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EXAM 1 > DIARRHOEA > Flashcards

DIARRHOEA Flashcards

1
Q

What is the Type 1 and 2 of the Bristol stool form scale?

A
  • Type 1: Separate hard lumps, like nuts and hard to pass
  • Type 2: Sausage shaped but lumpy
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2
Q

What is the Type 6 and 7 of the Bristol stool form scale?

A

Type 6: Fluffy pieces with ragged edges, a mushy stool

Type 7: Watery, no solid pieces

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3
Q

What is Diarrhoea?

A

A change in normal bowel habit resulting in increased
frequency of bowel movements and the passage of soft or watery stools

 May be accompanied by colicky pain

 SYMPTOM – not a disease

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4
Q

Describe Acute Diarrhoea?

A

 Abrupt onset of >3 loose stools/day and lasts no longer than 14 days

 Dietary insults

 Bacterial/viral infection

 Majority resolve within 2-3 days without specific treatment

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5
Q

Describe Chronic Diarrhoea?

A

 Pathological cause

 Lasts >14 days

 Possibly flare up of previously diagnosed condition eg IBS

 Needs further investigation

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6
Q

What is most common Diarrhoea in children under 5 yrs?

A

 Acute gastroenteritis

 Between 1-3 bouts per year

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7
Q

How many episodes of Diarrhoea does adults have in a year and what’s the most common?

A

 Just under 1 episode/year

 22% food related

 Traveller’s diarrhoea

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8
Q

What are the most important host factors in determining severity and duration of Diarrhoea?

A

-Age

-Nutritional status

 The younger the child, the higher risk for severe, life-threatening dehydration

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9
Q

What is the Pathophysiology of Diarrhoea?

A
  • Change in the balance between the absorption and
    secretion of water and electrolytes
  • Due to:
     Osmotic force that drives water into the gut lumen, eg after ingestion of nonabsorbable sugars
     Proportional to the intake and responsive to fasting

OR

 Enterocytes actively secreting fluid eg enterotoxin-induced
diarrhoea
 Not responsive to fasting
 Ion transporters activated by eg bacteria resulting in pathogens
-Invading enterocytes or
-Producing enterotoxins which damage cells or
- Inducing cytokine secretion to produce prostaglandins which stimulate secretion

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10
Q

Describe the mechanism of INVASIVE bacteria causing Diarrhoea?

A

 Directly attack mucosal cells which causes diarrhoea

 Stools may contain blood and Pus

 Fever

 Eg Shigella, Salmonella, Yersinia, Enteroinvasive E coli

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11
Q

Describe the mechanism of NON-INVASIVE bacteria causing Diarrhoea?

A

 Do not directly damage gut

 Bacteria produce enterotoxins that disrupt secretion

 Watery diarrhoea

 Eg S aureus, B cereus, C perfingens, Enterotoxigenic E coli

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12
Q

What is Virally-induced Diarrhoea (Gastroenteritis) ?

A
  • Short-term Diarrhoea

 Mechanism not fully understood
 Enterocytes become secretory resulting in watery diarrhoea

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13
Q

What factors should be considered when Diagnosing Diarrhoea?

A
  1. Symptoms (Accompanying symptoms, Rapid onset, Absence of stool formation?)
  2. Trigger factors ( “bad”/unusual food; alcohol; drugs; contaminated water)
  3. Time/ Intensity ( Dehydration in major risk groups)
  4. Faecal studies ( Identify pathogen)
  5. Serum albumin
  6. Faecal alpha 1 antitrypsin ( Intestinal biopsy)
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14
Q

What is the common cause of Diarrhoea in Infants?

A

-Infectious gastroenteritis

-Toddlers diarrhoea

-Food intolerance

-Coeliac disease

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15
Q

What is the common cause of Diarrhoea in School age children?

A

-Infectious gastroenteritis

-Drugs (Antibiotics)

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16
Q

What is the common cause of Diarrhoea in Adults?

A

-Infectious gastroenteritis
-IBS
-IBD
-Drugs
-XS alcohol
- Spicy food
-Coeliac disease ( Immune system attacks own tissue when you eat GLUTEN)

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17
Q

What is the common cause of Diarrhoea in Older people?

A

-Infectious gastroenteritis
-large bowel cancer
-Faecal impaction
-Drugs
-Ischaemic colitis ( inflammation of LI/C)

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18
Q

What Organism is most common cause of Diarrhoea in Children <5 yrs?

A

-Rotavirus

  • Onset 12-48 hr
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19
Q

What Organisms are the most common cause of Diarrhoea Adults?

A

-Campylobacter (onset 2-5 days)

-Followed by Rotavirus

20
Q

Name some other Organisms that cause Diarrhoea?

