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Diarrhoea Flashcards

1
Q

According to the Bristol stool chart what is the transit time for somebody with diarrhoea?

A

Can be as little as ten hours between eating and evacuation for a patient with diarrhoea

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2
Q

According to the Bristol stool chart what is the classification for diarrhoea?

A

5,6,7

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3
Q

How is diarrhoea defined?

A

A change in normal bowel habit resulting in increased frequency of bowel movements and the passage of soft or watery stools. Can be accompanied with colicky pain (due to smooth muscle contraction)

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4
Q

Compare acute and chronic diarrhoea.

A

Both acute and chronic diarrhoea involve the passing of three or more stools within one day. Acute diarrhoea lasts less than 14 days (is self-limiting) and you would expect a resolution within 2-3 days whereas chronic diarrhoea lasts longer than 14 days.
Acute diarrhoea usually occurs as a symptom of a bacterial/viral infection or dietary insult (food poisoning) whereas chronic diarrhoea has an underlying pathological cause and may be a symptom of another disease such as an IBD flare and requires further investigation to find the cause.

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5
Q

How common is diarrhoea in children and adults?

A

Children under 5 suffer between 1-3 bouts per year
Similarly adults are predicted to suffer with an episode each year

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6
Q

What are the common causes of diarrhoea in infants?

A

Infectious gastroenteritis
Toddlers diarrhoea
Food intolerance
Coeliac disease

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7
Q

What are the common causes of diarrhoea in school aged children?

A

Acute gastroenteritis (infective diarrhoea) - due to underdeveloped GI system.
Antibiotics use alongside other drugs

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8
Q

What are the common causes of diarrhoea in adults?

A

22% is food related (food poisoning but also intolerances)
Traveller’s diarrhoea
Infectious gastroenteritis
IBS
IBD
Drugs
Excessive alcohol and spicy food
Coeliac disease

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9
Q

What are the common causes of diarrhoea in the elderly?

A

Infectious gastroenteritis
Large bowel cancer
Faecal impaction (spilling over the sides)
Drugs
Ischaemic colitis

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10
Q

What factors influence the severity and duration of diarrhoea?

A

Age and nutritional status

For example the younger the child, the higher risk for severe, life threatening dehydration
In addition acute diarrhoea in a child who is already malnourished could also lead to life threatening complications

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11
Q

What is the key principal regarding the pathophysiology of diarrhoea?

A

It occurs when there is a change in balance between the absorption and
secretion of water and electrolytes

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12
Q

Explain the pathophysiology of diarrhoea.

A

The pathophysiology of diarrhoea (the change in balance between absorption and secretion of water and electrolytes) can arise due to two reasons.
Either there is an osmotic force and that drives water into the intestinal lumen. This could occur after indigestion of non-absorbable sugars such as sorbitol and mannitol. Certain conditions such as Coeliac disease, Cystic fibrosis can render sugars to become non-absorbable and hence diarrhoea occurs due to the build up of the sugars.
Enterotoxin induced diarrhoea is occurs when ion transporters in the intestinal epithelium are activated by bacterium resulting in pathogens either:
Invading enterocytes or
Producing enterotoxins which damage cells of the mucosal lining
Inducing cytokine secretion to produce prostaglandins which stimulate secretion (extra fluid and electrolyte secretion, promoting water loss through diarrhoea)

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13
Q

If a patient has diarrhoea due to the build up of non-absorbable sugars, what could be appropriate management?

A

In relation to diarrhoea caused by non-absorbable sugars, the symptoms that the patient experiences is proportional to their sugar intake and therefore their symptoms (diarrhoea) will be responsive to fasting.

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14
Q

Is enterotoxin induced diarrhoea responsive to fasting?

A

No, fasting will not make a difference in enterotoxin induced diarrhoea as a pathogen present is the underlying cause rather than food aggravating the intestinal wall causing an increase in osmotic force driving fluid into the lumen.

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15
Q

Compare the mechanism of invasive vs non-invasive diarrhoea.

A

In invasive diarrhoea, the bacterium directly attacks the mucosal cells lining the GI epithelium resulting in diarrhoea that additionally may contain blood and pus.
Whereas in non-invasive diarrhoea as the name suggests the bacterium doesn’t directly affect the gut but instead the bacterium produces enterotoxins which disrupts secretions, producing a watery diarrhoea.

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16
Q

What is the mechanism of virally induced diarrhoea?

A

Enterocytes become secretory resulting in a watery diarrhoea.

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17
Q

What are some examples of bacterium causing invasive diarrhoea?

