Classifications of diarrhoeal disease

Classifications of diarrheal disease
Manson-Bahr, Philip:
The Dysenteric Disorders: The Diagnosis and Treatment of Dysentery, Sprue,
Colitis and other diarrhoeas in General Practice
London 1939
1: classification of the causes of diarrhoea ( people were concerned about the
1. Primary diarrhoea
- dietetic
- constipation
- changes of climate
- food poisoning
2. Alterations of intestinal secretions or absorption
- acute and chronic dyspepsia, pancreatogenous diarrhoea and cholecystitis
- idiopathic steatorhoea ( coeliac disease)
- Sprue and Hill diarrhoea
- Nervous diarrhoea
3. Secondary diarrhoea: infectious
- typhoid
- bacillary Dysentery
- colear
- Gaerner and Aertrycke infections
- Amoebiasis, giardiasis, flagelate diarrhoea, coccidiosis, malarial dysentery,
leishmanial dysentery
- Bilharziasis and other worm infections
4. .... Special type of diarrhoea:
- ulcerative colitis
- muco-membranous colitis
- polyposis
- polypus
- sterecoral ulceration
- foreign body in rectum
Special divisions: IN CHILDREN
- simple diarrhoea from chills or diet errors
- acute gastro-enteritis, summer diarrhoea
- amoebic Dysentery
- Coeliac disease
Hippocrates distinguished between dysentery and other forms of diarrhoea
Other authors mentioned it as „bloody flux“ with crude clinical descriptions
5th c AD epidemics were noted in Europe
epidemics of dysentery were noted in 534 538 in France, 760 northern Europe
17th c clearly distinguished bloody-stained dysentery stools
first half of 19th century dysentery was thought of being “but one expression of
resemblance to malaria: tendency to break out at long intervals in pandemic
during wars it was classified along with typhoid and typhus amongst the
foremost pestilence of war. (17-19th)
19th century India brought forth a lot of research and study o dysentery, and
early 20th century once pathogens were discovered classification was:
bacillary dysentery
amoebic „
clinical „
Dysentery was seen different from colitis and diarrhoea though all of them had
as symptoms diarrhoea.
classification of dysentery, was necessary for the professional as the diseases of
a wide and distinct aetiology resemble each other in many ways. Thus the
„experts“ showed that classification according to micro-organisms would be
applied ( which cannot be seen by patients/public)
took medicine a step further ahead into distance from public and individual
illness experience.
Bacillary or epidemic dysentery
Protozoalor endemic dysentery: e.g. amoebiasis, giardiasis, malaria dysentery
Metazoal or helminthic dysentery: ulceration by helminths
Def: dysentery Greek „ a bowel complaint“ explains main outstanding
symptoms, passage of abnormal blood stained mucus with tenesmus and pain
Field Michael: Diarrheal Diseases, Amsterdam 1991
Part of gastroenterology
P ix: maturation of the field leads to fragmentation of the knowledge-base and
its diffusion through an ever-expanding literature. This should be seen as
„intellectual vitality of our speciality“ (of gastroenterology)
Infectious and non-infectious diarrhoea
Classification of chapters is chosen to address specialisation of the field, like
paediatricians, patients with D of obscure origin, etc.
Look at D more as a symptom and start with the intestinal ion transport and list
Section 2: pathophysiology of diarrhoea:
Mechanism of diarrhoea is explained in relation to intestinal inflammation and
immune system modulation
Bacterial Enterotoxins
Viral Gastroenteritis
Nutrient induced diarrhoea
Role of motility in diarrhoea diseases
Section 3:
Basic investigation of a patient with diarrhoea
Chronic D of obscure origins
Bacterial Enteridities
Antibiotic-associated diarrhoea
Protozoal diarrhoea
diarrhoea diseases in children
Congenital diarrhoea
Endocrine tumor-associated diarrhoea Symptoms
Diabetic D ( modern disease, only because of research of the past 30 years can it
be classified separately, though first described in 1936)
Ileostomy D ( came up with specific surgery )
Section 4: therapies of diarrhoea
Gracey M.,Walker-Smith J.A (eds.)
Diarrheal Disease
Nestle Nutrition Services
New York 1997
Basic classification is: 1-4
Acute infectious and persistent ( over 14 days) and chronic diarrhoea
Acute D:
- rotavirus and other virus infections
- enteric bacterial infections
- antibiotic induced diarrhoea through e.g. Clostridium difficile ( toxin
producing bacterium), recognised since late 1970s
- algae
- traveller’s D: salmonella , shigella, parasites, viruses ( overlap with other
- food-borne D, ( mentioned especially as it is a major problem in
industrialised as well as developing counties because of the food chains):
overlap with the microbes: salmonella, staphylococcus aureus,
camphylobacter, yersenia...