A

-E.coli (1-6 days)
-Salmonella (12-24 hours)
- Shigella(1-7days)
-Clostridium difficile (usually starts during AB therapy)
-Clostridium perfringens (12-18 hours)
-Bacillus cereus(1-16 hours)
-Staphylococcus aureus (1-7 hours)

21
Q

Examples of Drugs that can Induce Diarrhoea?

A

 Antibiotics – most common- broad spectrum
 Laxatives
 Metformin
 Ferrous sulphate (iron)
 NSAIDs
 Colestyramine
 Antacids – Mg Salts
 Beta blockers
 Digoxin
 Misoprostol

22
Q

How do you prevent Diarrhoea from spreading?

A

Good hygiene: Wash hands

 After visiting the toilet
 Before touching food
 After gardening
 After playing with pets
 Between handling raw and cooked food

23
Q

What is the Treatment AIMS for Adults with Acute Diarrhoea IN terms of Drugs?

A
  • Prevention and reversal of fluid and electrolyte depletion
  • Management of dehydration (if present)
  • Most settle spontaneously (at around 3 days)
  • Oral rehydration therapy (ORT)
  • Rapid control of symptoms required?
24
Q

What is the Prescribed dose Of Loperamide in >12yrs?

A
  • Prescribed dose >12 years: Initially 4 mg, followed by 2 mg after each
    loose stool (for up to 5 days max); usual dose 6–8 mg daily; maximum
    16 mg per day (8 caps).
25
Q

What is the GSL/P dose Of Loperamide in >12yrs?

A
  • GSL/P dose > 12 years: Initially 4mg, followed by 2 mg after each loose
    stool (for up to 48 hours max); usual dose 6–8 mg daily; maximum 12 mg
    per day (6 caps).
26
Q

What is the Treatment AIMS for Adults with Acute Diarrhoea IN terms of general advice?

A
  • Eat as soon as able (bland) – soups, bread, pasta, rice, potatoes
  • Avoid caffeine, alcohol, carbonated drinks
  • Avoid anti-motility drugs in severe gastroenteritis or dysentery
  • These are more serious – blood/mucus in stools, fever
  • The concern is that Loperamide can prolong the infection
  • Prevention and treatment of fluid and electrolyte depletion is primary
    importance
27
Q

What is Oral Rehydration therapy and What drug is used?

A

Mainstay of treatment for Acute Diarrhoea and it is there to prevent and correct Dehydration

Maintain appropriate fluid intake once rehydration established

  • I.e. Dioralyte (if under 2 years only under medical supervision).

Mix sachet with 200ml water

  • Dioralyte Relief: Contains rice starch (bulks)
  • If under 1 year old-only under Doctor
  • Severe cases require hospitalization for IV fluids
28
Q

What are the treatments of CHRONIC diarrhoea that is >4 weeks?

A
  • Determine underlying cause and treat as appropriate
  • Foreign travel
  • Laxative abuse
  • Medications-PPIs, antibiotics —- ORT and LOPERAMIDE while investigations are ongoing
  • Immunocompromised
  • Family history of IBS/coeliac disease
  • Lactose intolerance (if worsened by dairy), excess caffeine/sorbitol
  • Refer for specialist investigations
29
Q

What is the advice given in pregnant and breastfeeding women?

A
  • Loperamide manufacturers advise to avoid in pregnancy (no info
    available)
  • Weigh up risks to both baby and mum (if severe enough-refer)
  • Loperamide appears in breast milk
  • Amount probably too small to be harmful
  • ORT and fluids essential – avoid dehydration
  • If symptoms warrant Loperamide, refer in both instances from
    community pharmacy
30
Q

What to do if children have Diarrhoea?

A

Feeding babies: Continue with normal milk feeds
* Children: encourage plenty of fluids
* Use ORT
* Anti-diarrhoeals not recommended by NICE (BNF state doses for children, but not licenced in <12 year olds for most products, so never sell from community
pharmacy)

31
Q

How to Prevent the Spread of Diarrhoea?

A
  • Careful washing and drying of hands after using toilet, nappy changing and before meals
  • Don’t share towels
  • 48h exclusion from school following cessation of symptoms
  • Avoid swimming for 2 weeks following last episode of diarrhoea
32
Q

What OTHER medications can be used to treat Diarrhoea?

A
  • Co-Phenotrope
  • Kaolin and Morphine
  • Bismuth subsalicylate
    *Probiotics
33
Q

What is the Pharmacology of Loperamide?

A
  • Synthetic opioid analogue – pethidine congener which doesn’t
    readily pass BBB
  • Binds to mu-opioid receptors in gut wall
  • This inhibits Acetylcholine (ACh) and Prostaglandin release
  • ACh is the main excitatory neurotransmitter in the GI tract
  • ACh binds to muscarinic/nicotinic ACh receptors, increasing
    parasympathetic activity
34
Q

What does ACh inhibition lead to in the pharmacology of Loperamide?

