Diarrhea

What is Diarrhea ???

• Overall weight & volume of stool is increased > 200 mg or ml/day.

• Water content of stool is increased to 60 – 90%• Can have many causes which may be infectious or

non infectious.

Classification of Diarrhea:According to mechanism:

Motility Diarrhea

Secretory Diarrhea

Osmotic Diarrhea

Motility disorder results in decreased contact time of fecal mass with intestinal

wall so decrease water absorption

from feces.

Intestinal wall is damaged resulting in increased secretion

rather than absorption of

electrolytes into intestinal tract.

Non – absorbable solute pulls excess

water into intestine tract. DESCRIPTION

Motility disorders :•IBS•Gastric/intestinal resection.

Lactase deficiency

EXAMPLE

According to duration:

Chronic Diarrhea Acute DiarrheaLasts more than 2 weeks Self limiting

Lasts from 2 – 3 days up to 2 weeks

CausesMay be due to:

•IBS•Protozoal infection•Malabsorption•Pancreatic disease•Hyperthyroidism

May be due to:

• Infection → (Infection induced diarrhea) , caused by microorganisms.

• Diet → (Diet induced diarrhea) , results from food allergies.

• Drug → (Drug induced diarrhea) , results from medication.

Infection induced DiarrheaACUTE

Protozoa Bacteria Viruses

1. Giardia lamblia

2. Entamoeba histolytica.

1. Toxigenic Bacteria:(E-coli, Vibrio cholera, Shigella, Staph. Aureus)

2. Invasive Bacteria:(Invasive E-coli, shigella, salmonella, campylobacter, clostriduim difficile)

1. Rotavirus2. Nowalk virus

Causative Organism

•Foul smelling.•Large Volume. •Watery Stool.

1. Toxigenic Bacteria:-large volume-watery or greasy.

2. Invasive Bacteria:-Extreme urgency of defecation & small volume of stool.-Contain pus & blood.

•Watery diarrhea. •No pus, No blood. •Self limiting.

Stool Characteristics

:Complications of Diarrhea

Fluid loss & electrolyte imbalance.

Due to

Adults with acute Diarrhea when the intake of fluids is limited by associated nausea & Vomiting

Common in Infants & Young children having viral gastroenteritis or bacterial infection.

When to refer to physician ?

Patient younger than 3 years or older than 60 years (with multiple medication problems)

Blood or mucus in stool. High fever greater than 38˚C.Dehydration or weight loss more than 5% of

total body weight. Diarrhea lasted more than 2 days.IF patient suffering frequent vomiting.

Diagnostic Tests

Stool Culture test. Blood tests of the intestines. X- rays.Endoscopy.Colonoscopy.

My child always suffers from diarrhea after drinking milk or eating dairy products is it a serious condition. How it could be treated?

Lactose intolerance (Lactase Deficiency)

 Inability to digest lactose due to lacking of enzyme (lactase) that breakdown lactose in the gut.

So increase lactose in the intestinal tract Osmotic diarrhea.It occurs when a non-absorbable solute pulls excess water into the

intestinal tract.

Symptoms of lactose intolerance:

Loose stool.Abdominal pain.

Bloating and flatulence.Nausea.

Treatment:

1) Reduced dietary lactose intake:For infants:Use Lactose-free formulas (Bebelac FL - S26 LF).

For older children and adults:- Calcium fortified soy milk and lactose free milk may be used.- People differ in the amount and type of food they can handle.- Yogurt containing lactose is well tolerated by the patients as it contains live culture of bacteria that produce lactase.

2) Administration of commercially available enzyme substitute: Lactase enzyme (Lactrase - Lactaid – Dairy ease).

3) Maintenance of calcium intake:• Eat foods that have more calcium:

- Leafy greensand broccoli.

- Sardines, Salmon and shrimp.• Take calcium supplements.

Lactose Intolerance Tests

• Hydrogen breath test. This is the most accurate lactose intolerance test..

