Diarrhea Flashcards
What is the definition of diarrhea?
- a symptom characterized by increased frequency of defecation, with the stools being loose and watery
- 3 or more loose stools during a limited time period (24 hours) perceived to be diarrhea
What are the complications that are often associated with diarrhea?
- electrolyte imbalances
- risk of dehydration
- hemorrhoids
What is acute diarrhea?
- diarrhea lasting under than 14 days
What is chronic diarrhea?
- lasts more than 14 days or recurring diarrhea lasting under 14 days each
What are some examples of foods to avoid while travelling?
- unpeeled or uncooked veggies and fruits, unpasteurized, milk or egg based, water or ice
What are some of the most common reasons that a patient has acute diarrhea?
- infections (this is the most common cause of diarrhea, typically transmitted via oral/fecal routes)
- medications
- diet/nutrition
How long does acute diarrhea usually last?
- usually only about 2-3 days and is self limiting
- symptoms usually being abruptly
What is the most common viral cause of all gastroenteritis?
- noroviruses
What is norovirus usually transmitted by?
- usually transmitted by contaminated water or food (also person to person)
What is the result of the norovirus infection?
- 24 hour stomach flu
What is the result of the rotavirus?
- causes severe diarrhea
- highest incidence in children between 3-24 months of age
- peak infectious period if during the winter months (November to february)
What route is rotavirus spread by?
- spread by the focal oral route
What different bacterial species are diarrhea most commonly caused by?
- Campylobacter sp, Salmonella sp, and E. coli
What part of the bacterial species causes diarrhea?
- can cause diarrhea through the enterotoxin or by directly invading the mucosal epithelial cells
What food products is salmonella typically ingested in?
- infected poultry, eggs, beef, juice, raw fruits and veggies and milk
- typically lasts for 1 to 7 days
What are the symptoms of salmonella species?
- nausea, vomiting, abdominal pain, fever and passage of blood and mucous
What food products do campylobacter bacteria come from?
- undercooked chicken, unpasteurized milk or contaminated water
- lasts for 1-10 days
What are the typical places that e.coli can be found?
- ingestion of contaminated food or water, recent travel
- lasts 3-5 days for example, or can be 5-10 days
What are the symptoms associated with an E.coli infection?
- watery diarrhea
- fever
- abdominal cramps
- bloating
- malaise
- occasional vomiting
What are the symptoms associated with shigatoxin?
- watery, often bloody diarrhea, abdominal cramps, hemolytic uremic syndrome
What are the parasites that diarrhea can be caused by?
- may be caused by G. lambda, E. histolytica, Isospora belli and Crystosproriduim sp
How is giardia spread?
- by ingestion of water or for contaminated with animal of human species containing system
- may be infected by drinking water from sources with inadequate purification systems
How is E. histolytica spread?
- spread by ingestion of contaminated food or water
What are the medications used to treat acute diarrhea?
- penicillins, cephalosporins, erythromycins - these alter the normal bacterial flora in the gut
What is the pseudomonas colitis?
- c. diff
- treat mainly with clindamycin, fluoroquinolones, penicillins and cephalosporins, but can occur with any antimicrobial agent
What are some of the examples of medications that cause diarrhea?
- laxatives
- antacids
- metoclopramide
- orlistat
- acarbose
- misoprostal
- antineoplastics
What are some common foods that are associated with intolerances to food components or food allergies?
- most common: gluten and lactose
- foods containing large amounts of sorbitol or mannitol may cause osmotic diarrhea
- fatty, spicy, highly salted foods
- may occur when there is rapid increases in dietary fibre
- food poisoning (important to focus on prevention)
Chronic diarrhea is when symptoms are present for ______
more than a month
Chronic diarrhea is often indicative of what?
- of an inflammatory process (IBD, UC, Crohn’s)
- can also be tumours, chemotherapy, malabsorption of carbs and diabetes
Why should we always refer chronic diarrhea?
- for an unknown/known underlying cause
What are some of the main is factors for infectious diarrhea?
