Diarrhea

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Diarrhea is an increase in the frequency and looseness of stool.

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It results when some factors impair the ability of the intestine to absorb water from stool.

ClassificationAccording to: 1. MechanismOsmotic Secretory Motility

2. Origin Acute Chronic

Classification According to Mechanismy

Osmotic diarrhea:when non absorbable solute pulls excess water into the intestinal tract.

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Secretory diarrhea:When the intestinal wall is damaged, increased secretions rather than absorption of electrolytes in the intestinal tract.

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Motility disorder:Decreased contact time of fecal mass with the intestinal wall

Classification According to Originy

Chronic: (more than 2 weeks).Due to:

Protozoal infection IBS Malabsorption syndrome Pancreatic disease

Why milk ?y Milk

contain lactose which needs lactase enzyme to be digested. y In case of lactase deficiency undigested lactose lingers in the intestine and ferments causing intestinal discomfort.

Treatment :y

Drink milk with meals Use lactaid Use lactase For infants try lactose-free infant formula Try calcium-fortified soy milk Yoghurt may be safe

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IBS( spastic colon): Is a central or lower abdominal pain relieved by defecation ,abdominal bloating, altered bowel habit, tenesmus and passage of mucus. Causes: y After GIT infection y Young age y Prolonged fever y Anxiety y Depression

Treatment:1) Diet patients are hypersensitive to fats and fructose soluble fibers e.g.: psyllium may be effective 2) Medications y Laxative y Antidiarrheal (opiates, opioids, loperamide) y Serotonin (agonist or antagonist) y Antispasmodic (hyoscyamine) y Anti-depressants

Causes of Infectious diarrhea1) Virus -Rotavirus -Astrovirus 2) Bacteria and toxins -Campylobacter jejuni. -Salmonella -E.coli -C.dificile 3) Protozoa -Giardia lamblia -E.histolytica

Treatment :Oral rehydration solution 2) Antibiotics (Norfloxacin) 3) Anti- protozoal (Antinal) 4) Anti- secretory agents ( enkephalinase inhibitor)1)

Travelers diarrhea(TD):

Causative agents are usually bacterial, viral and may be giardiasis. TD largely is due to absence of treated water and poor hygiene.

Treatment of travelers diarrhea1)Quinolones: -Ciprofloxacin ( Cipro). -Levofloxacin (Levaquin). 2)Subsalicylate(Pepto-Bismol). 3)Alternative drugs: -Diphenoxylate. -Atropine (Lomotil). -Loperamide (Imodium). 4)Oral fluids.

Stomach flu (Gastro-enteritis): Inflammation of stomach ,small and large intestine. Causes: -Viruses (Rota , Adeno, Noro , Sapo and Astro virus). -Not Caused by Bacteria or Parasites.

Symptoms : -Watery diarrhea. -Vomiting. -Headache. -Fever. -Abdominal cramps (stomach ache). Possible treatment: -Oral rehydration solution.

Vibramycin :

Doxycyclin 100mg . Semi synthetic member of Tetracycline Antibiotics . Inhibits protein synthesis . Causes stomach upset.

Velosef 1000Cephadrine y 1st generation Cephalosporin.y

Bactericidal antibiotic that inhibits cell wall synthesis. Disrupts normal flora causing Pseudo -membranous colitis in some cases.

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Pseudo membranous colitis or C.Difficle colitis:Severe inflammation of the inner lining of colon. Antibiotic associated colitis: caused by broad spectrum antibiotics as they alter the normal flora by: 1) destroying normal intestinal bacteria 2) causing extensive growth of others ex. Clostridum difficle that change to the active infectious form producing toxins that are responsible for diarrhea which characterizes pseudo membranous colitis.

Characterized by: - Offensive smelling diarrhea. - Fever > 38C -Abdominal pain and cramps -Pus in stool -Complications : Toxic mega colon. Treated by: Metronidazole 400 mg/ 8 hours to restore the balance of bacteria in colon.

Antibiotic-induced diarrhea: 1) intestinal irritation / stomach upset. 2) increased bowel motility. 3) disruption of normal bacterial flora .

Primpran ( Metoclopramide )Uses: Anti-emetic, Nausea, and GERD. Causes Diarrhea as it is a prokinetic drug increasing the gastro-intestinal motility by stimulating the GIT muscles via ACH/ DA receptors.

Other drugs causing Diarrhea: 1) Motility diarrhea: decreased contact time of feces in intestine, low water absorption. Example: Prokinetics D2 Antagonists: Domperidone ( motilium ) - Parasympathomimetics: Bethanichol, Digitalis and Quinidine 2) Secretary diarrhea: intestinal wall damage, resulting in increased secretion of electrolytes into the intestinal tract. Examples : - Antibiotics - Chemotherapeutic agents - Colchicine (gout) PGs ( secretagouges) 3) Osmotic Diarrhea: extra water is pulled into the intestine. Examples - laxatives (lactulose -> Laxolac) - Mg antacids

When is diarrhea considered chronic?y Acute

diarrhea:

Self-limiting in 2-3 days.y Chronic

diarrhea:

Loose stool that lasts for more than 2 weeks.

