W10. Diarrhea and Dehydration Flashcards
what is diarrhea
3 or more loose or waery stools in 24 hours
*type 5, 6 or 7
can be acute <14day
chronic >28 days
etiology of chronic diarrhea
- chronic infection or mediaction use
- Neoplasias (colon cancer, lymphoma)
- malabsorption syndromes (celiac disease)
- endocrinopathies (hypoertyroidism, addisons disease)
- motility disorders (diabetic autonomic neuropathy, IBC)
- chronic inflammation (diverticulitis, IBS, Crohn’s, ulcerative Colitis, ischemic colitis, radiation colitis)
*REFER all chronic diarrhea
athophysiology of acute diarrhea: osmotic or solute induced
*caused bc too many osmotically active solubtes in gut lumen, cant be adequately brough in, not absorabable/poorly abs. water stays where soltues are
- osmotically active solutes present in gut lumen -> dec osmotic gradient -> dec water abs
- unabsorable or poorly abs solutes
- > lactose intolerance/lactase deficiency
- > osmotic laxatives (polyethylene glycol/PEG, magnesium salts, sodium phsopshate, lactulose)
- > large intake of fructure (fruit juices, soft drinks) or sugar substitues (sorbitol, mannitol, xylitol)
*little kids drinking lots of soft drinks or fruit jucies can get diarrhea form this
how can you differentiate osmotic or solute induced acute diarrhea from others
when patient stops eating diarrhea stops
if solutes are not in the gut lumen then they dont keep water iwth it and dont have diarrhea
peristaltic & diarrhea
*due to inc peristalsis, thigns mvoign trhough faster so not enough contact time to reabs the water
- stimulation fo enteri NS -> INC peristalsis -> DEC time for water abs
ex: triggered by stress, caffeine, abrupt cessation of opioids(opiods slow peristalsis so will have storng rebound effect)
pathophysioloy of acute diarrhea: Secretory or Electrolyte‐Related
*simialr to first one, but this one the ion transporter isnt working properly
*ions stay in gut lumen or its reversed and pumps pump ions into gut lumen
- Ion transport across intestinal membrane is reversed (ions are secreted into gut lumen)
- causes decrease in osmotic gradient -> decreases water abs (may even pull from intravascular space)
- often combines with inc in peristalsis
*this is pulling water out your BV so they beocme SUPER dehydrated
ex of tings triggering Secretory or Electrolyte‐Related diarrhea
- Bowel ischemia (causes pump to not work properly)
- Misoprostol (i.e., prostaglandin analogue, makes ion pump malfunction)
- Viral enterotoxins (e.g., rotavirus, norovirus)
- Bacterial enterotoxins (e.g., cholera, C. difficile, E. coli )
*also sitmulates enteric NS
*main way that viruses cause this
Etiology of Acute Diarrhea:: dietary triggers
- Alcohol (e.g., wine, beer)
- Caffeine (e.g., coffee, tea, cola)
- Fructose (e.g., juice, soft drinks)
- Lactose (e.g., milk, ice cream, yogurt)
- Sorbitol (e.g., sugar‐free gum, prunes)
Etiology of Acute Diarrhea: Medication Triggers
• SSRIs
• NSAIDs
• Laxatives
• Colchicine
- Magnesium‐containing antacids (not well abs solute)
- Antibiotics (kill off gut flora, cause special type of diarrhea)
- Lithium • Digoxin Allopurinol • Levothyroxine • ACE inhibitors • Anticoagulants • Prostaglandins • Mycophenolate • Antidiabetic agents • Proton pump inhibitors • H 2‐receptor antagonists • Chemotherapeutic agents • Acetylcholinesterase inhibitors • Sorbitol‐containing elixirs (e.g., potassium)
types of poop
1: rabiit droppings
2: lumpy bunhc of grapes more water drawm out
3-4 two iteal ones: more smooth consistent piece
5: soft blobs with clear but edges, passed easily
6: more broken some like porridge
7. lqiuid no solid
Etiology of Acute Diarrhea: Infections (aka Gastroenteritis)
- Viruses (most common)
- facal oral transmission
- year round, most common in Nov-Apil
- stomach flu (N/V, abdo pain, HA, malaise, fever/chills) *not acutally flu just lfu like symptoms
- Norovirus, Rotavirus (most sig cause of severe diarrhea, vaccine now available)
- Bacteria
- contaminated food/water (except C.diff)
- Aka food poisoning (travelers diarrhea)
- in canada: C.perfringes, S. aureus, B. cereus (N/V/bloat)
- Salmonella, shigella, campylobacter, e.coli (fever, severe abdopain, blood in stool) *more dangerous
- Parasites
- contimainted food/water (lakes/pools), fecal-oral
- both can lead to chronic symp
- less common
- in canada mainly Giardia lamblia (fatty looking stool steatorrhea, bloating cramps, weight loss)
how can you prevent infectious diarrhea
- drinka nd use clean, safe water
- follow hand hygiene guidelines, esp if sick
- practice food safety: watch best before dates, wash fruits and veg before cutting, cook thoroughly w/ food thermometer, sep utensils &cutting boards for raw meat
- thaw in fridge, old water or microwave and cook immediately
- keep raw meat separate from other foods in grocecry cart/fridge
most acute diarrhea is
infectious and self limiting
when to refer acute diarrhea
- Fever ≥ 38.5 °C
- Diarrhea > 14 days
- Worsening diarrhea
- Blood or mucus in stool
- Weight loss due to diarrhea
- Immunocompromised patients
- Severe abdominal pain or cramping
- Recent use of antibiotics/ recent hospitalization
most common complication of diarrhea
acute dehydration -> dehydration
- electrolyte and acid base imbalance, hemrrhoids and recal prolaps also possible