A
  • ACh inhibition leads to:
  • Decreased propulsive peristalsis
  • Decreased sensitivity to rectal distension
  • Increased sphincter tone of the ileocaecal valve and anal sphincter
35
Q

What does Prostaglandin lead to in the pharmacology of Loperamide?

A

Prostaglandin inhibition leads to:
* Reduced gut secretions
* Reduced gut motility (both mainly via inhibition of PGE2)
* Increases intestinal transit time (enhancing water and electrolyte reabsorption)

36
Q

What is the problem with using Morphine/ Codeine to treat Diarrhoea?

A
  • Morphine/codeine are also sometimes used to treat diarrhoea
  • As opioids, they share this mechanism of action
  • Problems with abuse/dependence
37
Q

What is the pharmacology of Co-Phenotrope?

A

100 parts diphenoxylate HCl to 1 part atropine sulphate

Diphenoxylate
* Synthetic opioid – pethidine congener; does not readily pass BBB* Does not usually have CNS activity; large doses lead to typical opioid effects* Insoluble salts mean that there is no potential for misuse by injectors

Atropine
* Muscarinic ACh receptor antagonist * Reduction in ACh reduces parasympathetic drive
* GI motility is inhibited
* Effect not marked as several excitatory transmitters, including Ach are important in the function

38
Q

What are the Red flags (when to refer) in Diarrhoea?

A
  • Recent travel abroad (especially to intermediate/high risk areas) * Blood or mucus in stools
  • Associated with severe vomiting and fever * Severe or persistent abdominal pain
  • Pregnancy or breastfeeding
  • Signs of dehydration
39
Q

When do you Refer to a GP if the durations exceed?

A
  • > 1 day: Infants under 1 year
  • > 2 days: Children under 3 and frail/older people
  • > 3 days: Children over 3 and otherwise healthy adult
40
Q

What Non-pharmacological advice should be given to people with Diarrhoea?

A
  • ANote: Absorption of medicines may be affected (sick day rules)
  • Drink plenty of clear fluids,
  • Avoid drinks high in sugar, alcohol or caffeine
  • Avoid carbonated drinks – cause bloating
  • void milk and milky drinks
  • Eat light, easily digested food
  • Advise not to return to work until they have been symptom-free for 48 hours.
  • Close attention to hygiene,
    • Hand washing
    • Cleaning of toilet seats, flush handles and basin tap
41
Q

What is travellers Diarrhoea?

A
  • Three or more loose stools in 24 hours with or without at least one symptom of cramps, nausea, fever, or vomiting
42
Q

What are the causes of travellers of Bacteria and prevention?

A

Causes
* Bacteria (most common, esp E coli); viruses; protozoan parasites
* Comparatively lower food hygiene and sanitation facilities in destination

Prevention
* Food, water, and personal hygiene * Vaccines (hepatitis A, typhoid and cholera

43
Q

What are the treatments of travellers Diarrhoea?

A
  • Maintain hydration
  • Loperamide
  • Antibiotic treatment?
44
Q

What are the Signs and Symptoms of Clinical Dehydration F2F assessment?

A

Symptoms:
-Appears to be unwell or deteriorating
-Altered responsiveness (e.g. irritable, lethargic)
-Decreased urine output
-Skin colour unchanged
-Warm extremities

Signs:
-Altered responsiveness (e.g. irritable, lethargic)
-Skin colour unchanged
-Warm extremities
-Sunken eyes
-Dry mucous membranes (except mouth breather)
-Tachycardia
-Tachypnoea
-Normal peripheral pulses
-Normal capillary pulses
-Reduced skin turgor
Normal blood pressure

45
Q

What are the Signs and Symptoms of Clinical Shock Dehydration F2F assessment?

A

Symptoms:
-Decreased level of consciousness
-Pale or mottled skin
Cold extremities

Signs:
-Decreased level of consciousness
-Pale or mottled skin
-Cold extremities
-Tachycardia
-Tachypnoea
-Weak peripheral pulses
-Prolonged capillary refill time
-Hypotension (indicates decompensated shock)

46
Q

What medicines should you stop on sick days?

A
  • ACE Inhibitors
    -ARBs
    -NSAIDs
    -Diuretics
    -Metformin
47
Q

What is the C.Diff infection and give an example of a drug including freq, and dose?

A
  • C.Diff bacterium usually present in gut
  • Broad spectrum antibiotics upset microbiome-allowing C.Diff to
    flourish
  • Toxins damage lining of colon
  • Highly contagious diarrhoea can develop, can be fatal
  • Risk factors include broad spectrum Abx use, >65 years old, prolonged stay in hospital care home, immunocompromised etc
  • Vancomycin 125mg-500mg every 6 hours for 10 day

EXAM 1 (14 decks)

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