Doctors Revision

Gastrointestinal & Hepatic System

Diarrhoea (General Approach)

Passage of three or more loose or watery stools in a 24-hour period. Can be acute (<14 days), persistent (14-29 days), or chronic (≥30 days). Dysentery refers to diarrhoea with visible blood and mucus. Management primarily focuses on fluid/electrolyte replacement and identifying specific causes requiring treatment.

Also known as: Loose Stools, Gastroenteritis

Open in the interactive guide
On this page

Referral and warning signs

When to refer

Refer to hospital (HC4/H) for: Severe dehydration requiring IV fluids (Plan C). Persistent vomiting preventing ORS intake. Bloody diarrhoea (dysentery). High fever. Severe abdominal pain. Signs of complications (altered mental status, decreased urine output, shock). Infants <2 months. Malnourished children. Persistent diarrhoea requiring further investigation.

Red flags

  • Signs of severe dehydration (lethargy, unable to drink, sunken eyes, loss of skin turgor, shock)
  • Bloody stools (dysentery)
  • High fever
  • Persistent vomiting
  • Severe abdominal pain
  • Altered mental status / Confusion
  • Failure to improve despite ORS/initial management

Signs and symptoms

  • Loose or watery stools (increased frequency/volume).
  • Abdominal cramps or pain.
  • Nausea, vomiting.
  • Fever (may indicate infectious cause).
  • Signs of dehydration: Thirst, dry mouth/mucous membranes, sunken eyes, decreased skin turgor, reduced urine output, dizziness, tachycardia, hypotension (severe).
  • Bloody/mucoid stools (Dysentery).
  • Weight loss (persistent/chronic diarrhoea).

Risk factors

  • Contaminated food or water (infectious diarrhoea)
  • Poor sanitation and hygiene
  • Travel to endemic areas ('Travellers' diarrhoea')
  • Close contact with infected individuals
  • Immunodeficiency (e.g., HIV - risk of opportunistic infections)
  • Antibiotic use (antibiotic-associated diarrhoea)
  • Malnutrition
  • Certain medications (laxatives, metformin, etc.)
  • Food intolerances (lactose)
  • Inflammatory bowel disease
  • Irritable bowel syndrome

Diagnosis

Clinical assessment

Diagnosis based on history (onset, duration, frequency, stool characteristics - watery/bloody/mucoid, associated symptoms, travel history, food intake, medications, exposures) and assessment of hydration status (crucial). Identify red flags requiring further investigation/specific treatment. Differential diagnosis vast depending on acuity/chronicity (see Causes list).

Investigations

  • Assessment of Dehydration (Clinical signs, weight loss if possible).
  • Stool Examination:
  • - Microscopy: For ova, cysts, parasites (Amoeba, Giardia, Cryptosporidium, Strongyloides), white blood cells (suggests inflammatory/invasive cause).
  • - Stool Culture & Sensitivity: If severe diarrhoea, dysentery, persistent diarrhoea, suspected outbreak (Cholera, Shigella, Salmonella, Campylobacter).
  • - Stool for Rotavirus/Adenovirus antigen (esp. in children).
  • Blood tests (if severe/persistent/systemically unwell): CBC, U&Es, Creatinine, Blood cultures.
  • HIV testing.
  • Further investigations for chronic diarrhoea: Endoscopy, biopsy, malabsorption tests (specialist).

Diagnostic criteria

Patient report of ≥3 loose/watery stools in 24h. Further classification based on duration (acute/persistent) and stool characteristics (watery/dysentery).

Management

Non-pharmacological management

  • Fluid and Electrolyte Replacement (Mainstay):
  • - Oral Rehydration Solution (ORS): Preferred method for mild-moderate dehydration (Plan A/B). Use low-osmolarity ORS. Give frequently in small sips.
  • - Intravenous (IV) Fluids: For severe dehydration or inability to tolerate oral fluids (Plan C). Use Ringer's Lactate or Normal Saline initially, then maintenance fluids. (See UCG Section 1.1.3 for details on Plans A, B, C).
  • Nutritional Support:
  • - Continue feeding (including breastfeeding) during diarrhoea.
  • - Offer frequent small meals as tolerated. Avoid sugary drinks.
  • - Reintroduce normal diet as soon as possible.
  • Hygiene Measures: Handwashing, safe water, proper food handling/preparation.

