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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
What is the GSL/P dose Of Loperamide in >12yrs?
* 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
What is the Treatment AIMS for Adults with Acute Diarrhoea IN terms of general advice?
* 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
What is Oral Rehydration therapy and What drug is used?
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
What are the treatments of CHRONIC diarrhoea that is >4 weeks?
* 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
What is the advice given in pregnant and breastfeeding women?
* 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
What to do if children have Diarrhoea?
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
How to Prevent the Spread of Diarrhoea?
* 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
What OTHER medications can be used to treat Diarrhoea?
* Co-Phenotrope * Kaolin and Morphine * Bismuth subsalicylate *Probiotics
33
What is the Pharmacology of Loperamide?
* 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
What does ACh inhibition lead to in the pharmacology of Loperamide?
* ACh inhibition leads to: * Decreased propulsive peristalsis * Decreased sensitivity to rectal distension * Increased sphincter tone of the ileocaecal valve and anal sphincter
35
What does Prostaglandin lead to in the pharmacology of Loperamide?
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
What is the problem with using Morphine/ Codeine to treat Diarrhoea?
* Morphine/codeine are also sometimes used to treat diarrhoea * As opioids, they share this mechanism of action * Problems with abuse/dependence
37
What is the pharmacology of Co-Phenotrope?
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
What are the Red flags (when to refer) in Diarrhoea?
* 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
When do you Refer to a GP if the durations exceed?
* >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
What Non-pharmacological advice should be given to people with Diarrhoea?
* 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
What is travellers Diarrhoea?
* Three or more loose stools in 24 hours with or without at least one symptom of cramps, nausea, fever, or vomiting
42
What are the causes of travellers of Bacteria and prevention?
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
What are the treatments of travellers Diarrhoea?
* Maintain hydration * Loperamide * Antibiotic treatment?
44
What are the Signs and Symptoms of Clinical Dehydration F2F assessment?
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
What are the Signs and Symptoms of Clinical Shock Dehydration F2F assessment?
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
What medicines should you stop on sick days?
- ACE Inhibitors -ARBs -NSAIDs -Diuretics -Metformin
47
What is the C.Diff infection and give an example of a drug including freq, and dose?
* 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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