- protozoan diarrhoea : giardia
- parasites: cryptosporidium
-2 –23% of cases in children last longer than 2 weeks and 45% of diarrhoea
death in Brazil are due to persistent diarrhoea or non-dysenteric persistent D
WHO def. (p.211):
Persistent diarrhoea „begins acutely and lasts for at least 14 days“, as in third
week mortality rate of diarrhoea changes in children affected by diarrhoea
Classification was made for case-management purposes and for comparability of
research findings which is essential in such an range of health-threatening
disease like diarrhoea
The def persistent D does not include specific disorders, like surgical conditions
of diarrhoea celica disease or hereditary syndromes.
classification according to severity:
acute, watery , dehydrating diarrhoea require rapid intervention with
replacement of water and electrolytes
invasive infectious D with systemic illnesses such as shigellosis, amoebiasis
require antibiotics
infective diarrhoea
classification according to cause in the intestines:
a) increased intestinal secretion due to enterotoxins
b) decreased intestinal absorption due to intestinal damage or inflammation
Infectious D:
due to
- enterotoxins
- bacteria
- viruses
213 classification in research on mortality:
acute D 35% of death rates in India, Bangladesh, Brazil and Senegal
dysentery (20%)
nondysenteric persistent D 45%
AIDS and diarrhoea
New classification in 1984 called „AIDS ENTEROPATHY“ or „culturenegative D“ no pathogens could be identified in this type of D
Growth retardation due to chronic diarrhoea
In most situations retarded growth is due to other factors, the D being one
classification according to pathophysiologic mechanisms of D:
- pancreas insufficiency
- intestinal malabsorption: celiac disease
- inflammatory bowel disease: crohn’s disease
The Evaluation and Treatment of the Patient with Diarrhea
Miskowitz P.F. Rochwarger A. M.
Andover Medical Publishers: Boston, London, Oxford,
diarrhea Greek „flowing through“
Patients will refer with this term to frequency, consistency or volume of stool.
Their descriptions may be vague. Physician has to classify the clinical history.
D may be rigorously defined as the presence of 250 ml of water in the stool per
24 hrs ( normal 100 – 150 gm per 24 hrs, out of which 60 – 80% is water)
Evaluation of D as a patient complaint has 17 classifications of acute and
chronic D depending on the type of patient ( table 3.1. p.4)
Classification between systematically or non-systematically ill patient with the
same symptom because „the clinical history is the most important determinant in
differentiation of the clinical problem.“ (p.3)
classifications according to stool evaluation ( colour, gross or occult blood,
bacterial culture, consistency etc.) (table 1.4. p.5)
e.g. classification of bloody D can still have several causes: anal fissures,
haemorrhoids, which are not relevant to the main problem D
classification of chronic D:
1. D due to abnormal bowel motility: irritable bowel syndrome is most frequent
cause of chronic :
2. Malabsorptive D: decreased absorption of fluid, celiac sprue, lactose
3. Secretory D: cholera or hormonal D, several litres daily
4. Inflammatory D
They can be single or overlaps each other, like in Morbus Crohn all 4 will be
present, celiac sprue will have 2 and 3
Main classif of infectious causes of D appeared with the increase in
microbiological tests and knowledge.
Bacterial D lists 36 types of bacteria, parasites (9 protozoa, 7 nematodes, 4
cestodes, 4 trematodes) 9 types of viruses. ( p. x and xi)
AIDS and D is listed separately, so is Traveller’s D because of their specific
target group
Malabsorption is listed as a major cause for several types of diarrhoea and
discussed separately.
New forms of D have been discovered that do not fit into the traditional
classifications, separate section „other causes of D „ is added (p. xii-xiii)
1. diarrhoea due to hormones, regulatory peptides and circulating humoral
messengers (e.g. types of cancer, pancreatic cholera, hyperthyroidism)
2. Idiopathic inflammatory bowel disease as a cause of diarrhoea
3. Microscopic and Collagenous Colitis („non-specific colonic inflammation in
patients with chronic idiopathic D“, term coined in 1980 by Read et al. After
discovering large group of patients with chronic secretory D of inapparent
4. Factitious D („not natural“ e.g. laxative abuse)
trend towards patient oriented classifications??