Pharmacological treatment

  • Zinc Supplementation (Children <5 years with acute diarrhoea): Zinc 20mg (10mg if <6 months) orally once daily for 10-14 days. Reduces duration and severity, prevents future episodes.
  • Antibiotics: Generally NOT indicated for acute watery diarrhoea (usually viral/self-limiting). Reserve for specific situations:
  • - Suspected Cholera (severe dehydration in outbreak): Doxycycline or Azithromycin/Ciprofloxacin.
  • - Dysentery (Shigellosis suspected): Ciprofloxacin preferred. Azithromycin alternative.
  • - Confirmed Giardiasis: Metronidazole or Tinidazole.
  • - Confirmed Amoebiasis: Metronidazole or Tinidazole.
  • - Severe Travellers' Diarrhoea: Consider Azithromycin or Ciprofloxacin.
  • - Specific identified bacterial pathogens based on culture.
  • Antimotility Agents (e.g., Loperamide): Generally AVOID in acute infectious diarrhoea, especially dysentery or suspected C. difficile (risk of prolonging illness/toxic megacolon). May consider cautiously for symptomatic relief in mild-moderate watery diarrhoea in adults IF infection unlikely/ruled out.
  • Probiotics: Limited evidence for routine use.
  • Persistent/Chronic Diarrhoea:
  • - Investigate underlying cause.
  • - Treat specific cause if identified.
  • - Consider Codeine Phosphate 30mg Q8-12H (Adults only) for symptomatic relief if cause unknown/untreatable.
  • - Vitamin A supplementation for children 6mo-5yrs with persistent diarrhoea (WHO recommendations).

Monitoring

  • Monitor hydration status frequently (clinical signs, urine output, weight if possible).
  • Monitor stool frequency and consistency.
  • Monitor electrolytes if IV fluids used or severe diarrhoea.
  • Assess response to treatment.

Complications

  • Dehydration (mild, moderate, severe)
  • Electrolyte imbalances (hypokalaemia, hyponatraemia, acidosis)
  • Hypovolemic shock
  • Malnutrition / Growth faltering (persistent/chronic diarrhoea)
  • Haemolytic Uremic Syndrome (HUS) - complication of E. coli O157:H7
  • Toxic megacolon (e.g., C. difficile, Shigella, Amoebiasis)
  • Bowel perforation (rare, e.g., severe amoebiasis, typhoid)
  • Reactive arthritis (post-Shigella, Salmonella, Campylobacter, Yersinia)
  • Guillain-Barré Syndrome (post-Campylobacter)

Prevention

  • Access to safe drinking water and adequate sanitation.
  • Handwashing with soap (critical times: after toilet use, before handling food, before eating).
  • Safe food handling and preparation (cook thoroughly, separate raw/cooked).
  • Exclusive breastfeeding for first 6 months.
  • Vitamin A supplementation.
  • Rotavirus vaccination.
  • Measles vaccination.
  • Cholera vaccination (in specific settings).
  • Proper disposal of faeces.

Patient education

  • Importance of fluid replacement (ORS preparation and administration).
  • Signs of dehydration and when to seek urgent care.
  • Importance of continued feeding/breastfeeding.
  • Zinc supplementation for children.
  • When antibiotics are/are not needed.
  • Hygiene measures to prevent spread.
  • Danger signs (red flags).

Uganda-specific notes

Diarrhoeal disease is a major cause of childhood morbidity/mortality. ORS + Zinc is the cornerstone of management for children. Cholera outbreaks occur. Dysentery requires specific antibiotic treatment (Ciprofloxacin often used). Consider parasitic causes (Amoeba, Giardia). Assess HIV/malnutrition status.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.1.5

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.1.3 (Dehydration Management Plans A, B, C)

  • IMCI Guidelines (for childhood diarrhoea)

    (Referenced implicitly)

Scroll to Top