**Patients showing symp of dehydration, or who are at high risk for complications, should be referred.
what populations are most susceptible to dehydration
frail elderly and child <2, more susceptible and less likely to demonstrate or be able to articulate symptoms
- also pregnanyc, vomiting >4, immunocompromised, diabetes, HF, Chronic kdiney disease, severe diarrhe
hypo vs hyper volemia
hypovolemia: Poor fluid intake, excessive fluid loss, third spacing (fluid leavs BV goes elsewhere)
- fatigue, dizziness (blood not perfusing), extremities get cold and blue (body prioritizes central organs so clamps down on peripheral vasculature), decrease bowel sounds, bowel ischemia bc dec blood flow, urien output dec bc kidneys dont get perfused, blood markers go up, orthostatic hypotension (big diff between bp sitting vs standing)
Hypervolemia: Excessive fluid intake, inappropriate fluid retention
*euvolemic = good where you want to be
symptoms of dehydration in adults and children
Thirst • Dry skin • Dizziness • Tiredness • Headache • Dry mouth • Crankiness • Sunken eyes • Constipation • Dark‐coloured urine • Cold or mottled extremities
*Any patient with evidence of dehydration should be urgently referred.
signs fo dehydration
- dec skin turgor
- dec BP, INC HR, INC RR
- INC urea: SCr/ INC Na
= INC capillary refill time (> 2 sec)
- >20 mmHg SBP dec from sit to stand
dehydration symtpoms in infants
Fever
• No tears •
Dry mouth
- Sunken eyes
- Sunken fontanel
- Unusual tiredness
- No wet diapers in ≥ 3 hrs
- Cold or mottled extremities
self limiting anture of acute diarrhea
Non‐infectious acute diarrhea with an identifiable dietary or medication trigger should resolve with avoidance or discontinuation, although complete normalization of bowel patterns may take several days.
usually imrpoves in 48 horus and normalizes in 7-10 days
ORT for acute diarrhea
Inexpensive sugar‐salt solution, usues glucose sodium pump v important that it a 1:1 ratio
- Reverses secretory diarrhea
- Replaces fluid and electrolyte losses
- Glucose enhances sodium absorption
- As effective as IV rehydration for mild‐to‐moderate dehydration
- Contraindicated if protracted vomiting
ORS
recommend early to treat diarrhea and prevent dehydration
*shown too decrease stool output, vomiting, and need for IV rehydration. It has saved millions of lives around the world
- avail as liq, powder, popsickle, effervescent tab
ex: pedialyte (has zinc and prebiotic), Hydralyte - homemade ORS are discouraged bs mixing errors frequent
what liq to aovid consuming when have diarrhea
- avoid plain water, fruit juice, sports drinks and carboanted beverages
- >Do not have solutes in necessary proportions
- >Plain water can lead to hyponatremia
- >Others may worsen osmotic diarrhea
* Apple juice half‐diluted with water is a reasonable alternative until suitable ORS can be obtained
ORS administration
- 15 mL/kg/hr or 60 mL/kg over 4 hrs
- If vomiting, give small volumes frequently (e.g., 15 mL q10 min) until vomiting stops
- If unpalatable, give via spoon, use oral syringe, or administer frozen
- Continue until diarrhea resolves
diy ORS
6 tsp of sugar, half tsp salt, 1 L water
dietary recommendations during acute diarrhea
- Do not limit diet (BRAT, no evidence) dont want to limit diet bc will alter nutrition which is already affected by diarrhea
- keep portion sizes until diarrhea improves
- breasnd and bottle feeding shoudl ontinue + ORS
*• WHO/ UNICEF recommend zinc supplementation x 10 – 14 days (for children at risk of deficiency) NOT COMMON TO HVE DEFICIENCY IN CANADA
-> • 10 mg daily (infants < 6 mos), 20 mg daily (infants > 6 mos)
When to sue Pharm options for acute diarrhea
*usually just use ORS
can be used in addition to ORT when needed for QoL or symptoms not improved within 48 Hours
Psyllium
what is it reasonable for
action
safety
adherence
dosing
- what is it reasonable for
- mild diarrhea
- action
- bulking agent
- abs fluid to make stool less watery
- safety
- cramping, flatulence
- separate from toher meds by 2 hours
- give w/ adequate water
- adherence
- power avail also capsules
- dosing
- BID to QID
Bismuth
what is it reasonable for
action
safety
adherence
dosing
- what is it reasonable for
- mild to moderate diarrhea
- action
- antisecretory agent
- stim reabsorption of electrolytes and water
- safety
- causes black tongue and stools
- tinnitus
- avoid in patients taking anticoagulants or saliculates or histroy of ulcer
- adherence
- liq available, chewable tabs, easy to swallow caplaets
- dosing
- q30-60 min prn with daily max
Loperamide
what is it reasonable for
action
safety
adherence
dosing
*not great bc if your body is needing to get rid of soemthing dont want to stop body from getting rid of it
- what is it reasonable for
- moderate to severe
- action
- antimotility agents
- binds to opiod receptor to slow down peristalsis
- safety
- cramping, dorwsiness, dizziness, dry mouth
- do not use in patients w/ high fever or bloody diarrhea
- contraindicated <3
- adherence
- caps, liq, tabs
- dosing
- intial dose followed by dose after each BM with daily max