• Lactose tolerance test. This test measures your blood sugar after you eat or drink lactose.

• Stool acidity test. Undigested lactose also increases the amount of acid in the stool.

Complications: - Osteopenia.- Fracture.

My physician prescribed Primperan®. Since taking it I suffered from diarrhea, why?

• Primperan® (Metoclopramide) is a D2- antagonist for treating of

nausea and vomiting.

• It has prokinetic effect which is produced by:

1. Inhibition of D2 receptors, stimulation of 5-HT4 receptors and

antagonism of presynaptic inhibition of muscarinic receptors.

2. This promotes release of acetylcholine (Parasympathomemic).

3. Leading to Motility diarrhea.

Other drugs that cause diarrhea:

• 1) Medications that induce motility diarrhea:

i. Parasymathomimetic drugs Bethanecol.

ii. D2-Antagonist Metoclopramide (Primpiran®)

Domperidone (Motilium®).

iii. Digitalis (Lanoxin®), Quinidine, Furosemide (Laxis®).

iv. Antibiotics by: increase bowl motility and altering bowl mirobial flora.

• 2) Medications that induce osmotic diarrhea:- Lactulose and magnesium containing antacids and

laxatives.

• 3) Medication that cause secretory diarrhea:

i. Prostaglandins Misoprostol (Cytotec® - Misotec®)

ii. Colchicine.

iii. Chemotherapeutic agents.

• 4) Orlistat : Decrease pancreatic lipase Decrease Breakingdown of fats steatorrhoea (Fatty diarrhea).

• 5) PPI : Omeprazole (Omez® - Omepac®)

Enumerate different classes of drugs used in treatment of diarrhea.

• According to FDA classification , 3 agents have been identified as category 1 “Safe and effective Kaolin, bismuth subsalicylate & Loperamide”

• In April 2003 The FDA reclassified attapulgite and polycarbophil products from category 1 to category 3 because of in sufficient effectiveness data.

Anti-diarrheal are classified on the basis of their chemical class or pharmacologic mechanism action

into:

1. Antiperistalsis drugs.

2. Adsorbents.

3. Miscellaneous agents.• Bismuth subsalicylate.• Lactobacillus.• Lactase.• Anti-infective agents.• Anti-cholinergic.

Antiperistalsis drugsThese drugs act by stimulating µ opioid receptors in musculature of small and large

intestine to normalize peristaltic intestinal movement.

PrescriptiveLomotil®

Dihpenoxylate/Atropine

OTCImodium®Loperamide

2- AdsrobentsThese medications are non-selective and

adsorb toxins, bacteria, gases, drugs…- No systemic absorption.

- For symptomatic relief in large doses.- Not effective in severe acute diarrhea.

Kapect® Suspension.Kaolin and pectin.

3- Miscellaneous agents

a- Bismuth subsalicylate.1- Adsorbent.2- Decrease the

secretion of water into the bowl.

b- Lactobacillus.Products containing non-toxic strains

of lactobacillus acidophilus are intended to replace normal bacterial

flora that is lost during the administration of oral antibiotics.

Eg: Lacteol fort®

Cont. Miscellaneous

c. Lactase enzyme

e. Anticholinergic drugs1- Decrease bowl

motility, so increase fluid absorption.

2- Decrease abdominal cramping.

d. Anti-infective agent

Eradicate the organism and decrease the

duration of symptoms.1- Nifuroxazide.

(Antinal)2- Metronidazole

(Flagyl)

7) Mrs. Robinson asks what you can recommend for diarrhea. Her son David, aged 11, has diarrhea and she's worried that her other two children, Natalie, aged 4, and Tom, aged just over 1 year, may also get it. David's diarrhea started yesterday, he went to the toilet and was sick once, but has not been sick since. He has griping pain, but in generally well and quite lively. Yesterday he had pie and chips from the local takeaway during his lunch break at school. No-one else in the family ate the same food. Mrs. Robinson has not given him any medicine, but has some kaolin and morphine mixture at home and wants to know if David could take some, and also if the other children could take it if necessary.

