Diarrhea Flashcards
Acute Diarrhea
- Definition
Less than 14 days duration
Persistient Diarrhea
- Definition
More than 14 days duration
Chronic Diarrhea
- Definition
More than 30 days duration or repeated episodes
Diarrhea
- Definition
Loose, watery stools 3 or more times a day
Diarrhea
- Complications
- Dehydration
- Fluid and Electrolyte Disturbances
- Hemorrhoids
Diarrhea
- Severe Complications
- Fever
- Abdominal Pain
- Flatulence
- Weight Loss
Diarrhea
- Groups at risk of dehydration
Infants, Young Children, Elderly
Patients with chronic conditions
- Renal failure
- Cardiovascular disease
Diarrhea
- Types
- Osmotic
- Secretory
- Exudative/Inflammatory
- Increased Gut Motility
Osmotic Diarrhea
- Cause
Poorly absorbed substances draw water into bowels
- Sorbitol, Mannitol
- Lactose Intolerance
- Medications (Magnesium)
- Malabsorption Syndrome
- Celiac Disease
Secretory Diarrhea
- Cause
Increase or decrease in absorption of water/electrolytes
- Bacterial infections (Toxins)
- Excessive bile salts
- Hormone producing tumours
- Medications (Chemotherapy)
Exudative/Inflammatory Diarrhea
- Cause
Inflammation
- Inflammatory Bowel Disease
- Other types of Colitis
- Infections
Dysmotility Diarrhea
Increased Gut Motility
- Irritable Bowel Syndrome
- Hyperparathyroidism
- Medications (Metoclopramide)
Diarrhea
- CDI
Clostridium Difficile Infection
- Associated with antibiotics (Fluoroquinolones, Cephalosporins, Clindamycin, Carbapenems)
Diarrhea
- Travelers Diarrhea (Onset and Symptoms)
Occurs after traveling from developing counties with poor hygiene standards
- Onset of 1-2days of ingesting contaminated food
- Onset of up to 7 days after returning
Symptoms: Abdominal cramping, fever, vomiting
Diarrhea
- Red flag questions
- Fever?
- Blood or Mucus in stools?
- Severe pain?
- Severe diarrhea (More than 6 loose stools for longer than 48 hours)
- Diarrhea lasting longer than 7 days
- Debilitating dehydration
- Clostridium Difficile Infection
- Overflow diarrhea from fecal impaction
Diarrhea
- At risk patients
- Children younger than 2
- Elderly
- Pregnant
- Multiple Chronic Conditions (CV,CKD, DM)
- Immunocompromised (HIV, Cancer)
Drugs Associated with Diarrhea
Magnesium Antacids
Antibiotics
NSAIDS
SSRI Antidepressants
Sulfasalazine
Diarrhea
- Nonpharm
Oral Rehydration Therapy (Gastrolyte, Pedialyte, Hydralyte)
- Maintain electrolyte balance
- Clear fluids for 24 hours
- Avoid juice and carbonated drinks
Discontinue medications/foods causing diarrhea
Diet
- Stop ingesting poorly absorbed carbohydrates (Sorbitol, Mannitol)
Diarrhea
- Nonpharm (Diet)
Avoid BRAT diet
- Bananas, RIce, Applesauce, Toast
Diarrhea
- Pharm
First Line: Loperamide (OTC)
Second Line: Diphenoxylate + Atropine (Rx)
Loperamide
- Role and Mechanism
Used in Moderate-Severe Diarrhea
Binds to opiate receptor in gut wall
- Inhibits Acetylcholine and Prostaglandins
Peripheral Action:
- Reduced peristalsis –> Increased intestinal transit time
- Increased tone of anal sphincter –> Reduced incontinence and urgency
Loperamide
- Dose and Duration
4mg, then 2mg after each bowel movement (max 16mg/day)
Not to be used more than 2 days (Can be used longer in patients with Chronic Diarrhea)
Loperamide
- Considerations
- Do not use in children younger than 2 years old
- Can be used in pregnancy and breastfeeding
- Avoid in Clostridium Difficile Infections, Malnourished, Severely dehydrated
Loperamide
- Contraindications
- Blood stools
- Liver failure
- High fever
Loperamide
- Adverse Effects
- Abdominal Cramps
- Dry mouth
- Drowsiness
- Constipation
Lomotil
- Role and Mechanism