A

Shigella, Salmonella, Yersinia, Enteroinvasive E coli

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18
Q

What are some examples of bacterium causing non-invasive diarrhoea?

A

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

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19
Q

State the important questions to ask a patient about diarrhoea?

A

Nature of stools
Periodicity
Duration
Onset of symptoms
Timing of diarrhoea
Recent change of diet
Signs of dehydration

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20
Q

How can asking about the nature of stools help to make a diagnosis of diarrhoea?

A

Diarrhoea is considered to be three of more watery stools a day.
Diarrhoea with the presence of blood and mucus requires referral to eliminate invasive infections such as Salmonella, Enterovasive E coli etc.
Bloody stools are also associated with IBD (UC)

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21
Q

How can asking about the periodicity of stools help to make a diagnosis of diarrhoea?

A

A history of recurrent diarrhoea of no known cause should be referred for further investigation

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22
Q

How can asking about the duration of stools help to make a diagnosis of diarrhoea?

A

Symptoms of chronic diarrhoea (lasting more than 14 days) should be referred due to their likely cause being IBD, IBS and colon cancer.

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23
Q

How can asking about the onset of symptoms help to make a diagnosis of diarrhoea?

A

Ingestion of bacterial pathogens can give rise of symptoms in a matter of hours or up to three days later. Therefore it is important to ask about consumption of any possible contaminated food within the next couple of days.

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24
Q

How can asking about the timing of symptoms help to make a diagnosis of diarrhoea?

A

Experiencing symptoms first thing in the morning is more likely to be associated with underlying pathology such as IBS.

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25
Q

How can asking about any recent changes in diet help to make a diagnosis of diarrhoea?

A

This can include recent changes in diet when travelling abroad (non-Westernised diets).

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26
Q

What is the purpose of conducting faecal studies in patients with diarrhoea?

A

In order to help identify the causative agent (specific pathogen) and make appropriate prescribing choices

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27
Q

What are the tests for detecting protein loss in diarrhoea?

A

Serum albumin
Fecal alpha 1 antitrypsin

Not very specific, but would suggest internal GI damage has occurred. Could also complete an intestinal biopsy for severe cases.

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28
Q

What organism causes diarrhoea in children under 5?

A

Rotavirus most common: onset 12-48 hr

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29
Q

What organism causes diarrhoea in adults?

A

Campylobacter (onset 2-5 d) most common, followed by rotavirus

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30
Q

What are some of the other organisms causing diarrhoea and their onset of action?

A

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

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31
Q

What are some of the drugs known to cause diarrhoea?

A

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

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32
Q

How can diarrhoea be prevented?

A

Good hygiene: Wash hands
 After visiting the toilet
 Before touching food
 After gardening
 After playing with pets
 Between handling raw and cooked food

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33
Q

What are the main treatment aims of diarrhoea?

A

Prevention and reversal of fluid and electrolyte depletion
Management of dehydration (if present)

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34
Q

Is diarrhoea self-limiting?

A

Most cases of diarrhoea (acute diarrhoea) are self limiting and will resolve in about three days

35
Q

What type of drug is Loperamide?

A

Peripherally acting central opioid agonist

36
Q

What is the prescribed dose of Loperamide?

A

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)

37
Q

What is the P/GSL (OTC) dose of Loperamide?

A

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)

38
Q

What foods are recommended and not recommended in cases of diarrhoea?

A

Recommend bland foods such as bread, pasta, potatoes
Avoid caffeine (diuretics), carbonated drinks and alcohol (diuretics)

39
Q

Why is Loperamide avoided in severe gastroenteritis or dysentery?

A

Prolongs the infection, leading to more complications
Instead ORT is crucial

40
Q

Is Dioralyte suitable for under 2s?

A

Yes but only can be given under medical supervision so not for the sale over the counter

41
Q

What is the purpose of Dioralyte?

A

To prevent or correct dehydration by containing essential body water and salts.
After being rehydrated it is important to emphasise to the patient the importance of continuing to maintain a substantial fluid intake.

42
Q

What are the instruction for the administration of Dioralyte?

A

They come in sachets and should be mixed with exactly 200mL of water, more or less can affect the balance. This results in reduced hydration status. Can be mixed in normal tap water but for children it is recommended to use freshly boiled and then cooled tap water.

43
Q

What is the difference with Dioralyte Relief?

A

Also contains rice starch which swells in vivo in the presence of water, causing water retention in the gut and the bulking up of stools.

44
Q

Can children have Dioralyte relief?

A

Yes but under 1, it can only be supplied by the Doctor

45
Q

What is Dioralyte dosing according to the BNF?