differentiated classification helps in accurate diagnosis, very individualised, diet,
medications, surgery, AIDS, are all individual adding factors to special cases of
treatment is still mainly symptomatic, because aetiology remains often obscure
diarrhoeal Disease and Malnutrition: A Clinical Update
Gracey M. Ediarrhoea
Churchill Livingstone: Edinburgh, London, Melbourne and New York
1940: D was common in a Melbourne hospital, infecting agents known were
shigella and salmonella, cholera was not a problem anymore, viruses were
suspected but not identified
Intestinal biopsy technology late 1950s lead to deeper understanding of
malabsorbtion and new classifications of D
1970S: understanding of viruses, notably rotavirus in cause of D, electronic
advance in classif took place along with advance in medical technology
Who developing world D projects included environmental, nutritional
background, water supplies
Cook G.C.: Communicable and Tropical Diseases
Heinemann Medical Books: London
traveller’s D
Spanish flux, Poona poohs, Bombay runs, Hong Kong Dog,
became prominent after 1970
differs from countries and continents
several organisms my be responsible for a single attack
Traveller’s D includes bacteria, viruses, parasites
shigella is a bacillus generally considered to be responsible for bloody D in
travellers along with Entamoeba histolytica (protozoa), is not always true.
small intestinal parasites divided into protozoa and helminths
helminths associated with malabsorption: Strongyloids stercoralis
„ not „ „ „“““““““: hook worm, tape worm
89 colorectal prozoa
divided into pathogenic ( Entamoeba histolytica) and non-pathogenic ( E.coli)
division depends on microscopic and medical technology internal investigations
isoenzyme techniques allow separation of 9 invasive and 13 non-invasive strains
of E. histolytica
chronic or bloody D is now a symptom that can occur with any of these strains.
A new short Textbook of Preventive Medicine for the Tropics
Lucas A O, Gilles H M
Edward Arnold: London, Melbourne, Auckland
My thoughts
Classification in acute and persistent/chronic D is a matter of statistics and
health management. As the problem is pandemic and occurs in many different
countries it is important to have an international classification scheme to
monitor the disease globally. Thus WHO has defined D accordingly.
Classif of persistant D allows addressing different risk factors: age, nutrition,
immunology, previous infections, concomitant bacteria etc.
On the other hand, advancement of science, especially in microscopic invasive
techniques have lead to detailed knowledge on absorption of different arts of the
intestines which led to further classification of D as malabsorption related or
unrelated or small intestinal and colon related diarrhoea
Electronic microscopic technology and the entire science stream of virology and
parasitology have brought detailed advanced knowledge on the actual causes for
D, thus bringing about another classification which is important for medical
treatment not so much for the patient who mostly doesn’t know about these
Patient related classification of D is important during taking the case history,
when the patient will describe the symptom of D and use simple classifications
such as frequency, consistency, colour, smell, etc. These are important
classifications during the patient-doctor interaction and from there, along with
additional tests the doctor had to come to an accurate diagnosis and treatment.
D is basically a symptom and not a cause of a disease, though D diseases are
summarised as a classification. Thus these classifications overlap each other
constantly, as the symptom can appear in many different types of illness.
New diseases like AIDS where D also appears occasionally, add new class to the
entire spectrum.
Earlier on, epidemics were certainly a major driving force to classify and
describe D diseases.
Because of the appearance of classifications at different times we find overlaps
and ... in classifications, which makes it more difficult for medical practitioners
to study and comprehend the complexity of the issues but also allows different
entrances into the disease complex from where one can get to the right
therapeutic conclusion
Conclusion one can say that medical classifications appeared in different times
of history, depending on advancements in medical science or international
monitoring schemes (WHO) to combat global disease and study their outcomes
with statistical measures.
WHO: Readings on diarrhoea, Student Manual
Geneva 1992
Types of D
Def. D comprises three or more loose watery stools in 24 hrs.
1. acute d: <14 days, E.coli, Shigella, Campylobacter jejuni, Cryptosporidium
2. dysentery: def: d with blood, causes: annoerxia, bacterial, Shigella, E.coli,
3. persistent or chronic d: def: >14 days with actute start, no sible cause, E.coli,
shigella, Cryptosporidium
diarrhoea epidemics: vibrio cholera, shigella dysenterica Type 1
most improtant cause of severe life-threatening D under 2 years of age
calssification: 4 serotypes, immunity after 1 infection, person to person
watery D: loss of water and electrolytes >decrease of blood volume >
cardiovascular collapse, death
1. Secretory D: infectious D that leads to secretory D, E coli, vibrio cholera O1,
2. Osmotic D: can be due to purgatives, lactoseand glucose intollerance,
increase in volume in the gut causes D
Therapy: ORAL REHYDRATION THERAPY (ORT) works for 95%
For home treatment and practical treatment palsn in developing countries thes
types of D classified accoring to dehydration are essential.
