Diarrhoea Flashcards
What is defined as Diarrhoea?
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
What is classed as Acute Diarrhoea?
*Abrupt onset of more than 3 loose stools a day and lasts no longer than 14 days
*Dietary intolerances/triggers - alcohol/spicy foods
*Bacterial/viral infection - 2-3 days should resolve
*Majority resolve within 2-3 days without specific treatment
What is classed as chronic diarrhoea?
*Pathological cause
*Lasts greater than 14 days
*Can flare up previously diagnosed condition IBS/UC/CD
*Needs further investigation
The younger the child the higher the risk of severe life threatening dehydration. True or False?
True
What happens within the body to cause diarrhoea?
There is a change in the balance between the absorption and secretion of water and electrolytes.
What changes the balance between absorption and secretion of water and electrolytes?
1) Osmotic force that drives water into the gut lumen, such as when ingesting of nonabsorbable sugars (Mannitol/sorbitol), this is proportional to the intake and is responsive to fasting.
2) Enterocytes in the gut cells lining the GI tract actively secret fluid (Enterotoxin-induced diarrhoea), this is not responsive to fasting as it is caused by a pathogen. Ion transporters are activated by bacteria resulting in pathogens.
This causes:
-Invasion of enterocytes or
-Production of enterotoxins which damage cells or
-Inducing cytokine secretion to produce prostaglandins which stimulate secretion
What does invasive bacteria do to cause diarrhoea?
*Directly attacks mucosal cells which cause diarrhoea, stools can contain blood and push. May be accompanied with a fever.
What are examples of Invasive diarrhoea?
Shigella, Salmonella, Yersinia, Entero-invasive E coli
What does non-invasive bacteria do to cause diarrhoea?
*Does not directly damage the gut, the bacteria produces enterotoxins that disrupt secretion of water and electrolytes.
*Causes watery diarrhoea
What are examples of non-invasive diarrhoea conditions?
S aureus, B cereus, C perfingens, Enterotoxigenic E coli
What is the mechanism of Virally-induced diarrhoea?
Not fully understood mechanism, enterocytes may become secretory resulting in watery diarrhoea.
-Loss of water and electrolytes.
What is used to diagnose Diarrhoea?
*Symptoms
*Triggers
*Time/intensity
*Faecal studies - travellers - may need antibiotic
*Serum albumin
*Faecal alpha 1 anti-trypsin - protein loss due to diarrhoea - damages Gi tract
*Intestinal biopsy - only if chronic issue
What is a cause of Diarrhoea in infants?
Infectious gastroenteritis
Toddlers Diarrhoea
Food intolerance
Coeliac disease
What is a cause of Diarrhoea in School aged children?
Infectious gastroenteritis
Drugs (Anti-biotics)
What is a cause of Diarrhoea in Adults?
Infectious gastroenteritis, IBS, IBD, Drugs, XS alcohol, Spicy food, Coeliac disease
What is a cause of Diarrhoea in older people?
Infectious gastroenteritis, large bowel cancer, faecal impaction, drugs, ischaemic colitis
What age is Rotavirus most likely to affect and the onset time?
<5 yrs (less than)
Onset -12-48 hours
*Can affect adults also
What age is Campylobacter likely to affect and the onset?
Adults
Onset 2-5 days,
What drugs can induce diarrhoea?
Antibiotics, Laxatives, Metformin, Ferrous sulphate, NSAIDS, Colestyramine, Antacids (Mg salts), B-blockers, Digoxin, Misoprostol
How to prevent Diarrhoea ?
Good hand hygiene
What should we consider when giving treatment for Diarrhoea?
Age, frequency, duration, assess dehydration risk
When does most Diarrhoea settle?
Within 72 hours
Dose of Loperamide for prescriptions?
POM - 12+, 4mg first, followed by 2mg after each loose stool, for 5 days max; usual sode is 6-8mg OD, max dose is 16mg OD (8 caps)
What is the dose of Loperamide for GSL/P?
12+, Initially 4mg followed by 2mg after each loose stool, (for up to 48 hours); Usual dose 6-8mg OD, max 12 mg per day!
What should be avoided if you have Diarrhoea?
Caffeine, alcohol, carbonated drinks.
Avoid anti-motility drugs when severe.
What is the concern when using loperamide?
That it can prolong infection
What is recommended when someone has Diarrhoea?
Prevention and treatment of fluid and electrolyte depletion is primary importance!
REHYDRATION!!
What age is Dioralyte only given under medical supervision?
2 years
What age is Dioralyte Relief only given under medical supervision?
1 years
If it is Chronic Diarrhoea what is the treatment?
-Underlying cause
-Travel Status
-Laxative abuse
-Medications - PPI’s, Antibiotics
-Immunocompromised
-Family history of IBS/coeliac
-Lactose intolerant/caffeine/sorbitol
-Refer for specialist investigations
Can a pregnant lady have loperamide?
No if it is severe refer
Does loperamide appear in breast milk?
A small amount which is small enough to not be harmful - if need loperamide Refer!