A

For adults:
200–400 mL, to be given after every loose motion, dose according to fluid loss

46
Q

What is recommended for severe cases of acute diarrhoea?

A

Hospitalisation for IV fluids

47
Q

What is the first step in the management of chronic diarrhoea?

A

Determine the underlying cause and treat as appropriate:
This could be reassessment of IBS/IBD management
Identifying any foreign travel
Check for Laxative abuse
Review Medications -PPIs, antibiotics
Check for immunocompromised
Ask about family history of IBS/coeliac disease
Lactose intolerance (if worsened by dairy), excess caffeine/sorbitol

May also involve specialist investigations if any of the above are possibilities

48
Q

Is Loperamide safe for use in pregnancy?

A

Loperamide manufacturers advise to avoid in pregnancy (no info available)
Therefore weigh up risk to Mum and baby, if symptoms are severe refer as patient may need IV fluids

49
Q

Is Loperamide safe for use in breast feeding?

A

Appears in small amounts in breast milk, unlikely to be harmful

50
Q

By understanding the licensing of Lopermaide what would you recommend for a pregnant/breastfeeding mother?

A

If symptoms were severe enough and potentially a risk to the mother, it is recommended to supply the patient with ORT and remind the patient to keep up with their fluid intake. As loperamide is not licensed for sale OTC to pregnant or breastfeeding mothers refer to a prescriber (GP) for assessment and they may be prescribed Loperamide.

51
Q

What is the recommendation for breast-fed babies suffering with diarrhoea?

A

Continue with milk feeds as breast milk is likely to contain the antibodies needed to fight off the infection

52
Q

What is the recommendation for children suffering with diarrhoea?

A

Encourage drinking plenty of fluids
ORT
Loperamide is not licensed OTC in children under 12 (may have to be referred for prescription)
Encourage preventative techniques for the spread of diarrhoea

53
Q

What are some of the techniques for preventing the spread of diarrhoea?

A

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

54
Q

What are the key points to remember regarding Kaolin and Morphine?

A

Not evidence based: such small amounts of Morphine
No evidence for Kaolin in acute diarrhoea
Historical use – elderly patients
Potential for abuse

55
Q

What are the key points to remember regarding Bismuth subsalicylate?

A

E.g. PetpoBismol (never in less than 16 years old due to Reye’s syndrome)
Limited evidence – not recommended in BNF or by NICE
Inhibits intestinal fluid secretion
Suppresses intestinal inflammation
Bactericidal action

56
Q

What are the key points to remember regarding Probiotics?

A

Live bacteria
Competes with pathogen for available nutrients
Insufficient evidence for use on the NHS

57
Q

What is the pharmacology of Loperamide?

A

It is a peripherally acting selective mu-opioid receptor agonist and binds specifically to mu receptors in the intestinal wall. This inhibits acetylcholine and prostaglandin release.

Acetylcholine inhibition leads to:
Decreased propulsive peristalsis
Decreased sensitivity to rectal distension
Increased sphincter tone of the ileocaecal valve and anal sphincter

Prostaglandin inhibition leads to:
Reduced gut secretions
Reduced gut motility (both mainly via inhibition of PGE2)

Overall this reduces the gut transit time leading to the increased absorption of water and nutrients.

58
Q

Which other drugs have the same mechanism of action as Loperamide?

A

Codeine and Morphine, however they are used less frequently due to opioid dependence.

59
Q

How does increasing the ileocecal valve tone reduce diarrhoea?

A

The ileocaecal valve separates the small and the large intestine and limits the rate of food passage into the large intestine in addition to reflux back into the small intestine. By increasing the muscle tone of this valve, this limits the rate of passage of digestive materials through the GI tract, this reduces gut motility and hence prolongs the amount of time waste passes within the large intestine allowing a greater time for reabsorption of fluids and electrolytes.

60
Q

How does increasing the tone of the anal sphincter reduce diarrhoea?

A

The anal sphincter is responsible for keeping the anus closed during the collecting of waste within the rectum. Sphincter relaxation enables passing of a stool. Increasing the muscle tone of the anal sphincter reduces diarrhoea symptoms.

61
Q

What are the constitutive parts of co-phenotrope?

A

100 parts diphenoxylate HCl to 1 part atropine sulphate

62
Q

How does Diphenoxylate work?

A

It is also a synthetic opioid and therefore has the same effect as Lopermaide.

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

63
Q

How does Atropine work?