Refer to a Physician when:Patient is younger than 3 years or older than 60 years. y Pregnant and breast feeding patients. y Blood or mucus in stool. y Fever (higher than 38 C). y Weight loss and signs of dehydration. y Duration more than 2 days with no response to common medication.y

Causes of chronic diarrhea:y

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Protozoal infection Entamoeba histolytica Giardia lamblia Diet induced Lactose intolerance Spicy food Caffeine Fibers Pancreatic disease (pancreatitis or pancereatic cancer) Endocrine disease (Hyperthyrodism or addisons disease) Intestinal Disorder (IBS or inflammatory bowel disease) Medications (chronic laxative abuse or Mg Antacids)

FDA strategy : The 2 days cutoff strategyThe patient should not receive any medication in the first 2 days. Antibiotics are administered rarely as diarrhea most likely is of viral origin; however, in severe cases and if stool examination proves the presence of bacterial or parasite infection antibiotics are used. Overuse encourages development of resistance.

Treatment

Nonpharmacological (Fluid replacement)

Pharmacological 1.kaolin 2.bisthmus subsalicylate 3.loperamide

Complications of diarrhea:Dehydration: Dryness, coma, electrolyte imbalance and kidney failure.

Occurs due to excessive loss of fluids and minerals, especially if the intake of fluids is limited and if diarrhea is accompanied by vomiting.

Diagnostic tests for the evaluation of diarrhea:y y y

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Stool examination and culture (bacteria, toxins, parasites, and blood) Blood test (full blood count, antibodies, and electrolytes) Colonoscopy (to examine entire colon lining ) and sigmoidoscopy (inspection of lower colon and rectum) Fasting test (test for food intolerance or allergy) Barium enema via anus (Barium sulphate to highlight colon and rectum in X-rays)

Pregnant women are susceptible to viral and bacterial infection.

Diarrhea in pregnancy:Hormonal changes Sensitivity to certain foods Lactose intolerance Certain antibiotics and antacids can cause it sometimes Gastrointestinal problems like inflammatory bowel disease, irritable bowel syndrome.

The biggest concern for pregnant women with diarrhea is the risk of severe dehydration, which can affect the baby. Because it can cause : Contractions Lack of water in the third trimester can also cause premature labor. Premature labor can have many health risks to the newborn baby.

Infectious Viral (Rota virus , Adenovirus, Calicivirus, Astrovirus, and Influenza Bacterial ( E.coli , Salmonella, Shigella, Staphylococcus,Campylobacter) Protozoal (Entamoeba histolytica ) Ear infection Non infectious Food allergy: Milk protein allergy Lactose intolerance. Teething and change in mother's diet if the baby is breastfed.

Prevention measures 1. Health education. 2. Breast feeding. 3. Clean surfaces. 4. Washing hands of infants and parents. Treatment 1. Rehydration therapy 2. Symptomatic treatment (antispasmodic and antidiarrheal) 3. BRAT diet

Dehydration more severe in infants due to their small body mass. Mild to moderate dehydration ORS containing glucose and electrolytes. Severe dehydration IV therapy. Signs of dehydration. - Dry mouth and tongue - Crying with no tears. - High fever. Avoid certain foods and drinks

Oral Rehydration Solution ORS is safe but has no effect on duration of diarrhea, it acts as fluid replacement. Fluids to be avoided in ORS 1. Hypertonic fruit juices 2. Drinks (apple juice and powdered drink mixes) 3. Carbonated beverages 4. Caffeine containing drinks

The FDA classified 3 agents as category 1 (safe and effective) 1- Antiprestaltic drugs: Loperamide (Imodium). 2- Adsorbents: Kaolin & Pectin (Kapect). 3- Miscellaneous drugs: - Bismuth subsalicylate ( Kaopectate, Pepto-Bismol). - Smecta - Lacteal fort - Entocid - Antinal & Diax

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ImmodiumR (loperamide) LomotilR (diphenoxylate , atropine)

They are antiperistaltic contraindicated in acute bacterial diarrhea as they: - Decrease clearance of the organism. - Enhance systemic invasion.

ImmodiumRy

Precaution:Pregnancy,Nursing mothers,and with hepatic impairment. Allergy to loperamide If you have stools that are bloody, black, or if you have diarrhea that is caused by taking an antibiotic. Drink extra water while you are taking this medication to keep from getting dehydrated Talk with your doctor if your symptoms do not improve after 10 days of treatment. Imodium can cause side effects that may impair your thinking or reactions.

LomotilRy y y y y

Its active ingredients are diphenoxylate and atropine. Diphenoxylate is anti-diarrheal and atropine is anticholinergic. Diphenoxylate is chemically related to the narcotic drug . A sub therapeutic amount of atropine sulfate is present to discourage deliberate overdosage. Atropine has no anti-diarrheal properties, but will cause tachycardia when overused.

Lomotil is contraindicated in the following cases: 1. Allergy to diphenoxylate or atropine. 2. Presence of jaundice. 3. Diarrhea associated with pseudomembranous enterocolitis. 4. Diarrhea caused by antibiotic treatment. 5. Diarrhea caused by enterotoxin producing bacteria.

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KapectR adsorb drug from GIT So it is recommended that this product not to be given within 3 hours of other medication because it may decrease the absorption of other orally administered drugs.

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Adverse effects:y y

Grayish charcoal coloring of stool or tongue. Ringing in the ears (tinnitus).

Some of the risks of salicylism can apply to the use of bismuth subsalicylate.

Contraindications:y y y y y

Pregnant or breast feeding patients. Patients with black or bloody stool. Patients with allergy to salicylate. Patients on anticoagulants should be monitored closely if taken these products. It should not be given to children or teenagers during or after recovery of chickenpox or flu.

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Lactobacillus product containing non-toxin strains of lactobacillus acidophilus. Intended to replace the normal bacteria flora that is lost during the administration of oral antibiotic.

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However, there is little information to show that these products are useful. For antibiotic induced diarrhea as with increase in bowel organism patient experience flatulence.

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