Biochemical

Aspect of
DIARRHEA

SUGAWARA.SOR.SISON.SECILLANO.SHOCKLEY
Objectives:
At the end of the discussion, the students must
be able to:
• Describe the sequence of various metabolic
changes observed in diarrhea,
• Evaluate nutritional and electrolyte status, and
state of hydration of the patient,
• Determine adequacy of the patient’s diet,
• And understand basic concepts of fluid
replacement and ORS.
Case A
• 10 month old
• Female
• 8kgs
• Diarrhea 4x in 1 day
• No vomiting
• Breastfed since birth
• 5 months old- lugaw with fish and vegetables
• Onset of diarrhea-stop breast feeding and solid
foods, instead giving am with sugar
• Condition: alert, good skin turgor, adequate
urine output
Case B PE
• Irritable
• 3 y/o
• 37°C
• Male
• CR: 100bpm
• 11kgs
• RR:20cpm
• Diarrhea 6x/day
• Sunken eyeballs,
• Vomiting 3x/day for 3 mouth and tongue
days were dry, poor skin
• Breastfed for 2months turgor, decreased urine
• Shifted to Bonna 1:2 output.
dilution • Abdomen was slightly
• 4 months old-solid food distended with
hypoactive bowel
• Onset of diarrhea- sounds.
lugaw • Serum eletrolytes:
• ↓Potassium
DIARRHEA
• Passage of abnormally liquid or
unformed stools at an increased
frequency.
• >200g/d
• Acute <2 weeks
• Persistent 2-4 weeks
• Chronic >4 weeks (Harrison)
• Disturbed intestinal solute transport
and water absorption (Kliegman)
MECHANISMS OF DIARRHEA (Nelson textbook of pediatrics)

Primary Mechanism Defect

secretory Decreased absorption,
Increased secretion,
Electrolyte transport
osmotic Maldigestion,
Transport defects ingestion of
unabsorbable substances
Increased motility Decreased transit time
Decreased motility Defect in neuromuscular unit, stasis

Decreased surface Decreased functional capacity

area
Mucosal invasion Inflammation, decreased colonic
reabsorption, increased motility
Metabolic Changes in GI function &
Motility
Irritated mucosa

↑secretion ↑motility
Strong propulsive
movements
Loose watery stool
 Alteration in fluid volume
↑secretion ↓absorption

Passage of loose watery stool

Loss of fluid volume

dehydration
 Isotonic dehydration
Balance deficit of water
and Na

Normal serum Na
Normal serum osmolality

hypovolemia
 Hypertonic dehydration
deficit of water and Na but
more of water

↑ serum Na
↑ serum osmolality

Dehydration (irritable)
 Hypotonic dehydration
Deficit of water and Na
but more of Na

↓ serum Na

↓ serum osmolality

Lethargic
 Metabolic acidosis
↓serum bicarbonate

↓arterial pH
Deep and rapid
breathing

Increased vomiting
Hypokalemia
Large losses of potassium ion in feces
Losses are greatest in infants

