Management of Acute Diarrhea

What is Diarrh(o)ea? Diarrhoea is a symptom characterized by an abnormal increase in stool frequency (more than 3 times daily) or liquidity (> 80% water); The normal frequency of bowel movements varies with each individual < 14 days: acute; 14 days-4 months: persistent; > 4 months: chronic diarrhea Only acute diarrhea can be treated by OTC

Causes: bacterial or viral infection through ingestion of contaminated food or drink; E.Coli, S.aureus  toxins  mucosal cells hypersecretion of fluid watery diarrhoea with little or no fever or other symptoms;

Causes: Invasive E. coli, Salmonella and Shigella: directly invade mucosal epithelial cells and cause an inflammatory reaction less fluid diarrhea accompanied by nausea, vomiting, cramps and sometimes low-grade fever

Causes: Viral infections, which often affect babies and young children, also produce watery diarrhoea Non-infective causes: stress, alcohol, and hot spicy food Drugs: antibiotics “all but varying degrees”. Depends on extent that drug disrupts normal intestinal microflora. Other: laxatives, misoprostol. Olsalazine, anticancer, antihypertensive agents

Consequences Normal faeces contain 60-85 % water Water loss during defecation= 70-200 mL/day In diarrhoea: water loss 4X normal K and Na loss fall in plasma pH (acidosis) serious metabolic consequences Fluid & electrolyte losses are increased if vomiting also occurs

Consequences In babies/children: hazardous as high proportion of total body weight is lost and dehydration can occur very rapidly Elderly are also particularly sensitive to the effects of fluid and electrolytes loss, especially if on diuretics Reduction in blood volume + RAS  + aldosterone (1) loss of K (hypokalemia) (2) Excessive fluid loss reduction of renal artery flow renal failure

When to Refer? If diarrhoea lasts more than: 72 hours : adults and older children 48 hours : children < 3 years old & elderly 24 hours in children < 1 year old Refer immediately in infants under 3 months old

Medical evaluation is needed for:

Treatment Oral rehydration therapy (ORT) Opioids Adsorbents Dietary management In UK: belladonna extract

Self-care of acute diarrhea in children aged 6 mo to 5 yrs

Self-care of acute diarrhea in children > 5 yrs, adolescents & adults

Oral rehydration therapy (ORT) First line treatment of acute diarrhoea the very young & elderly (particularly important) ORT not intended to relieve symptoms Use of antidiarrheals (antimotility drugs or adorbents) is regarded unnecessary and sometimes undesirable Use of antidiarrheals (for comfort/convenience) is used as adjunct to ORT

Oral rehydration therapy (ORT) Mode of action: replace water and electrolytes lost through diarrhea and vomiting; K & Na: replace ions citrate and/or bicarbonate: correct acidosis glucose: carrier for Na ions and hence water across the mucosa of the small intestine

Oral rehydration therapy (ORT) ORT is not intended to stop diarrhoea, but acute diarrhoea is self-limiting and normally ceases within 24-48 hours; ORT can be recommended for patients of any age, even when referral to a doctor is considered necessary

Dose & Administration of ORS the content of 1 sachet or 2 effervescent tablets should be dissolved in 200-250 ml of water (freshly boiled and cooled in case of infants) discard unused solution 1 hr after reconstitution or no longer than 24 hrs (if refrigerated) Dose in adults: 200-400 ml after every loose motion, or 2-4 L over 4-6 hrs

Dose & Administration of ORS Patients may prefer to sip 1-2 tsp every few minutes rather than drink large quantities less frequently children > 2 yrs: cupful (200ml) after every loose stool children < 2 yrs: ¼- ½ cupful Infants: 1-1.5 normal feed volume Both breast and bottle-fed babies should continue to be fed normally (without dilution)

Contraindications & cautions No contraindications to ORS unless the patient is vomiting frequently  IV fluid and electrolyte replacement; fluid overload from excessive administration of ORS is highly unlikely unless continued for babies and young children > 48 hrs (recognized by puffy eyelids)  rapidly withhold ORS and other liquids

