Acute Diarrhea

Question 1

Acute diarrhoea is that which lasts less than ________________, but symptoms usually improve within ______________.

Answer 1

14 days

2–4 days

Question 2

What are the common causes of diarrhea? (6)

Answer 2

1. Infection
2. Side effect of a drug
3. Acute symptom of a chronic GI disorder (IBS, IBD)
4. Accumulation of non-absorbed osmotically active solutes in the GI lumen (eg lactase deficiency)
5. GI effects of secretory stimuli (other than enterotoxins from infection)
6. Intestinal motility or morphology disorders

Question 3

What are the red flags of diarrhea? (6)

Answer 3

1. Unexplained weight loss
2. Rectal bleeding
3. Persistent diarrhea
4. Systemic illness
5. Recent hospital treatment or antibiotics
6. Following foreign travel

Question 4

What are the aims of treatment in a patient with acute diarrhea? (2)

Answer 4

1. Prevent or reverse fluid and electrolyte depletion
2. Management of dehydration if present

*particularly important in infants, frail, and elderly patients when electrolyte loss and dehydration can be life-threatening

Question 5

What is the preferred treatment of acute diarrhea in most cases?

Answer 5

Most episodes will settle spontaneously without the need for any medical treatment

Oral rehydration therapy (ORT) to prevent or correct diarrhea dehydration and maintain appropriate fluid intake once rehydration is achieved

Question 6

What is the management of patients with acute diarrhea who are severely dehydrated or unable to drink?

Answer 6

Immediate admission to hospital and urgent fluid replacement with IV rehydration fluid

Question 7

Which drug is used as first line treatment when rapid control of diarrhea symptoms is required?

Answer 7

Loperamide

Can also be used for mild-to-moderate travellers’ diarrhea (eg where toilet amenities are limited or unavailable)

Question 8

Loperamide should be avoided in patients with which symptoms? (3)

Answer 8

1. Bloody diarrhea
2. Suspected inflammatory diarrhea (febrile patients)
3. Significant abdominal pain (which also suggests inflammatory diarrhea)

Question 9

_____________ is also the first line treatment for patients with fecal incontinence (unlicensed) after underlying causes of incontinence have been addressed

Answer 9

Loperamide

Question 10

Racecadotril is licensed as an adjunct to ________________ for the symptomatic treatment of uncomplicated acute diarrhoea in adults and children over 3 months.

Answer 10

rehydration

Question 11

______________ is licensed as an adjunct to rehydration for the symptomatic treatment of uncomplicated acute diarrhoea in adults and children over 3 months.

Answer 11

Racecadotril

Question 12

What is the mechanism of action of loperamide?

Answer 12

Trade name: Imodium
Drug class: opioid agonist, also inhibits the effects of calmodulin

Acts by slowing intestinal motility and by affecting water and electrolyte movement through the bowel

Question 13

What is the mechanism of action of racecadotril?

Answer 13

Peripheral enkephalinase inhibitor (enkephalins are endogenous opioids, thus drug leads to an increase in their number and effect); reduces hypersecretion of water and electrolytes in the intestinal lumen

*unlike loperamide, which reduces intestinal lumen motility

Question 14

________________ is occasionally used for prophylaxis against travellers’ diarrhoea, but routine use is not recommended

Answer 14

Ciprofloxacin

Question 15

_______________ is used to treat travellers’ diarrhea (that is not associated with fever, bloody diarrhea, blood or leucocytes in stool, or 8 or more unformed stools in the previous 24 hours) AND in the treatment of hepatic encephalopathy to reduce recurrence

Answer 15

Rifaximin

Question 16

How does rifaximin help prevent recurrence of hepatic encephalopathy?

Answer 16

Rifaximin is a minimally absorbed antibiotic and exhibits its effects by reducing ammonia production in the colon via the elimination of ammonia-producing bacteria

Question 17

Can rifaximin be used to treat systemic infections?

Answer 17

Not well absorbed by the gut so NOT effective in treating systemic infections

Question 18

Serious ________________ events, including fatalities, have been reported in association with large overdoses of loperamide.

Answer 18

cardiovascular (such as QT prolongation, torsades de pointes, and cardiac arrest)

Question 19

If symptoms of overdose occur with administration of loperamide, ______________ can be given as an antidote

Answer 19

Naloxone

The duration of action of loperamide is longer than that of naloxone (1–3 hours), so repeated treatment with naloxone might be indicated; patients should be monitored closely for at least 48 hours to detect possible CNS depression

Question 20

What are the contraindications to using loperamide? (5)

Answer 20

1. Active UC
2. Abx-associated colitis
3. Bacterial enterocolitis
4. Conditions where abdominal distension develops
5. Conditions where inhibition of peristalsis should be avoided

*not recommended for children under 12

Question 21

Is loperamide safe to prescribe in patients with hepatic and/or renal impairment?

Answer 21

Caution in hepatic impairment due to risk of reduced first pass metabolism leading to CNS toxicity

Question 22

Because loperamide is an opioid, side effects may include…? (4)

Answer 22

1. Nausea and vomiting
2. Drowsiness and impaired consciousness
3. Miosis
4. Urinary retention