GI - Diarrhoea Flashcards
Symptoms:
Increased frequency of bowel evacuation, associated with abnormally soft or watery
faeces. Abdominal cramps, flatulence, nausea and weakness may also occur.
Cautions and when to refer:
• Babies < 3 months refer immediately
• Children <1 year: Diarrhoea of Duration > 1 day
• People with diabetes: Diarrhoea of Duration > 1 day
• Children <3 years: Diarrhoea of Duration > 2 days
• Adults and Children: Diarrhoea of Duration > 3 days
• Nausea, vomiting and fever all increase the risk of dehydration
• Signs of dehydration: dry skin, sunken eyes, dry tongue, drowsiness, less
urine
• If other people in close proximity to the patient are suffering from the same
symptoms it suggests that the diarrhoea may be infective (bacterial or viral)
• Blood or mucus in the stools may indicate an underlying condition e.g. gastric
ulcer or gastric carcinoma
• Alternating constipation and diarrhoea in elderly patients (may indicate faecal impaction)
• Longstanding change in bowel habit in patients >50 years with concurrent
weight loss (can indicate colorectal cancer)
• Certain drugs can cause diarrhoea e.g. magnesium salts, antibiotics, digoxin,
diuretics, iron, laxatives, NSAIDs, SSRIs
• Regular purchase of morphine/codeine based products
Treatment: 1st Line
Oral Rehydration Therapy (ORT) is suitable for all ages. These are
sachets of powder or already formulated liquids containing sodium (chloride
and/or bicarbonate), glucose and potassium
Treatment: 2nd Line
Loperamide 2mg (not recommended in children under 12, pregnant or breast feeding women), best to use in conjunction with oral rehydration. Loperamide has a high affinity for opiate receptors in the gut wall, leading to reduced motility
• Alternatives:
o Kaolin is a traditional remedy but the evidence to support its use is lacking.
In theory kaolin absorbs water as well as adsorbs toxins and bacteria onto
its surface and then removes them from the gut
o Attapulgite and bismuth salicylate are also adsorbents that act similar to kaolin
o Morphine (as with codeine) slows the action of the GI tract and has also been included in old antidiarrhoeal remedies for many years
Commonly used OTC preparations:
Dioralyte, Imodium, Pepto-Bismol
Counselling points:
- Advise patients to take special care and check the instructions when reconstituting oral rehydration powders; fruit, fizzy, sugary drinks, and boiling water must not be used to reconstitute the powder, recommend boiled and cooled water. The solution can be kept for 24hrs if stored in a refrigerator.
- Bismuth subsalicylate use can result in salicylate absorption. It should be avoided by
individuals hypersensitive to aspirin. - Patients should be advised to drink plenty of fluids but avoid drinks high in sugar as
these can prolong diarrhoea and avoid milky drinks as a temporary lactose intolerance occurs due to damage to cells lining the intestine. - Formula feeds for babies should be diluted to quarter-strength and built back up to
normal over 3 days. During period of suffering from diarrhoea, babies should be fed
more frequently than normal and feeds supplemented with oral rehydration therapy.
To avoid contracting or spreading infective diarrhoea:
- Always wash hands with soap and dry in air or with a clean towel before eating
- Avoid shared drinking water, especially untreated water when abroad
- Eat fresh foods, no uncooked meat
- Avoid shellfish and fish unless fresh and from freshwater
It can be classed as acute (), persistent () or chronic ().
It can be classed as acute (less than 7 days), persistent (more than 14 days) or chronic (lasting
longer than a month).
Chronic diarrhoea
A person who presents with a history of chronic diarrhoea should be referred. The most frequent causes of chronic diarrhoea are IBS, inflammatory disease and colon cancer
Timing of diarrhoea
Patients who experience diarrhoea first thing in the morning might well have underlying
pathology such as IBS
Nocturnal diarrhoea is often associated with inflammatory bowel disease
Medicines known to cause diarrhoea
- α-blocker Prazosin
- ACE inhibitor Lisinopril, perindopril
- Angiotensin receptor blocker Telmisartan
- Acetylcholinesterase inhibitor Donepezil, galantamine, rivastigmine
- Antacid Magnesium salts
- Antibacterial All
- Antidiabetic Metformin, acarbose
- Antidepressant SSRIs, clomipramine, venlafaxine
- Anti-emetic Aprepitant, dolasetron
- Anti-epileptic Carbamazepine, oxcarbamazepine, tiagabine, zonisamide, pregabalin, levetiracetam
- Antifungal Caspofungin, fluconazole, flucytosine, nystatin (in large doses), terbinafine, voriconazole
- Antimalarial Mefloquine
Antiprotozoal Metronidazole, sodium stibogluconate - Antipsychotic Aripiprazole
- Antiviral Abacavir, emtricitabine, stavudine, tenofovir, zalcitabine, zidovudine,
amprenavir, atazanavir, indinavir, lopinavir, nelfinavir, saquinavir,
efavirenz, ganciclovir, valganciclovir, adefovir, oseltamivir, ribavirin,
fosamprenavir - Beta-blocker Bisoprolol, carvedilol, nebivolol
- Bisphosphonate Alendronic acid, disodium etidronate, ibandronic acid, risedronate, sodium clodronate, disodium pamidronate, tiludronic acid
- Cytokine inhibitor Adalimumab, infliximab
- Cytotoxic All classes of cytotoxics
- Dopaminergic Levodopa, entacapone
- Growth hormone antagonist Pegvisomant
- Immunosuppressant Ciclosporin, mycophenolate, leflunomide
- NSAID All
- Ulcer healing Proton pump inhibitors
- Vaccines Pediacel, haemophilus, meningococcal
- Miscellaneous Calcitonin, strontium ranelate, colchicine, dantrolene, olsalazine, anagrelide,
nicotinic acid, pancreatin, eplerenone, acamprosate
Giardiasis
Giardiasis, a protozoan infection of the small intestine, is contracted through drinking contaminated drinking water.
It is an uncommon cause of diarrhoea in Western society. However, with more people taking foreign holidays to non-Western countries, enquiry about recent travel should be made. The patient will present with watery and
foul-smelling diarrhoea, accompanied with symptoms of bloating, flatulence and epigastric pain. If giardiasis is suspected, the patient must be referred to a GP for confirmation and appropriate antibiotic treatment.
Treatment 1st line
Since diarrhoea results in fluid and electrolyte loss, it is important to re-establish normal fluid balance and so ORS
is first-line treatment for all age groups, especially children and the frail elderly. Loperamide is a useful adjunct in reducing the number of bowel movements but should
be reserved for those patients who will find it inconvenient to use a restroom.
ORS age
Infant upwards
Loperamide age and dose
> 12 years
- The dose is two capsules immediately, followed by one
capsule after each further bout of diarrhoea.