WHO case record form uses classification accoring to dehydration becuase it is
practical in the field without laboratory to classifiy microbes
classif focuses on dehydration and also if there is visible blood not on microbes
simple class of acute-persistent or dysentery is enough
Bailliere’s Clinical Gastroenterology, Infectious diarrhoea
International Practice and Research
Gracey M. Bouchier I.A.diarrhoea ( eds.)
Vol 7/2 1993
Bailliere Tindal: London
it is important to have an agre ment anout definitions. Def. Are not always celar
in published reports which makes interepretation and comparison difficult.
This book calssifies:
1. diarrhoea
2. Dysentery
3. Acute D
4. Persistent or chronic D
classific. Of routes of transmission of infectious D: a) direct ( e.g. finger),
b) indirect ( e.f. conatminated food
classifc. Of cofactores: bottle feeding, contaminated water, AIDS malnutrition
these class touch on social issues as well
199 class acc to food poisoning organisms causing D
His class is helpful to control foodpoisoning and prevent food p.
Traveller’s D always separate clas.
Def: 3 or more unformed stool per day and one of the follwing symtomps:
abdominal pain, cramps, nausea, vomiting, dysentery..., occuring within two
weeks of arrival in a foerign country. 30-50% of travellers are affectediarrhoea
Useful calss because of special traget group
E.coli D
1940s first suggestion that e-coli caused D
advances in molecular biology lead to further class.
Now: 5 major categories of E- Coli: ETEC EIEC EPEC EHEC EaggEC (Levine,
1987), each of them have several sub groups ( p.245)
EPEC was detected in the 1980s as the main cause of D epeidemics in the UK in
1940s and 1950s.
You need a microbiology lab to classifiy these, not useful for the feield or
undeveloped countries.
But this class. Has been indetified by gene coding worldwide.
other bacterial D
“ Each year new organsims are found to be pathogens, and old ones are found to
have new tricks that cause disease.”
Double classification is useful:
Watery, bloody and chronic and the underlining molecualr pathogens ( bacteria,
virus, parasites)
Problem of drug restistance ( shigella)
There has been a change of focus from ameobas to bacterial pathogens!
treatment of chronic D is unclear becuase of malnurishment involved as a factor
classifi of organisms accoring to the part of the intestinal tract which is attacked
by the toxins
class of INVASIVE organisms: salmonella, shigella, campylobacter, yersenia
These invasive organism invade the gut eptelium in the distal ileum and colon.
Nicher Mark and Nichter Mimi, Anthrolpology and International Health
Asian Case Studies
Gordon and Breach Publishers
Chapter 5 p. 135Social Science Lessons from Diarrhea research and Their Application to ARI
(acute respiratoy infections)
p.157 No.. 14
“Use local illness categories when evaluating the impact of health
Study in Bangladesh on usage of ORS among D patients have shown that “use
rates vary significantly by illness category.” A meaningful assesemnt of the
project could only be done by analysing local illness categories and e.g.
indigenous concepts of “blood” in diarrhoea The analysis of local illness
categories in relation to ORS made a difference to programme planning and
evaluation (Bangladesh Study by Chowdhury, Vaugan and Abed 1988).
Chapter 4 p. 111-134
111 dysentery accounts for 20% of D related eaths, 750 000 death per year
Health Social Science Research on the Study of Diarrheal Disease: A focus on
Simply classif of secretory-watery D and invasive-inflammatory forms of
dysentery. This class is useful in the field because “these two broad categories of
enteric infection require disinct lind of monitoring and care.” (p.112)
Ehnographic data of South Asia and Phillipines suggest that health workers do
not often distinguish between the two. They have been trained to judge the
severity of D bin relation to signs of dehydration (see WHO Form) and give
ORT. ORT needs to continue but bloody D needs promt antbiotic treatmentAnthropoloical studies are requireed becuase this process depends on
- cutura conyepualisation of blood and blood loss
- local categories of blood stools
- language of illness
- sensitivity and specificity of local inllnes terms for bloody D which
corespond to clinical cases of dyentery
- popular use of biomedical terms of D
- hometreatment
- perceived signs of illness severity ( bloody – sorcery involved)
- parnet health care decision making
- prescription pracices f local docotrs for bloody D
- pharmaceutical involvement
connotative and dennotative illness classifications
Good 1977 semantic ilness networks: connotative illnes categories
are important to look at because it shows that illness categoeries are embedded
in culture and cannot be seen just dennotative
Harrison’s Principles of Internal Medicine 14th ed
New York: McGraw-Hill