Homework The place of household oral solutions in rehydration

Opioids Loperamide Mode of action: increase tone of both small and large bowel and reduce intestinal motility (enhances fluid and electrolyte reabsorption); increase the sphincter tone and decrease secretory activity along GIT

Loperamide It is a synthetic opioid agonist that has a high affinity for, and exerts a direct action on  opiate receptors in the gut wall; also has a high first-pass metabolism so very little reaches the systemic circulation; effective in reducing the duration of diarrhea (25 vs 40 hrs with placebo)

Loperamide 50 fold more potent than morphine and 2-3 times more potent than diphenoxylate in its effect on GI motility, but penetrates the CNS poorly, thus has lower risk of CNS side effects; Other mechanisms: disruption of cholinergic and non-cholinergic mechanisms of peristalsis, inhibition of calmodulin function and inhibition of voltage dependent Ca channels

Loperamide Indications: traveller’s diarrhoea non-specific acute diarrhoea chronic diarrhoea associated with inflammatory bowel disease AAP does not recommend use in children < 6 years old Used when patient is afebrile or have mild fever and does not have bloody stool

Loperamide Dosage & Administration dosage forms: caplets (2 mg), and liquid (1 mg/5ml) Dose: 4 mg initially, then 2 mg after each loose stool/ Do not exceed 16 mg/day Consult product instructions for pediatric dose

Loperamide Side effects: At usual doses: few side effects other than occasional dizziness and constipation Other: abdominal pain and distension, nausea, vomiting, dry mouth, fatigue and hypersensitivity reactions It may worsen effects of invasive bacterial infections and may cause toxic megacolon in antibiotic-induced diarrhoea If abdominal distension, constipation, or ileus occurs, loperamide should be discontinued

Loperamide Contraindication Loperamide should not be used in patients with fecal leukocytes, high fever, or blood or mucus in the stool (dysentery); Loperamide may cause paralytic ileus in patients with dysentery Paralytic ileus: paralysis or inactivity of the intestine that prohibits the passage of material within the intestine. May be a result of anticholinergic drugs, injury or surgery

BSS BSS (Bismuth subsalicylate): claimed to pocess adsorbent properties; large doses are required and salicylate absorption may occur (be cautious!). Not labeled for children < 12 yrs HW: toxicity of BSS Drug interactions with BSS

Adsorbents Mode of action: adsorb the microbial toxins and micro-organisms to their own surfaces drugs not absorbed from the GIT toxins and MOs are excreted in stool; Hydrophilic adsorbents (e.g. pectin and bulk-forming agents; ispaguala, methylcellulose, and sterculia), bind water within the intestine causing watery stool to become more formed

Adsorbents the main constituents in the antidiarrhoeal preparations for young children (whom opiates and antimuscarinics are contraindicated); not absorbed from GIT harmless and safe to use Debate: reduce evacuation of faeces- prolong presence of pathogens/toxins in bowel. Adsorption: non-specific process (medicines)

Dietary Management Traditionally: withdrawal of feedings, initiation of clear liquids, with a slow reintroduction of feedings over several days However, oral intake does not worsen diarrhoea, clinically significant nutrient malabsorption is uncommon (80-95% CHO, 70% of fat and 75% of the nitrogen from protein) in acute diarrhoea and bowel rest is generally not necessary

Dietary Management Early refeeding in combination with maintenance ORS therapy, improves outcomes of acute diarrhoea in children by reducing the duration of diarrhoea, reducing stool output and improving weight gain

What foods are best for refeeding? most infants and children with diarheoa can tolerate full-strength breasts milk and cow’s milk; The familiar BRAT (bananas, rice, apple sauce and toast) is frequently prescribed- insufficient calories, protein and fat especially in strict or prolonged use and is not recommended by AAP

What foods are best for refeeding? Diet should include: complex carbohydrate-rich foods (e.g. rice, potatoes, bread, cereals) Yogurt lean meats Fruits and vegetables

What foods are best for refeeding? Avoid: fatty foods foods rich in simple sugars that may cause osmotic diarrhoea spicy foods that may cause GI upset Caffeine (WHY??)