Kaolin and morphine mixture

• -In treating diarrhoea, morphine works by acting on opioid receptors that are found in the muscles lining the walls of the intestines. This reduces the peristalsis that move food and faecal matter through the gut.

• -Light kaolin is an absorbent substance. It is insoluble and is not absorbed into the bloodstream. Instead it acts locally in the intestines, where it absorbs toxins and helps make the stools less liquid.

• -It is used for acute diarrhea but it is not recommended in this case as it isn’t that serious and it is not used for children

• Instead he can use kapect suspension( sulphamethoxazole – trimethoprim – kaolin – pectin)

• kapect suspension• -it is non-selective• -used in case of acute & chronic diarrhea as intestinal disinfectant • -Suitable for children 2 years or older • -sulphamethoxazole + trimethroprim = synergistic effect

Recommendation for this case

1. Large fluid intake to replace the lost fluids this can be achieved by oral rehydration solutions (ORS)

2. Anti peristaltic drugs

• Example: Loperamide (Imodium tablets).

• Gives effect after 1 hour• 2-3 times more potent than diphenoxylate (Lomotil tablets)• 20 times more potent than morphine in slowing GIT motility• Indication:• -Acute non-specific diarrhea• -chronic diarrhea with IBD• Advantages:• No CNS penetration • Administration: • Adults: 4mg followed by 2 mg after each loose stool, not exceed 16mg/day • Children:1-2 mg up to three times/day• Her other children shouldn’t take any medicine as they didn’t eat from the

same food and it is not contagious

8) Mrs. Jean Berry wants to stock up on some medicine before her family sets off on their first vacation abroad; they will be going to Spain next week. Mrs. Berry tell you she has heard of people whose holiday have been ruined by holiday diarrhea and she wants you to recommend a good treatment. On questioning you find out that she has 2 boys aged 10 and 14

• Travelers' diarrhea is a gastrointestinal illness that occurs in travelers it is caused by eating food contaminated with bacteria or, less commonly, with parasites or viruses.

• Drugs that are used in prophylaxis and treatment of travelers' diarrhea are bismuth subsalicylate and anti infective agents

• If antibiotics are used to prevent Travelers' diarrhea, therapy should be started 1 day before arrival and continued 2 days after departure, if diarrhea has occurred, antibiotic treatment should last for 3 days

• Anti motility drugs shouldn't be used in Traveler's diarrhea with fever or bloody diarrhea as the increase contact time between pathogen and intestine, increase severity of the case

Prevention:

1. Avoid raw fruits or vegetables-unless you peel them yourself

2. Avoid raw or undercooked meat or seafood3. Avoid tap water, ice, unpasteurized milk, or

dairy products4. Avoid street vendors5. Avoid swimming in water that maybe

contaminated

Stomach flu

Stomach flu

• Viral gastroenteritis-winter vomiting disease

• An infection of the stomach and intestines

• It is frequently referred to as the stomach or intestinal flu

CAUSES

• Viruses – such as rotavirus, norwalk virus.• By eating contaminated food• Direct person to person spread

(contagious)

SYMPTOMS

• Nausea and Vomiting• Diarrhea

SYMPTOMS

• Abdominal Pain and Cramps

• Body Aches

SYMPTOMS• Fever and Weakness• Often begins suddenly and the

infected person feel very sick

TREATMENT• Self limiting course• Plenty of fluids and Right Diet• Oral rehydration drinks, available from your chemist• No antiviral and vaccine for

prevention• Cannot be treated with antibiotic

MR Radcliff suffer from mobility disorder and drug induced diarrhea (motility diarrhea) after taking amoxycilline

Recommendation for treatment:• Stop amoxicillin or the effect could be

minimized by taking with food or milk• 2days cut off strategy (no medication)• Avoid dehydration by fluids and rehydration

solution• Adsorbent may used

• The U.S. Food and Drug Administration today approved Fulyzaq (crofelemer) to relieve symptoms of diarrhea in HIV/AIDS patients taking antiretroviral therapy, a combination of medicines used to treat HIV infection.