Manifestations
• general muscle weakness
• Cardiac arrhythmias
• Paralytic ileus
Case A Case B
• Diarrhea 4x in 1 • Diarrhea 6x/day
day • Vomiting 3x/day for 3 days
• Irritable
• No vomiting • Sunken eyeballs, dry
• Condition: mouth and tongue, poor
skin turgor, decreased
• alert, urine output.
• good skin turgor, • Abdomen slightly
• adequate urine distended
output • hypoactive bowel sounds.
• Decreased Serum
Potassium
Case A Assessment of Nutritional Status
10 month Compute for Ideal Body Weight (IBW)
old
8 kg female IBW in g = (age in months)(500) + birth weight*
1 day of IBW in g = 10 (500) + 3000g
diarrhea
without IBW in g = 8000 g or 8 kg
vomiting
alert
good skin
turgor
adequate
urine
output *Average birth weight of a Filipino infant (used when
birth weight is not given) = 3000g
Case A Assessment of Nutritional Status
10 month Anthropometry using Gomez Classification
old 𝐴𝑐𝑡𝑢𝑎𝑙 𝐵𝑜𝑑𝑦 𝑊𝑒𝑖𝑔ℎ𝑡
8 kg female 𝑥 100
1 day of 𝐼𝑑𝑒𝑎𝑙 𝐵𝑜𝑑𝑦 𝑊𝑒𝑖𝑔ℎ𝑡
diarrhea 8 𝑘𝑔
without 𝑥 100= 100 %
vomiting 8 𝑘𝑔
alert Weight for Age Status
good skin >120% Obese
turgor 101-120% Overweight
adequate 90-100% Normal
urine 75-89% First Degree malnutrition
output 60-74% Second Degree malnutrition
<60% Third Degree malnutrition
Case B Assessment of Nutritional Status
3 y.o., 11 kg Compute for Ideal Body Weight (IBW)
male
3 days of IBW in kg = (age in years) (2) + 8
diarrhea
(6x/day) with IBW in kg =3 (2) + 8
vomiting
(3x/day)
IBW in kg = 14 kg
Irritable
sunken
eyeballs
poor skin
turgor dry
tongue &
mouth
decreased
urine
output
 Assessment of Nutritional Status
Case B Anthropometry using Gomez Classification
3 y.o., 11 kg male
3 days of diarrhea 𝐴𝑐𝑡𝑢𝑎𝑙 𝐵𝑜𝑑𝑦 𝑊𝑒𝑖𝑔ℎ𝑡
(6x/day) with 𝑥 100
vomiting (3x/day)
𝐼𝑑𝑒𝑎𝑙 𝐵𝑜𝑑𝑦 𝑊𝑒𝑖𝑔ℎ𝑡
Irritable
sunken eyeballs
poor skin turgor 11 𝑘𝑔
dry tongue & = 78.57 %
𝑥 100
mouth
decreased urine 14 𝑘𝑔
output
slightly distended
abdomen with
hypoactive sound Weight for Age Status
Temp 37C >120% Obese
Cardiac Rate
100/min 101-120% Overweight
Resp Rate 20/min
Normal Na 90-100% Normal
Decreased K
75-89% First Degree malnutrition
60-74% Second Degree malnutrition
<60% Third Degree malnutrition
 Assessment of HYDRATION Status
Case A
11 months
old
8 kg female
1 day of
diarrhea
without
vomiting
alert
good skin
turgor
adequate
urine
output
Case B Assessment of HYDRATION Status
3 y.o., 11 kg
male
3 days of
diarrhea (6x/day)
with vomiting
(3x/day)
Irritable
sunken eyeballs
poor skin turgor
dry tongue &
mouth
decreased urine
output
slightly
distended
abdomen with
hypoactive
sound
Temp 37C
Cardiac Rate
100/min
Resp Rate
20/min Normal
Na Decreased K
Case A CYCLE OF MALNUTRITION
10 month old
& DIARRHEA
8 kgs female
1 day of
diarrhea
without
vomiting
breastfeeding
since birth
lugaw with fish
and vegetables
at 5 months
old
stopped
breastfeeding
& solid foods
at the onset of
diarrhea; gave
“am” with
sugar instead
Management and
Treatment
Case A Case B
-10 month Treatment of -3y/o, 11kgs,
old, 8kgs, diarrhea male
female Diarrhea(6x/day
One day according to ) and
diarrhea 4x classification: vomiting(3x/day)
for 3 days
At the onset • “Plan C: Treat Severe
of diarrhea, Dehydration Quickly” Patient has
the mother been given
stopped • “Plan B: Treat Some “lugaw” since
breastfeeding Dehydration with ORS” the onset of
and giving of diarrhea
solid foods • “Plan A: Treat Diarrhea Lab results:
and instead At Home” Normal sodium,
shifted to Decrease
giving “am” potassium
with sugar.
Oral Rehydration Therapy
• Consists primarily of NaCl and Glucose
• Developed by the WHO
• The transport of glucose and sodium across
the intestinal epithelium forces(via osmosis)
movement of water from lumen of the gut into
intestinal cells, resulting in rehydration.
• Glucose alone or NaCl alone would not be
effective.
ORS available in the pharmacy
contains:
Reduced grams/litre Reduced mmol/litre
osmolarity ORS osmolarity ORS

Sodium chloride 2.6 Sodium 75

Glucose, 13.5 Chloride 65

anhydrous
Potassium 1.5 Glucose, 75
chloride anhydrous
Trisodium 2.9 Potassium 20
citrate, dihydrate

Citrate 10

Total Osmolarity 245

HOMEMADE ORS (Oral
Rehydrating Solution)
Amount of ORS Solution given:

Mild Moderate

1st 4 hours 20ml/kg/hr 20ml/kg/hr

Next 6-8 hours 10ml/kg/hr 15-20ml/kg/hr

Case A Case B
-10 month -3y/o, 11kgs,
old, 8kgs, Replacement of male
female
One day
losses: Diarrhea(6x/day
) and
diarrhea 4x • Up to 2 years: 50- vomiting(3x/day)
for 3 days
At the onset 100ml after each
of diarrhea, loose stool Patient has
the mother been given
stopped • 2years or older: “lugaw” since
breastfeeding the onset of
and giving of
100-200ml after diarrhea
solid foods each stool Lab results:
and instead Normal sodium,
shifted to Decrease
giving “am” potassium
with sugar.
Case A Case B
-10 month Nutritional -3y/o, 11kgs,
old, 8kgs,
female
Support male
Diarrhea(6x/day
One day • Continue the diet of ) and
diarrhea 4x the child and in vomiting(3x/day)
for 3 days
At the onset addition to ORS.
of diarrhea, • Give foods that are Patient has
the mother rich in potassium and been given
stopped “lugaw” since
breastfeeding
zinc such as the onset of
and giving of bananas, avocado, diarrhea
solid foods soya beans, egg, Lab results:
and instead fish, lettuce, Normal sodium,
shifted to tomatoes in mashed Decrease
giving “am” potassium
with sugar.
form.
Case A Case B
-10 month -3y/o, 11kgs,
old, 8kgs, male
female Zinc Diarrhea(6x/day)
One day and
diarrhea 4x Supplements vomiting(3x/day)
• has been found to for 3 days
At the onset
of diarrhea,
reduce the duration
the mother and severity of Patient has been
stopped diarrheal episodes. given “lugaw”
breastfeeding
and giving of
• This can only be since the onset
of diarrhea
solid foods given for children 2 Lab results:
and instead months up to 5 Normal sodium,
shifted to years. Decrease
giving “am” potassium
with sugar.
Case A
At the onset
“Am”/rice water
of diarrhea, • Suspension of starch obtained by
the mother draining boiled rice.
stopped • Rice water has a long history of use in
breastfeeding treating diarrhea or other
and giving of gastrointestinal disorders in
Southeast Asian families
solid foods
and instead • Effective treatment for diarrhea,
shifted to because rice starch is rapidly
converted to glucose by pancreatic
giving “am”
amylase and brush border
with sugar. hydrolases.
Case
Case 1 A Breastfeeding in
At
At the
the onset
onsetof diarrhea
diarrhea, the
of diarrhea,
mother stopped • The infant should continue to be
the mother
breastfeeding
stopped breast-fed during an attack of
and giving of
breastfeeding diarrhea in addition to the ORS
solid foods and
and giving of and clean water.
instead shifted
solid foods
to giving “am” • Breast-fed children are less
and instead
with sugar. prone to diarrhea. Since the
shifted to
giving “am”
human milk has low buffering
with sugar.
capacity, stools of breast-fed
babies are acidic. Their E. coli
count is low, but that of
Lactobacillus bifidus is high.
 Case B
Intravenous Therapy -3y/o, 11kgs,
male
• Required only for patient with Diarrhea(6x/day)
severe dehydration. and
vomiting(3x/day)
• To ensure adequate electrolyte
for 3 days
replacement, some ORS solution
and zinc supplements should be Abdomen was
given as soon as the patient is able slightly distended
to drink, even while the initial fluid with hypoactive
requirement is being provided by bowel sounds.
intravenous therapy.
Preferred Solution: Ringer’s lactate Lab results:
solution Normal sodium,
Decrease
May be given 30-40meq/L KCl potassium
Case A Case B
-10 month Foods to -3y/o, 11kgs,
old, 8kgs, male
female avoid: Diarrhea(6x/day
One day • All dairy products ) and
diarrhea 4x vomiting(3x/day)
• Fatty food for 3 days
At the onset
of diarrhea,
• Foods high in
Patient has
the mother sugar been given
stopped • Food cause “lugaw” since
breastfeeding the onset of
excess gas
and giving of diarrhea
solid foods • Food that may be Lab results:
and instead spoiled Normal sodium,
shifted to Decrease
giving “am” potassium
with sugar.
Case A When diarrhea Case B
-10 month subsides: -3y/o, 11kgs,
old, 8kgs,
• Avoid caffeine and foods male
female Diarrhea(6x/day
One day that are greasy, high in ) and
diarrhea 4x fiber, or sweet foods. vomiting(3x/day)
• Yogurt, which has less for 3 days
At the onset lactose than milk, is
of diarrhea, often better tolerated. Patient has
the mother been given
• Soft, bland foods can be
stopped “lugaw” since
breastfeeding added to the diet, the onset of
and giving of including bananas, plain diarrhea
solid foods rice, boiled potatoes, Lab results:
and instead toast, crackers, cooked Normal sodium,
shifted to carrots, and baked Decrease
giving “am” potassium
chicken.
with sugar.
Summary…..
THANK YOU!! 