Diarrhoea

Problems and possible causes

Diarrhoea is very common in people with AIDS. The diarrhoea is usually clear and watery and is sometimes accompanied by abdominal cramps and vomiting.

What is diarrhoea?

The number of stools normally passed in a day varies with diet and age. In diarrhoea, the stools contain more water than normal - they are called loose or watery stools. They may also contain blood, in which case the diarrhoea is called dysentery. Frequent passing of normal stools is not diarrhoea.

People usually know when they have diarrhoea - the stools smell strongly or pass noisily, as well as being loose and watery. Someone has diarrhoea if they have three or more loose or watery stools in a day.

Diarrhoea is more common in people who have AIDS than in those who do not.

There are two types of diarrhoea, acute diarrhoea and persistent diarrhoea.

· Acute diarrhoea lasts for less than two weeks.

· Persistent diarrhoea is when someone has more than three liquid stools a day every day for more than two weeks.

The most common causes of diarrhoea in people with HIV infection are:

· intestinal infections from food or water that is not clean and fresh.
· opportunistic infections related to AIDS
· side-effects of some medicines.

Why is diarrhoea dangerous?

The two main dangers of diarrhoea are dehydration and malnutrition. Dehydration is the loss of a large amount of water and salt from the body, which if not treated can cause death.

How does diarrhoea cause dehydration?

The body regulates the amount of water and salts it needs by a two-way process. It takes in water and salts from the food and drink consumed. It also gets rid of excess water and salts through the stools, urine and sweat. In a healthy person there is a balance between intake and output. When someone has diarrhoea, however, the intestines do not work normally and this balance breaks down. Increased amounts of water and salts are passed into the intestines and the output of water and salts becomes greater than the intake. This results in dehydration. The greater the frequency of diarrhoea the more water and salts are lost. Dehydration can also be caused by vomiting, which often accompanies diarrhoea.

Dehydration occurs faster in infants and young children, in hot climates, and in people who have fever.

How does diarrhoea cause malnutrition?

Diarrhoea (either acute or persistent) can cause malnutrition or make it worse because:

· nutrients are lost from the body in the stools

· people with diarrhoea often do not feel hungry

· some think wrongly that they should not eat when they have diarrhoea, or even for some days after the diarrhoea lessens.

What to do at home

How to prevent diarrhoea

· Drink clean water. Boil water that is to be used in making food or drinks. The water need only boil for a few seconds. Drinking water from a dirty well, or water kept in a dirty container, can cause diarrhoea.

· Eat clean, safe food. Eat freshly prepared foods. Make sure that raw foods are washed and that cooked food, especially meat, has been cooked properly. Badly washed food, or food not protected against dirt, flies and animals can be unsafe to eat because it can become contaminated with disease-causing organisms. If previously cooked foods are to be eaten, make sure they have been stored safely and reheated thoroughly at a high temperature.

· Clean your hands. This is particularly important. People should always wash their hands:

- after using the latrine
- after helping somebody else use the latrine
- after cleaning soiled children or sick people
- before preparing food or drink for them-selves or other people.

Three rules for treating diarrhoea in the home

The treatment recommended here is suitable for anyone with diarrhoea, with or without AIDS.

I. Drink more fluids than usual

Dehydration can usually be prevented in the home by drinking more fluids as soon as the diarrhoea starts.

What fluids?

People should be advised by health care workers on the type of fluids to drink (see the section on how to treat dehydration below). Fluids such as unsweetened juices and weak tea or food-based fluids such as gruel, soup or rice water are all effective in combating dehydration.

In the case of breast-fed infants with diarrhoea, the mother should continue to breast-feed and try to do so more often than normal (at least every three hours).

Figure

How much?

Drink as much as possible.

If someone does not feel thirsty they may have to force themselves to drink. It may help people to keep a glass of water nearby and sip some of it every five to ten minutes.

It is particularly important to encourage children with diarrhoea to drink. Give children under two years old about a quarter to a half of a large cupful of fluid (50-100 millilitres) after each loose stool. Give older children one half to one large cupful (100-200 millilitres) after each loose stool.

2. Continue to eat

Figure

If people try to stop eating when they have diarrhoea this can cause malnutrition or make existing malnutrition worse, and will not decrease the diarrhoea. The fluids taken in do not replace the need for food. It is very important for people to take the nutrients needed to stay strong and prevent weight loss - a strong person will resist illness better.