• Diarrhea is experienced by many HIV/AIDS patients and is a common reason why patients discontinue or switch their antiretroviral therapies. Fulyzaq is intended to be used in HIV/AIDS patients whose diarrhea is not caused by an infection from a virus, bacteria, or parasite.

• Fulyzaq decrease chloride ions are excreted into gut which also decreases the excretion of sodium ions and water , improving stool consistency and reducing duration of the diarrhea Patients take Fulyzaq two times a day to manage watery diarrhea due to the secretion of electrolytes and water in the gastrointestinal tract.

Causes of diarrhea during pregnancy

1. Certain hormonal changes that take place within the body during this time

2. Changes in diet to provide the fetus with all the necessary nutrients

3. The extra water for keeping the body hydrated 4. Pregnancy workouts in prenatal vitamins , (changing

brand of vitamin may also be responsible)5. Food poisoning6. Stomach flu caused by certain bacteria or viruses7. Maternal gastrointestinal conditions like

inflammatory bowel disease and irritable bowel syndrome (chronic diarrhea)

In most cases it does not cause any harm to the baby , however severe diarrhea can hydrate the mother , hampering the blood flow to the fetus.

Diarrhea occuring due to some serious pregnancy complications such as abdominal or uterine infections , especially during the second and third trimesters may also be dangerous for the baby.

• I am taking bismuth subsalicylate for diarrhea, I noticed some annoying effects. What are adverse effects and contraindications ?

Adverse Effects:1. Black tongue & black stool. 2. Ringing in the ears (Tinnitus)

Occur with high doses specially if patient is simultaneously taking other salicylate products.

Contraindications:1. Patient with black or bloody stools.

2. Children or teenagers during or other recovery from chiken pox or flu because of possible associations of salicylates with Reye’s syndrome.

3. Patients with documented allergies to salicylates.

4. Pregnant & Breast feeding women.

5. Patients in anticoagulants should be monitored closely if taking these products.

• A patient is taking Lanoxin®, he suffers from diarrhea & takes Kapect®.

What do you recommend ? What is Kapect Compound ?

I recommend to do dose spacing between Kapect® & Lanoxin® at least 3 hours because Kapect® decreases absorption of other concomitant oral administered drugs, specially the potent like Lanoxin®

Kapect® Compound is ( Kaolin, pectin, trimethoprim, & sulphamethoxazole ) suspension.

• 13) Dehydration is a serious complication of persistent diarrhea, especially in infants as it could be lethal. How does this imbalance be corrected? What is ORS according WHO/UNICEF definition?

• All patients should receive their normal diet or breast feeding

• fatty foods, foods rich in simple sugars and spicy food should be avoided

• Most important part of treating acute diarrhea is the replacement of lost electrolytes

• If patient has mild to moderate fluid loss: oral rehydration solution (ORS)

• If fluid loss is severe (>10% loss of body weight) and/or severe vomiting: IV rehydration is needed

• Fluids to be avoided : hypertonic fruit juices and drinks, carbonated beverages and caffeine.

Guidelines for the oral replacement therapy established by the WHO :

• All of these solutions are considered safe but have no effect on the duration of diarrhea

Dose Ingredients90mEq (1/2 teaspoon) Sodium chloride (table salt)

20mEq (1/4 teaspoon) Potassium chloride

30mEq (1/2 teaspoon) Sodium carbonate

20 g ( 2 teaspoons ) Glucose (sugar)

Enough to make 1L solution Water

Guidelines for the recommended doses established by the WHO:

Moderate(4-5 stools/day) Mild (2-3 stools/day) Age group

2-4L/ first 4 hr then replace ongoing losses

2L/first 4hr then replace ongoing losses >5 years of age

100ml/kg/first 4 hr then 1/2-1 cup per stool

50ml/kg/first 4 hr then 1/2-1 cup per stool

<5 years of age

• 14) What is the mechanism of action of anti-peristaltic and adsorbents as anti-diarrheal drugs and what are their contraindications?