Is loperamide licensed for pregnancy and breastfeeding women?
No –> refer!
What should you recommend if you get a child under 12 needing something for Diarrhoea?
-Oral rehydration treatment
-Loperamide not licenced for anyone younger than 12, need to be prescribed
-Prevent the spread of Diarrhoea
*48 hours exclusion from school following cessation of symptoms
*Avoid swimming for 2 weeks following last episode of Diarrhoea
What is Co-Phenotrope used for?
*Atropine and Diphenoxylate
-Rehydration in acute Diarrhoea
-Take 4 tablets, then 2 tablets every 6 hours until controlled
What is Kaolin and Morphine used for?
No evidence
Old fashioned
Can be abused
What is Bismuth subsalicylate used for?
PeptoBismol (Do not use in anyone less than 16 years of age - Reye’s Syndrome)
Inhibits intestinal fluid secretion, suppresses intestinal inflammation and has bactericidal action.
What do Probiotics do?
They are a live bacteria which compete for available nutrients with pathogens, not a lot of evidence for use on the NHS.
MOA of Loperamide?
1) Synthetic opioid analogue, pethidine congener which doesn’t readily pass BBB.
2) Binds to the mu-opioid receptors in the gut wall
3) This inhibits acetylcholine (ACh) and prostaglandin release
4) ACh is the main excitatory neurotransmitter and the GI tract.
5) ACh binds to muscarinic/nicotinic ACh receptors, increasing parasympathetic activity
What does ACh inhibition cause from taking Loperamide?
-Decreased propulsive peristalsis
-Decreased sensitivity to rectal distension
-Increased sphincter tone of the ileocaecal valve and anal sphincter
When loperamide inhibits prostaglandin what does this lead to?
Reduced gut secretions and reduced gut motility (mainly via inhibition of PGE2)
What Opioids share the same MOA of loperamide and can be used for Diarrhoea?
Morphine/codeine
100 parts of Diphenoxylate is in co-phenotrope, what is the MOA within this?
-Synthetic opioid - pethidine congener, does not readily pass BBB
-Does not have CNS activity, but large doses cause typical opioid effects
-Insoluble salts mean that there is no potential misuse by injector
1 part of Atropine sulphate is in co-phenotrope, what is the MOA within this?
-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
What are the red flags we need to refer when thinking about Diarrhoea?
*Recent travel abroad
*Blood or mucus in stool
*Severe vomiting / Fever
*Severe/Persistent Abdo pain
*Pregnancy and breastfeeding
*Signs of dehydration
If an infant (under 1) has Diarrhoea for over 1 day should they be referred to the GP?
Yes
If a child under 3 or frail/older person has Diarrhoea for more than 2 days should they be referred to the GP?
Yes
If a child over 3 and a healthy adult has Diarrhoea for more than 3 days, should they be referred to the GP?
Yes
What is some lifestyle advice when a patient has Diarrhoea?
-Sick day rules regarding normal medication
-Clear fluids
-Avoid high sugar/alcohol/caffeine
-Avoid milk/milky drinks
-Eat light foods
-Do not return to work until they have been symptom free for over 48 hours
-Close attention to hygiene
What is traveller’s Diarrhoea?
Three or more loose stools in 24 hours with or without at least one symptom of cramps, nausea, fever or vomiting
What causes travellers Diarrhoea?
Bacteria - E coli. Viruses - Protozoan parasites
Comparatively lower food hygiene and sanitation facilities in destinations
What is the treatment for travellers Diarrhoea?
Maintain hydration
Loperamide
Antibiotic treatment - this depends on what has caused it - perhaps give ciprofloxacin
*If symptoms are really severe stool culture and appropriate treatment given after results maintained
Pt D comes into the pharmacy and looks unwell, is irritable, lethargic, saying they are only passing dark brown urine in small amounts, hands and feet are warm -
Upon doing observations - pt has Tachycardia and Tachypnoea and sunken eyes.
what is the diagnosis?
Clinical Dehydration
Pt X has a decreased level on consciousness and pale or mottled skin, with cold hands and feet. They have weak peripheral pulse and prolonged capillary refill time, they are tachycardic and tachypnoea, also there BP is low. What is the diagnosis for this patient?
Clinical shock - requires hospitalisation.
What medications should be stopped when a patient has vomiting or diarrhoea, fevers, sweats or shaking? as they could cause AKI.
*ACE Inhibitors ‘pril’
*ARBs ‘sartans’
*NSAIDs
*Diuretics
*Metformin
What is C.DIFF?
The C.Diff bacterium is usually present within the gut, and broad spectrum antibiotics upset the microbiome allows C.Diff to flourish. The Toxins damage the lining of the colon. This is highly contagious and can be fatal as it can cause sepsis.
What are the risk factors for C.DIFF?
Broad spectrum antibiotics in people older than 65 with prolonged stay in hospital, care home or are immunocompromised.
What is the treatment for C.DIFF?
Vancomycin 125mg-500mg every 6 hours for 10 days.
