5 - GI: Diarrhea Flashcards by Karlo Sison

Epidemiology of Diarrhea

Prevalence HIGHEST in children <5 yo

lowest in adults >65 yo

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Etiology of Diarrhea

Poor Sanitation + Hygiene

parasites / bacteria / virus

Day care / food handler / caregiver / close living

Consumption of unsafe foods

Medications / Medical COnditions

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EX-ST for Diarrhea

< 6 months old

SEVERE DEHYDRATION HIGH FEVER >102.2F

PREGNANCY

blood / mucus / pus / protracted VOMIT

Severe ab pain / risk for complications w/ disease

chronic / persistant diarrhea

Inability to take ORT (or poor response to ORT)

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Fluid / ELectrolyte Management

for Diarrhea

ORAL REHYDRATION THERAPY (ORT)

glucose / sodium / chloride / citrate / potassium

Recommended in Mild-Moderate Diarrhea

as effective as IV replacement in children

Lower Osmolarity vs

electrolyte dextrose drinks (gatorade

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Mild to Moderate

Dehydration / Diarrhea

3 - 9 % loss of body weight

Fatigued / restless / irritable

normal to increased HEART RATE

normal to decreased pulse quality*
decreased tears / urine output*

cool extremeties / thirsty

_<_5 unformed stools per day

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ORT for childrean

1 month to 5 years old

50-100 ml/kg

over 3-4 hours

10ml/kg per each loose stool

Maintanance:

Continue ORT for 4-6 hours until rehydrated

resume normal eating

Ideally 3:1 ratio of glucose to sodium

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ORT for children or adults

>5 years old

2-4L

over 3-4 hours

Replace losses

Maintanence:

Continue ORT PRN

normal diet

Symptomatic Drug Therapy

Gatorade is 15:1 ratio (lot of water)

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Pharmacologic Treatment of

Diarrhea

Loperimide

Imodium A-D

Bismuth Subsalicylate

Pepto Bismol

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Loperamide

Indication / MoA

Imodium AD

Opioid agonist

slows motility –> allows for absorption

Used for: Traveler’s Diarrhea / Acute diarrhea / IBD

afibrile or low grade fecer

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Loperamide

ADR / DI / Counseling

Imodium

DNU <6 yo

Ab pain / dizziness / constipation

avoid in pt if signs of INVASIVE INFECTION

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Bismuth Subsalicylate

MoA / Indications

Pepto Bismol

Reacts w/ HCL –> bismuth oxycholride + salicylic acid

ANTIMICROBIAL EFFECTS OF BISMUTH

Reduces freq of unformed stools*
Relives ab cramp*
decrease nausea + vomiting*

Used for Acute Diarrhea / Traveler’s Diarrhea

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Bismuth Subsalicylate

ADR / DI / Counseling

Pepto Bismol

DNU <12 y/o

Avoid in other viral infections in children

Tinnitus / BLACK STOOL+TONGUE

Aspirin / Warfarin

Valproid Acid / methotrexate

TCA / quinolones

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Pepto Bismol for children

ONLY FOR ADULTS AND CHILDREN >12 y/o

But there is a Children’s Version* (calcium carbonate)
only treats Heartburn though.*

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Diatary Management of

Diarrhea

BRATT diet
- Bananas + Rice + Applesauce + Tea + Toast
  - DNU alone or for a long time
Recommend eating:
- Yogurt + Complex carbs / Fruits / Veggies / Lean meats
Avoid:
- dairy / fatty foods / spicy foods / simple sugars
- alcohol / caffeine

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Diarrhea Recommendations

FLUID INTAKE is important

SEE MD if on OTC meds for >48 Hours

Most diarrhea is SELF LIMITING

(use non-pharm treatment first)

Double check active ingredients

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Lactose Intolerance

Epidemiology

Most Common in:

Asians > Native americans

> African

Hispanic > Caucasian

Symptoms after ingestion of

LACTOSE

Ab Pain

Bloating

Flatulence

Diarrhea

bulky / frothy / watery stools

Vomiting in Adolecents

Tips for Lactose Intolerance

Decrease Dietary Lactose

Alternate nutrient sources for energy/protein

Dietary Enzyme Substitute (lactase)

Maintain CALCIUM + VIT D

Lactase

Lactaid

Digestive Enzyme

don’t completely hydrolyze all dietary lactose

Liquid Lactaid can be added to milk

14 drops -> 1 quart

Refrigerate overnight

Adjust dose and lactose load to tolerance

Probiotics

Derived from cultured milk products

Help maintain normal GI Flora by:

inhibiting bacterial overgrowth

Role not coclusive

generally safe

Lactobacillus GG

Culturelle

Uses: Mild Viral Diarrhea

in infants/young children

also in some yogurts

for infectious / antibiotic-associated diarrhea

Lactobacillus Acidophilus

Used for Management / prevention of:

Acute uncomplicated diarrhea

Vaginal Infections

Not considered effective by FDA

for infectious / antibiotic associated diarrhea

Bifidobacterium Animalis / Lactis

Activa / Align

Added to yogurt

to promote intestinal transit / aid in reguarity

Bifidobacterium Infantis

Constipation / Diarrhea / Urgency / Gas / Bloating

**Align** **Dose & Indication**

_Bifidobacterium **INFANTIS**_ 4mg **1 Capsule Daily** For **IBS / Constipation / DIARRHEA /** **Nausea & Cramping**

**Align** ADR / CI / Counseling

*Immunocompromised patients* ***Pregnancy / Lactation LIMITED*** **Flatulence / Bloating / Diarrhea** Store at **ROOM TEMP / has milk products**

**Culturelle** **Dose / Indication**

_Lactobacills **GG**_ **1 Dose Per Day** or **BID** during digestive upset or travel **14 day course** may be repeated once every **q4 MONTHS**

**Culturelle** ADR / CI / Counseling

Lactobaccillis **GG** *Immunocompromised patients* ***Pregnancy / Lactation limited*** **flatuelence / bloating / diarrhea** **_CAPSULE MAY BE OPENED AND MIXED WITH_** **_COOL DRINK OR FOOD_** ***do NOT add to WARM OR HOT foods/drink*** store in cool place / room temp.

**Lactaid** **Dose / Indication**

Lactase Enzyme Original Caplet = 3000FCC Fast Act = 9000FCC _To help prevent GAS / BLOATING / DIARRHEA_ **9000 FCC (1 or 3 capsules)** **with the FIRST BITE OF DAIRY FOODS**

**Lactaid** **ADR / CI / Counseling** lactase enzyme

* No known adverse effects* * See MD if symptoms persist after dairy* Take with **First Bite of dairy foods** Consider supplementing **CALCIUM**

**Loperamide HCL** **Dose / Indication**

**_Imodium A-D_** (anti DIARRHEA) Caps = **2mg** vs Liquid = **1mg / 7.5ml** **_2 Caps_** (4mg) or **4 ts** **_AFTER FIRST LOOSE BOWEL MOVEMENT_** _**1 Cap** (2mg) or **2 ts**_ ***After each subsequent loose bowel movement*** max 4 caps, \<2 days

**Loperimide HCL** **MAX Dose**

_Immodium A-D_ Max of **4 Caps (8mg**) or **8 ts** for no more than **\<2 days**

**Loperamide HCL** ADR / CI Immodium AD

use only for **_\< 2 days_** * Do not use if diarrhea is with **HIGH FEVER / BLOODY STOOLS*** * caution with hepatic dysfunction* * DNU w/ **Ulcerative Colitis*** or diarrhea from **E.Coli / Salmonella / Shigella** **_Constipation / Dry Mouth / Nausea / Vomiting_**

**Loperamide HCL** **Consultation** immodium AD

**\<2 days use** DNU with presence of ***HIGH FEVER / BLOODY STOOLS*** Prevent dehydration by drinking: **Fluids high in Electrolytes** *Avoid **Milk*** May cause ***DROWSINESS***

**Bismuth Subsalicylate** **Dose / indication**

**_Pepto Bismol_** Tabs / Caps = **262mg** Liquid = **525mg / 30ml** **2 tabs (524mg) every hour PRN** or **1 tbps** **q1hr prn**

**Bismuth Subsalicylate** **MAX Dose**

Pepto Bismol 2 tab (524mg) q1hr PRN Max dose of: **8 Doses** / day **(16 tabs of 262mg tabs)** _**4 Doses of extra strength (525mg tabs**)_

**Bismuth Subsalicylate** CI/P / ADR Pepto Bismol

High Fever + Bloody Stools **REYE SYNDROME** (children w/ flu) *ALLERGIC TO:* ***ASA*** ***Asthma / Ulcers / Bleeding*** ***Stomach Pain / Gout / Diabetes*** **_BLOOD THINNERS_** **_TEMPORARY DARKENING OF TONGUE OR STOOLS_**

**Bismuth Subsalicylate** **Consultation** Pepto Bismol

Ask about **RX meds** (anticoags / probenecid / sulfinpyrazone) **\< 2 Days** Drink **fluids w/ electrolytes** *Avoid **Milk*** **_Harmless darkening of TONGUE / STOOLS_**

**Saccharmomyces** **Florastor**

Non-pathogenic yeast **250-500mg BID-QID** 250 mg bid qid for children **_Prevention & Treatment of AB-associated diarrhea_** **_+ travelers diarrhea_**