A) Anti peristaltic drugs:Mechanism of action• These drugs act by stimulating μ-opioid receptors in musculature

of small and large intestine to normalize peristaltic intestinal movement

Contraindication:1. Acute bacterial diarrhea with fecal leukocytes, fever, blood or

mucus because it • Decrease bacterial clearance• Enhance systemic invasion2. Colitis : Toxic mega colon 3. Children < 6 years4. Not more than 48 hours

Prescriptive anti peristaltic:

• Lomotil tablets (diphenoxylate/atropine )• Atropine: sun-therapeutic dose to prevent addiction of

diphenoxylate due to its annoying side effects (anti-muscarinic effect)

• Contraindication of lomotil:• -glaucoma • -Asthma or other lung problems • -problems with urination or BPH• -Heart problems or high BP• - Pregnancy (cat. C) and lactation

ii. Non-prescriptive anti-peristaltic:

• Imodium® tablets

B) Adsorbents:• Kapect compounds: (sulphamethoxazole- trimethoprim –Kaolin-

Pectin)• Kapect suspension: (kaolin and pectin)• Mechanism of action:• These medications are non-selective and adsorb toxins, bacteria,

gases, drugs• Non systemic absorption• For symptomatic relief in large doses• Not effective in severe acute diarrhea• Doses:• Adults and children > 12 years :26.2 gms after each loose stool &

continue each 6 hrs• Not used > 2 days or >262 g/day

I suffered from diarrhea and I was prescribed Lacteol Fort® Which cause

me to siffer from flatulence, Is it necessary to continue the treatment ??

• . Many people, when they first start taking probiotics, whether it is acidophilusor one of the other helpful bacteria, notice an increase in wind (intestinal gas, flatulence.)

• Inside our intestinal tract are various types of bacteria. As they digest the fiber from our diet some of these bacteria produce gas in the form of methane and hydrogen. Other bacteria need this gas for them to grow and so they absorb it.

• I'm sure you can see that as long as those two different types of bacteria are in balance - everything is sweet. But let the gas producers outstrip the gas absorbers, and you have a bad flatulence problem! - the most common of the acidophilus side effects.

• Another type of acidophilus side effect is caused by the toxins that bacteria release as they die off. Harmful bacteria are being defeated and this can lead to a worsening of symptoms for a short time but it is not dangerous

• You feel worse before you feel better

• So, the temporary side effects of acidophilus may take the form of bloating, diarrhea and flatulence or they may be more flu like or allergenic.

• Most people will experience nothing at all

• Sometimes you can get round the side effects by taking a more balanced probiotic such as iFlora but remember to start slowly

Is there anything you can do to avoid this bloating and wind?

• Yes!

• Because this is the result of your intestinal microflora getting out of balance, your aim is to get it back in balance as rapidly as you can.

• First of all stop taking the acidophilus supplement

• The next day divide the capsule or tablet that you normally take into quarters. Do NOT worry about how exact all of this is. All we're trying to do is dramatically reduce the amount of acidophilus you are taking

• Take a quarter dose each day until the symptoms go

• Now increase to a half dose, again staying at that level until you are symptom free.

• When should I use Anti infective agent for treatment of diarrhea ? Give example to anti infective agent ?

• I use anti infective agent in infectious diarrhea which is caused by Bacteria as salmonella or shigella or viruses as ruta virus or parasites As Giardia lamblia this is called infectious diarrhea

• Ciprodiazole® is a good drug for treating these

types of diarrhea Ciprodiazole® is a combination of Ciprofloxacin 500 mg (Oral Fluroquinolones) and Metronidazole 500 mg (for anaerobic infections )