 Welcome back, last class we were seeing about the gastrointestinal tract disorders beginning from the constipation. So constipation becomes a very big problem at the same time the opposite diarrhea also becomes a very big problem. So let us see what is diarrhea there are different types of diarrhea and what type of diet we have to take. So diarrhea is a condition which involves frequent passing of loose and watery stools. You see it is just opposite to the constipation. It has come from the word diarrhea means, diarrhea means flow and diarrhea means through. So continuous I mean watery stools of more than 3 to 4 times is diarrhea. Now the factors are it may be because of infection any bacterial infection can cause diarrhea or sometimes when we get antibiotics the excess of antibiotics also leads to diarrhea and some of the foods when they are not I mean some of if they are stale or some foods which we have the gastrointestinal tract is not able to tolerate such foods also cause diarrhea and it is associated symptom along with some of the diseases. Sometimes fever, sometimes any other diseases may accompany with diarrhea. So the factor can lead to passage of unformed stools that means the transit time in the intestine is very low the food passes very fast through the intestinal tract and it is thrown out. Now people of all ages can get diarrhea but it is most common in children of below 5 years of age. Now children with poor nutritional status and over all health which is poor they are exposed to poor environmental conditions and are more susceptible to severe diarrhea and it leads to dehydration. So poor environmental condition, poor sanitation, poor hygiene is the main cause for diarrhea which leads to infectious diarrhea. Now there are 3 clinical syndromes of diarrhea one is acute watery diarrhea where the passage of loose and watery stools without any visible blood. So vomiting and fever also may occur and if it occurs for more than 14 days it is called as persistent diarrhea. Then the person has to be hospitalized and given intravenous fluids. Now dysentery is another type of diarrhea where blood is visible along with this stool. It is a symptom of the shigella, entomibia, histolica and salmonella. These 3 organisms generally cause dysentery. The chronic diarrhea this is a recurrent and long lasting diarrhea and it is mostly non-infectious. Now the causes of diarrhea these diarrhea are inflammatory disease if the intestines are inflamed then also there is no proper assimilation and breakdown of the food therefore it goes out. Then fungal bacterial or viral medications over consumption of sugars also causes the diarrhea because when you consume over amount of sugars this because of the osmotic conditions it pulls out all the water from the cells and diarrhea occurs. Then whenever there is damaged mucosal surface in the intestine this also causes diarrhea. Now osmotic diarrhea is poorly absorbed osmotically active solutions in the intestinal tract. So this occurs when too much of water is drawn into the intestinal lumen and diarrhea will result with 1 or 2 situations. Malabsorption so when there is some difficulty in the mucous membrane of the intestines there is the nutrients will not be absorbed. So the especially malabsorption of carbohydrates it is the most common deficit in category of diarrhea. So it can result in malabsorption of carbohydrates then ingestion of poorly absorbed substrate. So usually a carbohydrate or a divalent ion it is that is the mannitol, sorbitol, salt and some antacids when they are poorly absorbed also they attract more water into the lumen and cause diarrhea. Then there is another diarrhea called secretory diarrhea this results from the active chloride secretion into the bowel. So this chloride secretion it again it draws out more water and leading to a net loss of fluid. This generally happens in the disease which is called cholera. So when the toxins of cholera are produced it pulls out all the waters from the cell and then it clears off from the intestines. So it continues even if there is no food intake during cholera whatever water is present in the body cells is just drawn out and then evacuated from the body. So cholera leads to fast dehydration. Mucous diarrhea is another type of diarrhea it is caused because of intestinal mucosal damage. So there is release of mucous blood, fluid and plasma proteins from the cells of the lining of the mucosa and results in inflammation or injury. So this increases the content of feces because you have mucous blood, fluid and plasma proteins and leads to ulcerative colitis whenever there is a disease called Crohn's disease. So this Crohn's disease is again the inflammation of the entire intestinal wall. So ulcerative colitis is wherever the intestines some places there is ulcers. So all these are lost through the feces. So infections such as E coli or whenever there is food poisoning all these type causes exutative diarrhea. Then infectious diarrhea is generally caused either by virus bacteria or sometimes parasites and there is a norovirus cause for diarrhea which is a viral diarrhea. Then rotavirus, rotavirus is generally caused in children below 5 years of age then there is astro virus which is caused because of a number of viruses and other infections. Motility related diarrhea this is related to the peristaltic movement of the intestines. So and this is caused by the rapid movement of food through the intestines whenever the contractions are very fast the food moves very fast through the intestines. So this cause because of hyper motility of the intestines. So the food does not have enough time for breaking down or absorbing sufficient nutrients into the intestine. This generally occurs in conditions where vagotomy occurs. Vagotomy is the surgery whenever there is some surgery in the industrial tract the vagus nerve is sometimes cut off. So this vagotomy leads to the changes in the motility of the intestinal valve or during diabetic neuropathy. Neuropathy is a complication of diabetic therefore whenever they have neuropathy again it disturbs the motility of the intestinal valves. Then hyperthyroidism also can produce hyper