- attendance or employment at a day care centre
(most infectious causes are via the fecal oral route) - occupation as a food handler or caregiver
- congregate living conditions (nursing homes, prisons, etc)
- consumption of unsafe foods
- presence of certain medical conditions
What are some of the important questions that we should be asking to gather information about diarrhea?
- age of the patients
- how long have they had sx
- ask for description
- recent food intake or change in diet
- sorbitol, gluten, lactose, mannitol containing items
- allergies
- possible food poisoning
- any family history of crohn’s, IBS, cancer
- recent travel
- complications
- any medical conditions or new medications
What are the red flags for diarrhea?
- fever > 38.5, extensive abdominal pain or cramping
- blood or abnormal mucous in stool
- signs of debilitating dehydration or weight loss due to diarrhea
- vomiting > 4 hours
- age < 2 years or frail elderly
- severe diarrhea > 6 loose stools/day for > 48 hours
- chronic medical conditions
- suspected laxative abuse
- pregnancy
- immunocompromised patients
- recent antibiotic use (particularly those associated with C.diff such as clindamycin, ampicillin and cephalosporins
- worsening or persistent or chronic diarrhea
What are the main signs and symptoms of dehydration?
- dry mouth, tongue, increased thirst
- decreased urination
- weakness, lightheadedness
What are the signs and symptoms of dehydration in children?
- dry mouth, tongue and skin (skin turgor or greyish skin color)
- few or no tears when crying; irritability
- listlessness, sunken eyes, cheeks and abdomen
- under 4 wet diapers/ 24 hours
What are the goals of self treatment in diarrhea?
- determine the specific etiology and recommend appropriate treatment
- relieve symptoms and re-establish normal stools
- prevent or correct fluid and electrolyte loss or imbalances (dehydration)
- prevent complications (hemorrhoids)
What are the appropriate non-pharms to recommend in diarrhea prevention?
- encourage hand washing 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 foods hot and cold foods cold, rinse foods that are cooked before they are eaten under running water use separate cutting boards for ray meats and veggies, reheat foods) - oral rehydration therapy (replaces H2O and electrolyte deficit to restore normal body function over about 3-4 hours)
What is oral rehydration therapy?
- solution that has balances contents of glucose and electrolytes
- – glucose provides calories, as well as aiding in the absorption of sodium and water
- – glucose to sodium ratio should be 1:1
- – important aspect of the solutions is osmolality
- – sports drinks are not recommended due to high sugar and low amount of electrolytes
What is gastrolyte?
- oral rehydration salts (should be rank freely and frequently only when diarrhea continues/persists)
What is pedialyte?
- prevents dehydration and restores fluid and minerals lost in patients with mild or moderate diarrhea
- products have correct balances of electrolytes, sugar and water
Dosing of pedialyte is based on what?
- weight
What is the timeline of use when using pedialyte in the big bottle?
needs to be used within 48 hours
What is the action of electrolyte gastro?
- restores body water and minerals lost in mild/moderate diarrhea
- can be used in children and adults
What is the dose of electrolyte gastro that should be given to small children and infants?
- small frequent amount, slowly administered (150 mL/kg per day). Max dose is 2.4 L per day
- solution is offered every 3-4 hours
What are some of the non-pharms that can be used to manage diarrhea?
- early re-feeding and maintenance of hydration is encouraged
- follow age appropriate diet (combination of complex carbs, yogurt, lean meat, frui and veggies, etc)
- if breastfeeding an infant with diarrhea, continue breastfeeding
- avoid fatty foods and simple sugars- to avoid osmotic diarrhea
- avoid spicy foods that may cause GI upset
- avoid caffeine containing beverages
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 the indication for use of loperamide?
- nonspecific acute diarrhea, traveler’s diarrhea, chronic diarrhea associated with IBS, afebrile or low grade fever in the absence of bloody stool
- used as an adjunct to rehydration therapy
- most references state that this agent is not recommended for children under the age of 12 w/o medical supervision
- pregnancy risk factor- should only be used if it is recommended by a physician
What are the adverse drug effects of loperamide?