Diphenoxylate + Atropine
Used in Moderate-Severe Diarrhea
Slows digestion/gut motility
Atropine added to prevent misuse
Lomotil
- Considerations
- Less effective than Loperamide
- Avoid in Clostridium Difficile infection, malnourished, severely dehydrated
- Avoid in pregnancy and breastfeeding
Lomotil
- Adverse Effects
- Urinary Retention
- Dry Mouth
- Blurry Vision
- Constipation
Lomotil
- Contraindications
- Blood Stools
- High Fever
- Liver Failure
Caution use in elderly and children (Anticholinergic Effects)
Diarrhea
- Adsorbent Agent
Attapulgite
Adsorbent Agent
- Role and Mechanism
Attapulgite can absorb water, nutrients, toxins, bacteria
- Used in mild diarrhea
Adsorbent Agent
- Considerations
Attapulgite is:
- Less effective than Loperamide
- Generally well tolerated
- Avoid in children under 2 years old
Diarrhea
- Hydrophilic Bulking Agents
Psyllium
Hydrophilic Bulking Agents
- Role and Mechanism
Psyllium can absorb liquid to create firmer stools
- Used in mild diarrhea
Hydrophilic Bulking Agents
- Considearations
Psyllium should be spaced from other medications
- Should be cautious if combined with other laxatives
Diarrhea
- Antisecretory Agent
Bismuth Subsalicylate
Antisecretory Agent
- Role and Mechanism
Bismuth Subsalicylate’s mechanism is not well understood.
- Antimicrobial
- Decreased attachment of bacteria to GI
- Anti-inflammatory/Antisecretory
Role:
- Used in mild to moderate diarrhea
- Used to prevent/treat travellers diarrhea
Antisecretory Agent
- Dose
Bismuth Subsalicylate
- 524 mg (2 tabs or 30 mL) every 0.5-1 hour prn (Max 4.2 g/day)
Antisecretory Agent
- Adverse Effects
Bismuth Subsalicylate
- Black tongue
- Black stools
- Tinnitus
Antisecretory Agent
- Considerations
Interacts with
- Oral anticoagulants
- Other salicylates
- Methotrexate
Avoid use in children under 2 years old
Caution in pregnancy and breastfeeding
Zinc Supplements
- Role and Mechanism in Diarrhea
Used to treat childhood diarrhea
- Decreases severity and duration of diarrhea
Cholestyramine
- Role and Mechanism
Rx medication
Lipid lowering agent that binds bile acid
- Used to treat diarrhea from bile acid malabsorption
Cholestyramine
- Considerations
Can interact and bind with drugs (ex. digoxin)
- Administer other drugs 1 hour before or 4-6 hours after cholestyramine
How to treat Clostridium Difficile Infection
Metronidazole or Vancomycin
What antibiotics can treat/prevent Traveler’s Diarrhea
- Fluoroquinolones
- Azithromycin
- Rifaximin
Somatostatin
- Role and Mechanism
Octreotide, Lanreotide
Used in:
- Diarrhea from neuroendocrine tumours
- Chronic diarrhea from short bowel syndrome
- Chemotherapy diarrhea
Alpha2-Adrenergic Agonist
- Role and Mechanism
Clonidine
Used in opioid withdrawal, diabetic autonomic neuropathies
Acute Diarrhea Treatment
- Moderate to Severe
Loperamide
- Patients with severe diarrhea or red flags should be referred
Acute Diarrhea Treatment
- Mild to Moderate
Bismuth
Acute Diarrhea Treatment
- Mild
Attapulgite or Psyllium
- Antidiarrheals not needed
Chronic Diarrhea Treatment
Loperamide or Attapulgite
+
NonPharm Options
- Diet
- Hydration
- Discontinue drugs adding to diarrhea
Treat specific cause
Diarrheas treated by probiotics
- Antibiotic Associated Diarrhea
- Infectious Diarrhea
- Traveler’s Diarrhea
- Diarrhea in Irritable Bowel Syndrome
Who can not take Probiotics
Immunocompromised
Preterm infants
Critically Ill
Key Stains in Probiotics
Lactobacillus Sp
Saccharomyces Boulardii
Probiotics
- Dose
For Antibiotic Associated Diarrhea:
- Probiotics with duration of antibiotic therapy
- 5-7 days after course completion