motility and lead to pseudo diarrhea and occasionally real diarrhea. So this type of motility related diarrhea can be treated by anti motility agents like simple medicine like low permite that means decreasing the motility of the intestines. Then inflammatory diarrhea is damaged to the mucosal lining or the brush border. Last few classes I was telling about the villi. So these villi they cause like a brush border in the intestines. So when this brush border is disturbed then the mucosal lining is disturbed and the inflammation occurs. So passive loss of protein rich fluids and decreased ability of absorption of these lost fluids. So caused by bacterial infection, viral infection, parasitic infection and some autoimmune problems. Now when should you see a doctor when you have a diarrhea whenever there is high fever and it is not subsiding then see a doctor then severe abdominal pain, then bloody diarrhea and prolonged vomiting, acute diarrhea in pregnant women because pregnant women cannot afford to have a long duration of diarrhea because their nutritional status will come down and affect the fetus. So diarrhea occurs during or immediately after completing a course of antibiotics. So the first episode of diarrhea or second episode of diarrhea we should not take any medicines because there are some toxins or bacteria that are present in the stools. They have to be pushed out from the body. So body's natural mechanism of pushing out should not be obstructed. So after 1 or 2 days or 10 episodes of diarrhea then you can see the doctor. Then treatment diarrhea in adults you identify and treat the underlying problem what is we have seen the different types of diarrhea. So we have to identify which type of diarrhea and treat it properly. Then replacement of fluids and electrolytes is very important because during diarrhea a lot of fluid from the body is evacuated and there may be a disturbance in the fluid balance electrolyte balance therefore which has to be met. Then broths and electrolyte solutions which are high in sodium and potassium need to be given because the electrolytes which are so the main electrolyte sodium and potassium also are excreted along with the diarrhea. Then you can give fruits like apples and bananas which are rich in pectin because this pectin it tries to bind the residue and makes the stool I mean solid. Then avoid caffeine because caffeine will again stimulate the motility of the intestines therefore it is better to avoid caffeine. Then when diarrhea stops you can give starchy fruit foods like rice, potato and plain cereals. And slowly then you can start protein foods then but initially we should give the minimum residue diet because the intestine cannot tolerate the solid foods. Then modest amount of fats can be given because you have to supply sufficient energy and sugar alcohols like lactose, fructose and large amount of sucrose should be better avoided because it worsens the situation of the diarrhea because again it helps in attraction of more water or drawing out more water into the lumen and excrete. Now chronic diarrhea the nutrient should be replaced parentry or entirely because when the person is not able to swallow then it is better to give the nutrients directly into the veins intravenous administration of nutrient should be given so that the patient recovers very fast. Then short chain fatty acids should be given and it also facilitates the absorption of fluid and salts and also regulates the gastrointestinal motility. Then the best thing is you give probiotics. Probiotics is just the opposite of antibiotics. Antibiotics means we are removing the bacteria so it sometimes what happens is it kills the good bacteria also. So probiotics it initiates the bacterial growth in the intestine. And prebiotics these favor the growth of the probiotics that is lactobacillus and bipidus and they help in slowing the gastric emptying and also hold water. So you should restore very fast in the gastrointestinal tract disorders because the stool output and shortening of illness should be decreased that is the main aim and you have to replace the micronutrients. So even when you have diarrhea many of the people do not eat any food but whenever there is diarrhea also the gut has the capacity to absorb 60% of the food that is eaten. So when you rest the gut it is more dangerous because the body is not getting any nutrients then there is a diarrhea called weanling diarrhea that is when the child is weaned from the breast to the normal food under such conditions also there is weaning diarrhea and so encourage breast feeding before and follow the good food hygiene then improvement of nutritional status is should be our aim and good environmental sanitation will prevent the weanling diarrhea. In fluid management you have to replace the fluid losses very early as the diarrhea is episodes are going on you have to keep on replacing the fluid and electrolyte into the body then plenty of fluid should be given to prevent dehydration then initial management should be with fluids so you have to keep everything ready. Now coconut water, buttermilk, rice kanji with salt and lemon can reduce the dehydration and these fluids can be given in unlimited quantity so that dehydration can be prevented. Now there is a solution called you can make a oral rehydration solution at home by giving boiling 1 liter of water and adding a pinch of salt and a handful of sugar in it and giving the patient frequently as possible. Now there is a WHO recommended oral rehydration salt solution where it contains 20 grams of glucose, sodium chloride is 3.5, sodium carbonate 2.5 and trisodium citrate 2.9 and potassium chloride 1.5 grams per liter that is per liter of boiled and cooled water. This can be frequently fed to the patient with diarrhea so that dehydration does not occur. So therefore whenever there is diarrhea, diarrhea is very dangerous and if it is neglected it can become fatal and since the individual loses lot of water and the body undergoes dehydration the cells also become dehydrated and they lose their functions and lead to death. So proper care, initial care and fluid management in diarrhea is very important. Thank you.