19 - Diarrhea Flashcards
What are the signs of dehydration in adults?
- Dry mucous membranes
- Thirst
- Decreased urination
- Decreased skin turgor
What is the definition of diarrhea?
- Symptom characterized by increased frequency of defecation, w/ the stools being loose and watery
- 3 or more loose stools in 24 h
When is a person considered to have diarrhea?
When there is increased frequency in bowel movements from the px baseline w/ decreased consistency
What are some complications of diarrhea?
- Electrolyte imbalances
- Risk of dehydration
- Hemorrhoids
What is the difference between acute and chronic diarrhea?
- Acute = lasts less than 14 days
- Chronic = lasts longer than 14 days or recurring diarrhea lasting less than 14 days each
What are common causes of acute diarrhea?
- Infections (most common cause of diarrhea; caused by bacteria, viruses, parasites)
- Medications, and/or
- Diet/nutrition
What are common viral causes of diarrhea?
- Norovirus
- Rotavirus
- Adenovirus
- Calicivirus
What are common bacterial causes of diarrhea?
- Campylobacter
- Salmonella
- Escherichia coli
What are common parasitic causes of diarrhea? Are they an automatic referral?
- G. lamblia, E. histolytica, Isospora belli, and cryptosproridium
- Referral b/c not self limiting
What are some medications that can cause acute diarrhea?
- Broad spectrum antibiotics (penicillins, cephalosporins, erythromycins)
- Usually occurs 2-3 days after starting antibiotic
- Resolves when antibiotic withdrawn
- Others = laxatives, antacids, metoclopramide, orlistat, misoprostol
Which medications can cause pseudomembranous colitis (C. difficile)?
Clindamycin, fluoroquinolones, penicillins, and cephalosporins
Which foods can cause acute diarrhea?
- Intolerances to food components or food allergies (most common = gluten and lactose)
- Foods w/ large amounts of sorbitol or mannitol
- Fatty, spicy, highly salted foods
- Rapid increases in dietary fibre
What are some risk factors for infectious diarrhea?
- Attendance or employment at daycare centres
- Occupation as food handler or caregiver
- Congregate living conditions (ex: nursing homes, prisons)
- Consumption of unsafe foods (ex: raw meat, eggs, shellfish)
- Presence of certain medical conditions
What are some causes of chronic diarrhea?
- Most common = inflammatory process (IBD, UC, Crohn’s)
- Tumours
- Chemotherapy
- Malabsorption of carbohydrates
- Diabetes
- IBS
Is chronic diarrhea a referral?
Yes b/c don’t know unknown/known underlying causes
What are some red flags for diarrhea?
- Fever over 38.5, extensive abdominal pain or cramping
- Blood or abnormal mucous in stool
- Signs of debilitating dehydration or weight loss due to diarrhea
- Vomiting more than 4 h
- Age under 2 y/o or frail elderly
- Severe diarrhea, more than 6 loose stools/day for more than 48 h
- Chronic medical conditions (that could experience complications from dehydration)
- Suspected laxative abuse
- Pregnancy
- Immunocompromised px
- Recent antibiotic use (particularly those associated w/ C difficile)
- Worsening, persistent or chronic diarrhea
What are signs and symptoms of dehydration in children?
- Dry mouth, tongue and skin
- Few or no tears when crying
- Sunken eyes, cheeks, and/or abdomen
- Decreased urination (less than 4 wet diapers in 24 h)
- Sunken soft spot (fontanel) in infants
What are the self treatment goals for diarrhea?
- Determine specific etiology and recommend appropriate tx
- Relieve symptoms and re-establish normal stools
- Prevent or correct fluid and electrolyte loss or imbalances
- Prevent complications (hemorrhoids)
What are some non-pharms for prevention of diarrhea?
- Wash hands before preparing and eating food, as well as after going to the toilet or changing a diaper
- Prevent food poisoning (avoid unpasteurized milk and fruit juice; cook red meat, poultry and eggs thoroughly; keep hot foods hot and cold foods cold; rinse foods that aren’t cooked before eating; use separate cutting boards for raw meats and vegetables; reheat foods completely)
- Oral rehydration therapy good for children and elderly (only used to prevent dehydration; doesn’t work if px already dehydrated)
- Dietary management (avoid fatty foods and simple sugars, avoid spicy foods, avoid caffeine)
What are contraindications to oral rehydration therapy for diarrhea?
- Protracted vomiting despite small frequent feedings
- Worsening diarrhea and unable to keep up w/ losses
- Stupor or coma
- Intestinal ileus
What is the ideal sodium to glucose ratio for oral rehydration therapy?
1:1
Are sports drinks recommended for oral rehydration therapy?
No b/c high in sugar and low in electrolytes
What is the dosing for pedialyte?
- Infants and children = 100-150 mL/g per day
- Children 4 years and older = 2 L or more daily
What is the MOA of loperamide?
