Diarrhea With Generalized Weakness: The Body’s Electrolyte Balance Gone Haywire
Most people have experienced stomach aches accompanied by loose bowel movements. In many cases, simple hydration and a few hours' rest will allow the symptoms to subside on their own. In some cases it may take a few days before the diarrhea recedes. In a few cases, however, it may lead to a common but dreaded complication—electrolyte imbalance. In order to fully understand this disease condition, we present the hypothetical case of Mr. Q.
Case Study: Mr. Q
We are presented a case of a Mr. Q, 36-year-old male who is employed as a construction worker at a hydroelectric generator near a mountain falls. He reported that after eating lunch with his team, he suddenly developed diarrhea accompanied by abdominal pain, nausea, and vomiting. It persisted despite intake of Loperamide. He attributed the culprit to the water he and his co-workers drank, since several of them also suddenly developed the same symptoms. A few hours later, he suddenly developed generalized weakness. He described that he was unable to rise up from his bunk bed the next morning.
Should we attribute the diarrhea Mr. Q to his generalized body weakness? Or is it a separate entity? Is this a complication that is common in most cases of sudden loss of massive amounts of electrolytes in the body? In order to appreciate the condition, we should consider the different possible causes of these different disease entities.
What may cause the sudden onset generalized weakness?
Different etiologies of generalized weakness were listed and the neurologic causes and muscle disorders were not considered due to the absence of other neurologic manifestations. Since Mr. Q did not present with changes in consciousness, focal neurologic deficits, or other local symptoms aside from the changes in motor function. From the metabolic disorders, the different organ systems such as the gastrointestinal, renal, and endocrine system were considered since changes in electrolytes causes changes in the capacity of muscles to have initiation in action potentials for movement.
The renal system regulates the body’s electrolyte levels and massive renal losses can cause electrolyte changes. Since Mr. Q has not presented with signs of uremia, renal disorders isolated to tubular defects may be considered. For the endocrine system, the main cause of a hyperglycemic state can be ruled in due to the effects of glucose on different transporters in the body, but was not further explored due to the absence of a clear cause for hyperglycemia. Hyperglycemia is the state wherein the body has increased glucose in the blood. This is common in case with diabetes mellitus.
Diarrhea and its connection to Generalized Weakness
Mr. Q presented with acute onset diarrhea that is likely to be infectious in nature due to their exposure in their workplace. Several co-workers had diarrhea as well. Basing from the onset of symptoms, the pathogen may have be delineated based on the signs and presented such as the characteristic watery type with fishy odor, no abdominal pain, fever, and blood. The toxin producing agents and invasive agents may not be the likely cause due to the absence of abdominal pain and vomiting, and blood in the stool, respectively. This zeroes in to a possible enteroadherent agent in the intestinal mucosa. When time framed mapped on incubation period is added into the equation, possible etiologic agents include Enteropathogenic E. Coli, Giardia spp. Or Cryptosporidium spp. The final etiologic agent can be definitively identified via fecalysis.
Many disregard the type of diarrhea they have to the possibility of massive fluid and electrolyte losses. Several organisms have varying effects that may cause the development of diarrhea. As we see in this case, even the ingestion of small quantity of water may lead to neuromuscular complications in a short span of time.
Common Causes of Generalized Weakness
Brain or Spinal Cord Trauma/ Infection
Malnutrition, Vomiting, Diarrhea
Gitelman's Syndrome, and other Tubular Disorders
Neuromuscular Junction Disorders
Electrolytes and how it affects muscle movement
Fluid and Electrolyte losses during the multiple episodes of diarrhea have predisposed Mr. Q to the possibility of hypovolemia and electrolyte imbalance. Changes in electrolyte levels may lead to inability of the muscles to properly initiate and propagate action potentials leading to changes in membrane depolarization. The most common loss of electrolyte during diarrhea is losses of potassium. Since potassium is generally stored intracellularly, sudden changes in extracellular levels of potassium causes dramatic changes such as generalized muscle weakness.
Most cases also have instances wherein there is decreased appetite and minimal to no oral solid food intake. This aggravates the inability of the body to replenish the losses of both fluids and electrolytes. The disease process itself may also be considered contributory. Increased stress in the body doe to any form of insult (such as an acute disease) will predispose a beta- adrenergic response. This causes an increase in influx of potassium from the ECF to the ICF. Hence, on top of the decrease in GI losses, decreased intake and intracellular shift causes further depletion.
Zeroing into the Cause of Weakness
- Blood Chemistry: Serum Electrolytes Due to diarrhea, massive loses of electrolytes is expected. Blood chemistry is the definitive test to quantify the degree of imbalance. The actual levels may be correlated with the clinical manifestations and the amount in case there is a need for electrolyte replacement therapy.
- Stool Micro-biologic Studies- Assessment of the etiologic agent for diarrhea is needed for the appropriate antibiotic therapy. Management of this may help decrease diarrhea. Further culture and sensitivity test may be done in cases that the agent is not easily isolated.
- Fasting Blood Sugar, HBA1C- these tests detect the possible hyperglycemia and to fully rule out the possible etiology of diabetes. Long-standing diabetes may cause complications, one of which include alteration in the GI innervation leading to diarrhea.
- Urine Electrolyte level- the diagnosis of inherited renal tubular disorders may be diagnosed by the levels of excreted urine electrolytes. Hypomagnesemia and hypocalciuria is diagnostic for Gitelman’s syndrome. This is a tubular disorder that may cause apparent changes in serum electrolytes due to wasting the renal system without dramatic changes in the filtration capacity of the kidneys.
- EMG- this measures the condition of potentials in the muscle fibers. In case that the weakness of has not resolved even after replacement of electrolytes, and resolution of diarrhea, other neurologic and local cases should be entertained.
Among the different electrolytes, which one is lost greatly during persistent diarrhea?
What to do in suspected cases of generalized weakness due to electrolyte imbalance?
Upon admission, the main management consists of addressing the fluid and electrolyte alterations. Appropriate fluid replacement is the primary goal of treatment, which resolves imminent problems that may arise due to the presence of diarrhea. It generally depends on the patient's condition, and whether severe dehydration and possible electrolyte imbalance are already present. Fluid resuscitation may initially start with oral rehydration, and intravenous crystalloids (75ml/kg) to maintain the cardiac output.
If the diarrhea has continued to be watery, and without any blood or accompanied fever, symptomatic treatment may be done to decrease the fluid losses. Loperamide may be administered to control of symptoms.
Since the etiologic agent is likely infectious, antibiotics may be administered if the pathogen has been isolated via microscopy or culture. This can help reduce the bacterial load, and may help decrease the uncontrolled passage of water and electrolytes outside the body if the diarrhea has persisted even after admission.
The generalized body weakness should be addressed by initially isolating the cause of the electrolyte imbalance. The specific electrolytes should be replenished. In this case, potassium is the most likely electrolyte that may have caused the current symptoms. The target level is between 3.5- 5 mEqs. Administration of potassium may be done orally and intravenously (20 meQs diluted in 1 L PNSS). Continuous assessment of and monitoring of potassium level should be done to avoid overcorrection.
The most important measures to prevent this complication is prompt assessment and replacement of both fluids and electrolytes!
Non-pharmacologic management and health education may include the following:
- Assessment of hygienic and food preparation practices at home or in the workplace
- Hand hygiene and toilet hygiene may also help decrease the likelihood of transmission of pathogen
- Evaluation of the food intake and preferences should be considered
- Stocking of oral rehydration solutions at home and in the workplace is prudent for first aid replacement
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