- abdominal pain, distention, or cramps, N/V, dry mouth, constipation, drowsiness, fatigue, skin rash
- discontinue if there is abdominal distention and constipation)
- GI adverse effects occurs in < 5%
- worsens effects of invasive bacteria
What is the dose of loperamide?
adults: 4 mg initially, followed by 2 mg after each BM (max of 16 mg/24 hours)
- only use for 2 days maximum
What are the contraindication of using loperamide?
- individuals with blood or mucous in the stool, fever
- infectious diarrhea or infectious TD, acute ulcerative colitis
- pseudomembranous colitis associated with broad spectrum AB
- age under 2 y/o
What is the onset of action of loperamide?
0.5 to 1 hour
What are the interactions with other drugs and loperamide?
- saquinavir
- ritonavir
- gemifibrozil
- itraconazole
- st. john’s wort
- valerian
- quinidine
At high doses, loperamide can cause what?
- can cause CNS toxicity and cardiac toxicity (euphoria, analgesia, respiratory depression, conduction abnormalities (prolonged QT prolongation) or ventricular arrhythmias
- shows as sx as dizziness, urinary retention, syncope, SOB, palpitations, dystonia
What is the MOA of bismuth subsalicylate?
- bismuth: has antimicrobial effect against diarrhea-causing pathogens
- salicylates: exerts antisecretory effects that rescues fluid and electrolyte losses in acute diarrhea
- decreases the frequency of unformed stools
- increases stool consistency
- relieve symptoms from abdominal cramping
- decrease N/V in children and adults
What is the indication for bismuth subsalicylate (BSS)?
- symptomatic relief of mild diarrhea
- travellers diarrhea
- adjuvant to antibiotic treatment of h. pylori associated with PUD
- indicated for those under 3 y/o
- do not use in those under 18 that have febrile viral illnesses
What are the drug reactions associated with BSS?
- impaction
- gray-ish black stools/tongue
- tinnitus
- headache and confusion
What are the warnings to patients associated with BSS?-
- children and adults who have or are recovering from the flu or chicken pox due to risk of aspirin induced Reye’s syndrome (caution: children under 18 y/o)
- patient sensitive to aspirin (resulting in asthmatic bronchospasm)
- in susceptible patients, salicylate induced gout attack may occur
- salicylate may exert antiplatelt effects. Avoid in patients taking anticoagulants or other salicylate
- do not give to patient with current or a history of a GI bleed
What are the interactions with other medications and BSS?
- should be taken at least 3 hours apart from other medication
- avoid taking in patients also taking anticoagulants, salicylates, probenedic and methotrexate
What is the mechanism of action of adsorbents?
- abdorbs 8x its weight in water
- generally it is considered to be safe and effective
- absorption is non-selective, toxins, bacteria, digestive enzymes, other drugs
- reduce the number of BMs/improve stool consistency
- relieves cramps associated with diarrhea
What is the indication for the use of adsorbents?
- can be used safely in children over 3-6 years of age
- do not use for > 2 days unless under the supervision of a physician
What is the onset of action of adsorbents?
- initial response is 12-19.5 hours
How does fibre work to treat constipation and diarrhea?
- it is a bulk forming agent
- it will work to increase the consistency of the stool and pass it more easily
- metamucil can be used to create bulk and pass the stool more easily
- it adjusts the consistency of the stool by absorbing water in the intestinal tract
What is the dosage for psyllium fibre?
- 40 g/day in 2-4 divided doses
What ar the side effects of using psyllium fibre?
- cramping and flatulence
What is the onset of action of using a fibre product?
- onset of 12-24 hours and a peak effect of 2-3 days
What are the monitoring parameters that need referral in patients?
- if the condition does not resolve in 48 hours, if the diarrhea worsens, if the patient has a high fever or if there is blood/mucous in the stool
Improvement of diarrhea can be seen within ______ hours
24-48
What is the definition of travellers diarrhea?
3 or more loose, unformed stools per day along with at least 1 symptom of enteric infection such as fever, abdominal cramps, nausea, fecal urgency or dysentery