- Synthetic opioid agonist
- Slows intestinal motility allowing absorption of electrolytes and water through intestine
- Decreases GI secretion
- Reduction of daily fecal volume, increase viscosity and bulk volume, reduce fluid and electrolyte loss
What is loperamide indicated for?
- Non-specific acute diarrhea, traveler’s diarrhea
- Adjunct to rehydration therapy
- Only for children over 2 y/o
- Only used in pregnancy if recommended by physician
What are some SE of loperamide?
- Abdominal pain, distention, cramps
- N/V
- Dry mouth, constipation
- Drowsiness, fatigue
- Skin rash
What is the dosing for loperamide?
- Adults = 4 mg (2 tablets) initially, followed by 2 mg after each subsequent loose stool; max 16 mg per 24 h
- Children 2-12 y/o must consult physician before use
- Max duration = 2 days
What are some contraindications for loperamide?
- Individuals w/ blood or mucous in stool
- Fever
- Infectious diarrhea or TD
- Acute ulcerative colitis
- Pseudomembranous colitis associated w/ broad spectrum AB
- Age under 2 y/o
What is the onset of loperamide?
30 mins to 1 h
What drugs interact w/ loperamide?
- Saquinavir (major)
- Ritonavir, gemfibrozil, itraconazole, St. John’s wort, valerian, quinidine (moderate)
What are sx of loperamide abuse?
- Dizziness
- Urinary retention
- Syncope
- Shortness of breath
- Palpitations
- Dystonia
What is the MOA of bismuth subsalicylate for diarrhea?
- Bismuth has antimicrobial effect against diarrhea-causing pathogens
- Salicylates exert antisecretory effects that rescue fluid and electrolyte losses in acute diarrhea
- Decrease frequency of unformed stools and increase stool consistency
When is bismuth subsalicylate indicated?
- Symptomatic relief of milk non-specific diarrhea
* Don’t use in children under 18 y/o w/ febrile viral illnesses (like chicken pox) b/c of risk of Reye’s syndrome
What are some SE of bismuth subsalicylate?
- Impaction (infants and debilitated px)
- Grayish-black stools/tongue
- Tinnitus
- Headache and confusion
What is the MOA of attapulgite (adsorbent)?
- Reduces number of bowel movements, improves stool consistency
- Relieves cramps associated w/ diarrhea
What is the indication for attapulgite?
- Children over 3 y/o
- Not used for more than 2 days unless under physician supervision
What is a disadvantage to attapulgite?
Long onset of action (12-19.5 h) while self-limiting diarrhea should only last 2-3 days
Can fibre be a tx for diarrhea?
Yes
What should be monitored w/ diarrhea?
- Signs and sx of dehydration; if occurs, refer to physician for evaluation
- Refer if condition doesn’t resolve in 48 h, diarrhea worsens, px has high fever, or blood/mucous in stool
- Some improvement should be seen w/in 24-48 h w/ tx
What is traveller’s diarrhea?
3 or more loose, unformed stools per day along w/ at least 1 sx of enteric infection (fever, abdominal cramps, nausea, fecal urgency, or blood/mucous in feces)
Is traveller’s diarrhea generally self-limiting?
Yes, lasts max. 3-4 days
What is the most common cause of traveller’s diarrhea?
Non-invasive type E coli
Which px are considered at high risk of traveller’s diarrhea? What is our recommendation for them?
- Recommendation = go to physician for Rx prophylaxis
- Travellers visiting high risk areas on critical business that could be jeopardized if ill
- Px w/ underlying health problems that make them more susceptible to diarrhea or complications due to TD
- Px taking PPIs, H2 blockers, or antacids
- Px in which dehydration could cause medical complications
- Px w/ underlying disease
What are some non-pharms for traveller’s diarrhea?
- Education on prevention (boil it, cook it, peel it, or forget it)
- Use purified water to brush teeth
- Avoid drinking local water, drink water from sealed bottle
- Avoid consuming water while swimming
- Wash hands before eating and drinking
- Eat fully cooked food
- Avoid food from street vendors
- Avoid unpasteurized dairy products
What can be used for prevention of traveller’s diarrhea?
- Bismuth subsalicylate; may be used up to 3 weeks
- Vaccine; provides protection for 3 months
What is the tx for traveller’s diarrhea?
- Either loperamide or bismuth subsalicylate (if no red flags)
- Rx also available
When are probiotics used for traveller’s diarrhea?
- Can be started 3 days prior to departure for prevention
- Can treat TD w/ 2 capsules or sachets (500 mg) once daily for 5 days
What are the 3 main types of lactose intolerance?
1) Primary – late onset, occurs w/ increasing age and individuals exhibit tolerance to various levels of lactose
2) Secondary – transient, develops secondary to illness or disease involving mucosal injury
3) Congenital – extremely rate and requires lifelong lactose-free or very low lactose diet
What are the tx options for lactose intolerance?
- Lactase supplements taken immediately prior to ingestion of dairy product
- Px must experiment w/ how many tablets/drops protect against certain amounts of lactose-containing foods