A

Muscarinic ACh receptor antagonist
Reduction in ACh reduces parasympathetic drive
GI motility is inhibited

64
Q

What are some of the red flag diarrhoea symptoms?

A

Blood and/or mucus in stools
Fever or vomiting alongside loose stools
Abdominal pain
Diarrhoea following recent travel abroad to areas of tropical or subtropical climate
Pregnancy or breastfeeding
Signs of dehydration (covered later)

65
Q

What is the time frame for referral to the GP of diarrhoea?

A

> 1 day: Infants under 1 year
2 days: Children under 3 and frail/older people
3 days: Children over 3 and otherwise healthy adults

66
Q

What is the non-pharmacological advice following episodes of diarrhoea?

A

Absorption of certain medications can be affected such as COC - effect will be compromised (especially if vomiting additionally)
Drink plenty of clear fluids
Avoid drinks high in sugar, alcohol or caffeine
Avoid carbonated drinks – cause bloating Avoid 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 taps

67
Q

How is traveller’s diarrhoea defined?

A

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

68
Q

What are some of the causes of traveller’s diarrhoea?

A

Due to the ingestion of bacteria (most common, esp E coli); viruses; protozoan parasites
This is due to the lower food hygiene in other countries and sanitation

69
Q

What advice would you give to try and avoid traveller’s diarrhoea?

A

Avoid uncooked meat, shellfish or eggs. Avoid peeled fruit and vegetables (including salads).
Be careful about what you drink. Don’t drink tap water, even as ice cubes.
Wash your hands regularly, especially before preparing food or eating.
Be careful where you swim. Contaminated water can cause traveller’s diarrhoea

Ensure you receive all appropriate vaccines before travelling such as Hep A, typhoid and cholera

70
Q

What are the treatments for traveller’s diarrhoea?

A

Maintain fluids
ORT & Loperamide (mild treatment)
Antibiotics treatment (Ciprofloxacin) for severe cases after GP referral

71
Q

What are the high risk areas for traveller’s diarrhoea?

A

South and Southeast Asia, Central America, West and North Africa, South America, East Africa

72
Q

What are the medium risk areas for traveller’s diarrhoea?

A

Russia, China, Caribbean, South Africa

73
Q

What are the low risk areas for traveller’s diarrhoea?

A

North America, Western Europe, Australia and New Zealand

74
Q

What are some of the symptoms of dehydration in adults?

A

Tiredness.
Dizziness or light-headedness.
Headache.
Muscle cramps.
Sunken eyes.
Passing less urine.
A dry mouth and tongue.
Weakness.
Becoming irritable

75
Q

What are some of the symptoms of severe dehydration in adults?

A

Profound loss of energy or enthusiasm (apathy).
Weakness.
Confusion.
A fast heart rate
Producing very little urine
Coma, which may occur

76
Q

What are some of the symptoms of dehydration in children?

A

Passing little urine.
A dry mouth.
A dry tongue and lips.
Fewer tears when crying.
Sunken eyes.
Weakness.
Being irritable.
Having a lack of energy (being lethargic)

77
Q

What are some of the symptoms of severe dehydration in children?

A

Drowsiness.
Pale or mottled skin.
Cold hands or feet.
Very few wet nappies.
Fast (but often shallow) breathing

78
Q

What does the medicine sick day guidance involve?

A

The medicine sick day guidance lists certain medications that if a patient is experiencing diarrhoea and therefore at risk of dehydration, they should stop taking and restart 24-48 hours after the diarrhoea resolves. This is because these medications increase the risk of AKI (further reduce pleural effusion through the kidney).

79
Q

What are some of the medications that should be stopped in the medicine sick day rules?

A

ACE inhibitors (nephrotoxic in hypovolemia)
ARBS (same as above)
Diuretics (AKI risk)
Metformin (increased risk of lactic acidosis)
NSAIDs (AKI)
SGLT-2 (acidosis)

80
Q

When do C. diff infections occur?

A

Clostridium difficle occurs naturally in the microflora, broad spectrum antibiotics upsets microflora balance (wipeout good bacterium), allowing C. diff (entero-toxin producing bacterium) to flourish which can damage the lining of the the colon.

81
Q

What are the main concerns regarding C. diff infections?

A

Highly contagious, can spread easily in hospital and care homes
Can develop into sepsis and can be fatal

82
Q

What are the risk factors for C. diff?

A

Broad spectrum Abx use
>65 years old
Prolonged stay in hospital care home Immunocompromised

83
Q

What is the treatment for C. diff?

A

Vancomycin 125mg-500mg every 6 hours for 10 days

Lower gastro-intestinal diseases (15 decks)

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