Lecture 3 Managment Of Diarrhea. Flashcards
Definition of diarrhea
Frequent passage of loose, watery stool (>3 per day)
Normal stools 100-300gm/daily
Classification of diarrhea
Acute <14days
Persistent >14 days
Chronic > 30 days duration or repeated episodes
Complications of diarrhea
Fluid and electrolyte disturbances
Dehydration
May also see: fever, abdominal pain, flatulence, weight loss/anorexia if severe
Hemorrhoids
What are the types of diarrhea
Osmotic : poorly absorbed substances draw water into the bowel lumen
Secretory : derangement of fluid and electrolyte transport across the enterocolonic mucosa, stimulating substance increases secretion or decreases absorption of water/electrolytes
Excudative/inflammatory: inflammation
Increased gut motility: reduced contact time in small intestine, premature emptying of colon, bacterial overgrowth
Common causes of acute diarrhea
Infectious - one of the most common causes of
- bacterial
- viral
- food toxins
- in developing countries could lead to chronic diarrhea
Drugs most commonly associated with diarrhea
Laxatives
Antacids
Antibiotics
Cholinergic drugs
Promotility agents
SSRI antidepressants
Sulfasalazine
NSAID
Clostridium difficult infections (CDI)
Anaerobic bacteria - clostridium difficult
Associated with antibiotics: fluroquinolones, cephalosporins, clindamycin
Range of symptoms includes severe symptoms with watery diarrhea, abdominal pain/distension, fever
Travellers diarrhea
Onset usually 1-2 days of ingesting contaminated food and up to 7-10 days after returning home
May be accompanied by abdominal cramping, fever or vomiting
Most cases are self-limiting
Red flags of diarrhea that should be referred
Fever >38.5
Blood or abdominal mucus in stools
Sever pain
Sever diarrhea >6 stools per day
Diarrhea >7 days
Signs of debilitating dehydration
Clostridium difficult infection
Therapeutic approach: non pharmacologic for diarrhea
Discontinue medication/foods that could be causing diarrhea
Adequate rehydration
Maintain electrolyte balance
Clear fluids for 24 hours
Oral rehydration
Avoid fruit juice and carbonated drinks
Oral rehydration therapy
Contains appropriate proportions of Na+, K+, glucose/dextrose and others
Products available : gastrolyte, pedialyte, WHO-ORS, hydralyte
Treatment approaches : Non pharmaologic diarrhea
Stop ingestion of poorly absorbed carbs ( sorbitol, mannitol)
Complex carbohydrate diet - BRAT ( not usually recommended)
Regular diet in 1-3 days
Peripheral action of loperamide (Imodium) - OTC
Binds to opiate receptor in gut wall
Inhibits release of acetylcholine + prostaglandins
Reduced peristalsis, increases intestinal transit time
Increased tone of anal sphincter- reducing in continence and urgency
Central + peripheral action: diphenpxylate + atropine (lomotil)- RX
Slows digestion
Atropine added to prevent misuse
Loperamide (Adult dose, duration, role and children)
Adult dose: 4mg, then 2mg after each bowel movement (max 16mg/day)
Duration: recommended not to be sued for more than 2 days ( however, can be used longer in some patients with chronic diarrhea)
Role: moderate to severe diarrhea
Avoid using in children under 2
Adverse effects of loperamide and use in pregnancy and contraindications
Abdominal cramps, dry mouth, drowsiness, constipation
Safe in pregnancy
Contraindications: patients with bloody stools and high fever,liver failure
Diphenoxylate + atropine ( dose, role, effectiveness)
Dose 2.5-5mg, 3-4 times a day ( max 20mg/d)
Role : moderate to severe diarrhea
Less effective than loperamide
Diphenoxylate + atropine adverse effects, contraindications and use in pregnancy
Side effects: dry outs, blurry vision, urinary retention, constipation
Avoid in clostridium difficult infection or malnourished or severly dehydrated
Contraindications: caution with use in elder, children ( anticholinergic effects)
Avoid in pregnancy
Absorbent agents (attapulgite)
Absorbs water, nutrients, toxins, bacteria (8x weight)
Role : Mild diarrhea
May not be effective as loperamide
Well tolerated
Dose 1200-1500mg after each liquid bowel movement
Avoid in children under 2
Hydrophilic bulking agents (psyllium) role, dose, mechanism
Mechanism in diarrhea includes absorbing liquid to create firmer stools
Role: mild diarrhea
Dose 1tsp (5-6m) twice a day
Antisecretory agents ( bismuth subsalicylate ) role, dose, mechanism
Role : mild to moderate diarrhea, prevention or treatment of travellers diarrhea
Dose 524mg ( 2 tabs or 30mls) ever 0.5-1hr prn ( max 4.2g/day)
Mechanism: Antimicrobial, lower attachment of bacteria to GI apithelium
Bismuth subsalicylate adverse effects, drug interaction, use in pregnancy
Adverse effects: black tongue, black stools, tinnitus
Drug interactions: oral anticoagulants, other salicylates, methotrexate
Avoid in children under 2
Caution in pregnancy, breastfeeding
Zinc supplements for diarrhea
Used in developing countries
Lower severity and duration of diarrhea
20mg daily for 10-14days
Prescription drugs to treat diarrhea (cholestyramine), role, dose, cautions
Cholestyramine
Dose : 4 mg daily or bid for bile acid induced diarrhea
Role: treat diarrhea from bile acid malabsorption
Caution: drug interactions as it may bind drugs. Administer other drugs 1 hour before or 4-6 after
Prescription drugs to treat diarrhea (antibiotics)
CDI, ex. Metronidazole, vancomycin
Prevent/treat travelers diarrhe* fluroquinolones, azithromycin, Rifaximin
Prescription drugs to treat diarrhea (octerotide,lanreotide) role
Diarrhea from neuroendocrine tumours
Choosing among the OTC antidarrheals
Moderate to severe - loperamide
Mild to moderate- bismuth
Mild - attapulgite or psyllium
Treatment of chronic diarrhea
Treat specific cause
Discontinue drug that may be adding to diarrhea if possible
Non pharmacological
Maintain hydration
Loperamide or adsorbents are options
Prescription drugs to treat diarrhea from specific causes
Pregnancy/breastfeeding antidarrheals
Notes
Adsorbents
Loperamide
Avoid diphenoxylate/atropine,avoid bismuth subsalicylate
Probiotics for treatment of diarrhea (dose)
General safe for health individuals
Population at risk: immunocompromised, severe illness
Dose : Depends on strain used
Functional food with added probiotics
Fermented dairy products like yogurt
Choosing a probiotics
Determine type of probiotic strain needed
