infection: Consumption of contaminated food and water can cause diarrhea.
  • Virus- Rotavirus, Norovirus
  • Bacteria – Salmonella, Shigella, Campylobacter, E Coli, Vibrio Cholera..

E coli (enterotoxigenic) is the most common cause of traveler’s diarrhoea

Cholera is prevalent in the places with poor sanitation and often has

epidemic outbursts with high mortality in parts of underdeveloped countries

Protozoa/Parasites – Giardia, entamoeba, Cryptosporidium, Cyclospora, Microspora

• Gut/intestinal problems: Example – irritable bowel syndrome, ulcerative colitis
• Medications- like antibiotics, antacids; laxatives, alcohol can cause diarrhea.
• Food intolerance
• Endocrine (Hormone) related: overactive thyroid gland, diabetes related intestinal nerve damage
• Malabsorption syndrome- problem with food digestion

Symptoms

• Loose or watery stool more frequently than normal for person
• Abdominal cramps or pain
• Bloody stool with some infections
• Fever and headache
• Leg cramps
• Nausea and vomiting
• Symptoms of dehydration-
• Mild dehydration: thirst, restlessness or irritable behavior,
• Severe dehydration: Impaired consciousness, reduced amount of urine, cold and moist extremities.

When to seek Medical Care/Red Flags

• Diarrhea with fever
• Severe or profuse diarrhea
• Diarrhea lasting more than a day or two
• Diarrhea with severe abdomen pain
• Bloody diarrhea (dysentery)
• Diarrhea with signs of dehydration- thirst, reduced urine, dizzy, confusion
• Diarrhea in very young or old person
• Diarrhea after taking antibiotics
• Diarrhea in person with weak immune system like cancer,HIV or other chronic medical conditions
• Diarrhea after travel
• Diarrhea after recent hospitalization

Diagnosis

If you have diarrhea, you should consult your doctor.

The doctor will review your symptoms, your family and travel history and examine you to look for signs of dehydration like decreased skin elasticity, and sunken eyes, a rapid and weak pulse, low or unnoticeable blood pressure (shock).

Further test may be needed to find out cause of diarrhea and its effects on body.

• Stool test: to find cause of diarrhea
• Blood test
• Endoscopy: to check inflammation in colon (colitis).

Treatment

Mild diarrhea usually resolves on its own within few days without any treatment. If it is severe, it should be treated immediately. Methods of diarrhea treatment are:

• Plenty of fluids: Drinking a lot of fluid is necessary to prevent and treat dehydration. You should drink fluids more than you normally would and at least 200 ml after each episode of diarrhea. You should drink Oral Rehydration Solution along with water and other fluids to prevent from dehydration. In you are unable to drink in severe cases; fluid is administered through your veins as IV (intravenous) drip.
• Eating nutrient rich food: Although you might have decreased appetite, but still you have to eat small frequent and light meals. It is better to avoid fatty, spicy foods and sugary drinks.
• Medication:
• Over the counter anti diarrhoeal medicines like loperamide should not be uses as they can be more harmful.
• Diarrhea due to bacteria may need antibiotics which should be prescribed by your Physician.
• Medication suspected of causing diarrhea should be stopped.

Prevention

Hygiene and sanitary measures can help prevent diarrhea-

• Wash your hands thoroughly with soap and water before preparing and eating food or feeding others. Also wash hands after going to bathroom, changing diapers, touching dirt etc.
• Try to eat fresh and healthy food; wash and cook thoroughly
• Drink clean water
• Use clean dishes to prepare, store and eat foods
• Deworming regularly is essential especially in children where intestinal worms are common
• Keep your surroundings clean