Even if someone does not feel hungry they should eat small amounts of nutritious and easily digestible food frequently. After the diarrhoea has stopped, an extra meal each day for two weeks will help to regain any weight lost during the illness.

It is particularly important to encourage young children with diarrhoea to eat. Some children will continue to need extra food after the diarrhoea has gone for some time to make sure they regain any weight lost.

What foods?

Advise people to eat foods with the largest amounts of nutrients and calories relative to bulk. These should be mixes of cereal and locally available beans, or mixes of cereal and meat or fish. Oil can be added to these foods to make them more energy-rich. Dairy products, eggs and bananas are also suitable. Very dilute soups are recommended as fluids, but are not sufficient as foods because they fill you up without providing sufficient nutrients.

Advise people to avoid:

· high-fibre or bulky foods, such as fruit and vegetable peels, and whole grain cereals; these are hard to digest

· foods or drinks containing a lot of sugar, such as commercial soft drinks, as these can worsen diarrhoea.

Prepare foods by cooking well, mashing or grinding to make them easier to digest.

The section in this chapter on nutrition problems gives more detailed information about healthy foods.

How much food?

People should eat as much as they want. They should take some food every three or four hours (six times each day) - food should be given more often to young children with diarrhoea. A person may prefer small, frequent meals and these are best because they are more easily digested.

3. Recognize and treat dehydration early

People should watch for signs of dehydration (feeling very thirsty, feeling irritable or lethargic, and the skin going back slowly when pinched). If someone notices these signs, they should take oral rehydration solution used by health care workers to treat people with dehydration, and it can also be used in the home. It is made by dissolving a packet of oral rehydration salts (ORS) in cooled water that has previously been boiled.

ORS packets are available in most parts of the world. Dissolve the contents of the packet in the amount of water indicated on the packet. Not all packets are the same size so people will have to read the instructions to be sure how much water to add. If they use too little water, the drink could make the diarrhoea worse. If they use too much water, the drink will be less effective. The mixture should be stirred well and then drunk the same day it is prepared.

If ORS packages are not widely available you should advise people that they can still make a suitable solution at home. You should advise on the recipe for the solution used in your country.

Other treatments for diarrhoea

Discourage the use of medicines at home to control diarrhoea. Further details about when to use such medicines are given in the section on medicines for diarrhoea in Chapter Seven.

For severe stomach cramps that sometimes accompany diarrhoea, paracetamol may be helpful. Recommendations on the dose to take are given in the section on medicines for pain in Chapter Seven.

Figure

Other problems that may come with diarrhoea

Skin irritation in the rectal area

To prevent or treat sore or broken skin you should advise the sick person to:

· dean the rectal area gently with water after each bowel movement and pat dry

· apply a lotion to help relieve the discomfort and protect the skin

· sitin warm water containing a little pinch of salt three or four times a day; this may also relieve the discomfort.

Haemorrhoids

Haemorrhoids can develop after the diarrhoea has been present for some time. They are caused by a weakening of the walls and blood vessels of the rectum. The tissues around the anus become very sore and itchy. The blood vessels may become very tender and may bleed - small amounts of blood may be noticed in stools or during cleaning of the rectal area.

Trying to relax during bowel movements and not straining or pushing too hard to pass the stools can prevent haemorrhoids. Sitting in a bath may help to ease the discomfort and paracetamol can be taken to relieve the pain.

To help someone with diarrhoea who cannot get out of bed

Use a bedpan or other suitable plastic or metal container. Be sure it is not too high and can be used by slipping it under the person in bed. Empty the contents frequently. Do not use this container for any other purpose once it has been used as a bedpan. Change wet or soiled bedding immediately to prevent damage to the skin.

When sick people and their families must seek help

People are at risk of dehydration and should seek help if they have diarrhoea and:

· are very thirsty
· have a fever
· cannot eat or drink properly
· do not seem to be getting better
· pass many watery stools
· see blood in the stools
· are vomiting and cannot keep down fluids.

Help should be sought quickly if signs of dehydration have already developed, such as:

· the person is extremely thirsty
· the person is in an irritable or lethargic state
· the skin returns slowly after pinching.

The information contained in this section has been modified from the WHO programme for Diarrhoeal Disease Control modular course "Supervisory Skills: Treatment of Diarrhoea"; see the "Resource List" which follows Chapter Seven in this handbook.

Notes on diarrhoea
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