65: Diarrhea Flashcards by Brooke Thornburg

diarrhea physiology

-9 liters of fluid enters small intestine every day
-if SI water scapacity exceeded, chyme overloads colon

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Increased intestinal motility causes

diarrhea

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decreased intestinal motility causes

constipation

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Segmenting contractions

-delay passage and mix intestinal contents allowing for greater absorption
-fewer in pt w diarrhea

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Diarrhea

-inc frequency and dec consistency of fecal discharge
-episodes begin abruptly and usually subside 1-2 days w/o tx
-often symptom of systemic disease

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Fecal Incontinence

-inability to control bowels
-stool leaking from rectum
-may occur temporarily during diarrhea bout
-can be chronic/recurring
-more common in women and in the elderly

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Diarrhea epidemiology

-not routinely reported to CDC
-big time in daycare centers
-5% population
-Norovirus most common foodborne cause
-leading cause of childhood death in developing countries (typhoid fever)

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Types of diarrhea

-Secretory
-Osmotic
-Exudative
-Altered Intestinal Transit

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Secretory diarrhea

-change in active ion transport
-either dec Sodium absorption or
-or inc chloride secretion into lumen (water follows)

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Causes of secretory diarrhea

-pancreatic tumors, unabsorbed fat
-laxatives
-bacterial toxins
-LARGE STOOL volumes >1L/day
-normal ionic stool content
-not altered by fasting

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Osmotic diarrhea

-when poorly absorbed substances retained in intestinal fluids
-results in influx of water and electrolytes into lumen

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Causes of osmotic diarrhea

-malabsorption syndromes
-LACTOSE intolerance
-admin of divalent ions (mg antacid)
-consumption of poorly soluble CHOs
-improves with fasting! (no eating no diarrhea)

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Exudative diarrhea

-subset of secretory
-secondary to IBD
-IBD discharge mucus, proteins, and blood into gut
-characterized by LARGE stool volumes

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Bacterial causes of diarrhea

-shigella
-salmonella (most common in US)
-campylobacter
-staph
-e. coli

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viral causes of diarrhea

-Norovirus #1
-Rotavirus

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Drug-induced diarrhea

-laxatives
-antacids w Mg
-electrolytes
-sorbitol in liquid formulations
-antimicrobials
-motility agents
-cholinergic meds
-antiHTN
-misoprostol
-colchicine
-PPI and H2RAs
-mycophenolate
-metformin

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Drug induced diarrhea in cancer pts

-antineoplactics (-ecan)
-lots of mABs
-oral, IV, immunotherapy

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Diarrhea presentation

-small intestinal involvement: cramps, sounds, lower right pain w cramping
-Large intestinal involvement: aching sensation with straining (tenesmus)

-N/V, HA, pain, fever, chills
-weight loss if chronic
-hyperperistalsis w generalized local tenderness on exam

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Diarrhea diagnosis

-stool analysis
-endoscopic visualization and biopsy
-radiographic studies

Complications of diarrhea

-QOL
-social isolation
-DEHYDRATION
-electrolyte imbalance = cardiac

Dehydration from Diarrhea

-dry mucous membranes
-concentrated urine
-skin tenting
-dizziness when standing
-orhtostatic hypotension

Desired outcomes of diarrhea tx

-manage diet
-prevent excessive water/electrolyte disturbances
-provide symptomatic relief
-treat curable causes
-manage secondary causes of diarrhea

Non-pharma tx of diarrhea

-diet
-electrolyte replacement

Diet managment for diarrhea

-more important w OSMOTIC
-need to eliminate causative agent
-do not stop feedings in children w bacterial diarrhea
-mild, digestable, low-residue
-Bananas, Rice, Applecause, Toast

Electrolyte replacement

-re-hydrate and prevent electrolyte disturbances -infants and elderly at most risk -enteral admin preffered -IV for pt in shock, severe dehydration, or cant stop vomitting -pedialyte and enfalyte

Diarrhea pharma tx goals

-eliminate cause -dec fluid in lumen -dec PROPULSIVE contraction -inc MIXING contractions

Treatment of acute diarrhea with no fever

-fluid/electrolyte replacement -loperamide, diphenoxylate or absorbent -diet

Tx of acute diarrhea WITH fever/symptoms

-check for parasites -if no parasites treat like regular -if positive, use antibiotic and symptomatic therapy

Tx of chronic diarrhea

-treat specific cause -if no diagnosis: -replete hydration -D/C potential drug inducer -adjust diet -loperamide or absorbent

Traveller's Diarrhea

-most caused by bacteria -acute watery diarrhea -lasts 2-3 days

Prevention of traveller's diarrhea

-drink bottled water and drinks -wash fruits and veggies -antimicrobial prophylaxis should NOT be used routinely, consider for pt at high risk of complications then use rifaimin -Bismuth subsalicylate may be considered for any traveler -NOT fluoroquinolones

Treatment of traveler's diarrhea

-oral rehydration solutions for all -loperamide adjunctive therapy

tx of mild traveller's diarrhea

-no antibx -loperamide of BSS 60ml 2 tabs QID

tx of moderatte traveler's diarrhea

-antibx MAY be used -Loperamide alone or w antibiotic

tx of severe traveler's diarrhea

-antibx SHOULD be used -single-dose preffered -loperamide considered as adjunctive

Drug-induced diarrhea etiology/presentatino

-dec transit time leads to irregular absorption and secretion -alteration of bowel flora (antimicrobials) -mild to life-threatening -varied duration depending on causing agent

Tx of drug induced diarrhea

-d/c offender if possible -oral rehydration solutions -anti-motility agents

Antimotility drug action

-activate mu opioid receptors on smooth muscle of bowel to reduce peristalsis and inc segmentation =delayed transit of intraluminal contents

Antimotility drug concerns

-should NOT be used long term (esp opioid derivatives) -not to be used w C. diff diarrhea

Antimotility drugs

-diphenoxylate/atropine not for young kids -loperamide OTC -codeine

Loperamide

-antimotility -4mg start, 2mg after each loose stool no more than 16mg.day -high doses can lead to death and bad heart problems

Absorbents

-absorbe nutrients, toxins, drugs, juices -symptomatic relief -used for some patients w chronic diarrhea when they have trouble forming solid stools -absorb water and reduce intestinal motility -effectiveness if a lil iffy

Absorbents

-Psyllium (metamucil) -polycarbophil (fibercon) (can absorb more) -use for diarrhea or constipation

Antisecretory tx of diarrhea

-reduce secretions in gut -bismuth subsalicylate

Bismuth subalicylate

-pepto-bismol, kaopectate -antimicrobial/antiinflammatory effects -2 tabs every 30-60 min as needed up to 8 doses/day -may potentiate anticoagulants -cause stool and tongue to turn black -do not use in kids