LECTURE OF DIARRHEA.pptx clinical pharmacy

LECTURE OF DIARRHEA.pptx clinical pharmacy

1. Epidemiology and Management of Diarrheal Diseases COURSE TITLE : CLINICAL PHARMACY COURSE CODE : 716 P COURSE INCHARGE : SHUMAILA QADIR

2. RELATIVE AND ABSOLUTE Absolute diarrhea  is the passage of five or more bowel movements per day of liquid stool, while  relative diarrhea  is an increase in the usual number of bowel movements, especially if abnormally loose and watery, experienced by a particular perso

3. DEFINITION Watery Diarrhea: 3 or more liquid or watery stools in 24 h Dysentery: Presence of blood and/or mucus in stools Persistent Diarrhea: Diarrhea lasting for 14 days or more

4. Mechanisms Osmotic Diarrhea Secretory Diarrhea Deranged Motility Exudation

5. Osmotic Diarrhea R esults from poorly absorbable osmotically active solutes in the gut lumen ( Osmosis is the movement of a solvent through a semi-permeable membrane into a region of higher  solute   concentration. osmotically active  substances can be defined as the  solutes  cannot pass the given semi-permeable membrane .) S tops when the patient is fasting S tool analysis - Inc osmotic gap 290 mosm /kgH2O-2( Na+K ) mmol /l LOW OSMOLAR ORS: “ reduced osmolarity ” Studies have shown that the efficacy of  ORS  for treatment of children with acute diarrhoea is improved by reducing its sodium concentration to 75 mEq /l, its glucose concentration to 75 mmol /l, and its total  osmolarity  to 245 mOsm /l .

6. Some Causes of Osmotic Diarrhea Carbohydrate malab gluc-galact malab fructose malab disaccaridase def ingestion (poorly absorbable carbs) lactulose sorbitol fructose fiber Magnesium-Induced Nutritional supplemts antacids laxatives GI Lavage solutions Laxative sodium citrate sodium phophate sodium sulfate

7. Secretory Diarrhea Results from abnormal ion transport in intestinal epithelial cells Main categories of secretory diarrhea congenital defects of ion absorptive process intestinal resection diffuse mucosal disease abnormal mediators

8. Secretory Diarrhea Diarrhea persist during a fast S tool Na, K and the accompany anions account for the stool osmolality.

9. Some Causes of Secretory Diarrhea Laxatives Phenolophthalein , aloe Medications diuretics Toxins coffee, tea, cola, ETOH Bacterial Toxins S.aureus , C.perf +bot, B.cereus Congenital Bacterial entertoxins V. cholera, C.diff , Y.enterocol , toxigenic E. coli Endogenous laxatives bile acids, LCFA Hormone producing tumors

10. Deranged Motility Enhanced Motility (Intestinal Hurry) decrease contact time of the stool to the absorptive surface Abnormally slow motility may results in bacterial overgrowth and resultant diarrhea

11. Exudation Results from disruption of the intestinal mucosa from inflammation or ulceration blood, mucus and serum proteins in gut lumen bacillary dysnentery Inflammatory bowel disease

12. TYPES OF DIARRHEA

13. COMMON CAUSES OF DIARRHEA- BACTERIA Vibrio cholera Shigella Escherichia coli Salmonella Campylobacter jejuni Yersinia enterocolitica Staphylococcus Vibrio parahemolyticus Clostridium difficile

14. COMMON CAUSES OF DIARRHEA- VIRUS Rotavirus Adenoviruses Caliciviruses Astroviruses

15. COMMON CAUSES OF DIARRHEA PARASITE Entameba histolytica Giardia lamblia Cryptosporidium Isospora

16. COMMON CAUSES OF DIARRHEA OTHERS Metabolic disease Hyperthyroidism Diabetes mellitus Pancreatic insufficiency Food allergy Lactose intolerance Antibiotics Irritable bowel syndrome

17. TRANSMISSION Most of the diarrheal agents are transmitted by the fecal-oral route Some viruses (such as rotavirus) can be transmitted through air Nosocommial transmission is possible Shigella (the bacteria causing dysentery) is mainly transmitted person-to-person

18. SEASONALITY

19. PERSON-AT-RISK Cholera: 2 years and above, uncommon in very young infants Shigellosis: more common in young children aged below 5 years Rotavirus diarrhea: more common in young infants and children aged 1-2 years E. coli diarrhea: can occur at any age Amebiasis : more common among adults

20. TYPES OF VIBRIO CHOLERA Two major biotypes of Vibrio cholera that cause diarrhea are: Classical ElTor Two common serotypes of Vibrio cholera that cause diarrhea are: Inaba Ogawa

21. Vibrio cholerae Vibrio cholerae in O-group 139 was first isolated in 1992 and by 1993 had been found throughout the Indian subcontinent. This epidemic expansion probably resulted from a single source after a lateral gene transfer (LGT) event that changed the serotype of an epidemic V. cholerae O1 El Tor strain to O139.

22. Vibrio vulnificus The organism Vibrio vulnificus causes wound infections, gastroenteritis or a serious syndrome known as "primary septicema ."  V. vulnificus infections are either transmitted to humans through open wounds in contact with seawater or through consumption of certain improperly cooked or raw shellfish. This bacterium has been isolated from water, sediment, plankton and shellfish (oysters, clams and crabs)  

23. TYPES OF SHIGELLA The major serotypes of Shigella that cause diarrhea are: Dysenteriae type 1 or Shigella shiga Shigella flexneri Shigella sonnei Shigella boydii

24. TYPES OF E. COLI Six major types of Escherichia coli cause diarrhea: Enterotoxigenic E. coli (ETEC) Enteroinvasive E. coli (EIEC) Enteropathogenic E. coli (EPEC) Enterohemorrhagic E. coli (E. coli O157:H7) Enteroaggregative E. coli ( EAggEC ) Diffuse adherent E. coli (DAEC)

25. CLINICAL FEATURE: CHOLERA Rice-watery stool Marked dehydration Projectile vomiting No fever or abdominal pain Muscle cramps Hypovolemic shock Scanty urine

26. CLINICAL FEATURE: E. COLI DIARRHEA Watery stools Vomiting is common Dehydration moderate to severe Fever often of moderate grade Mild abdominal pain

27. CLINICAL FEATURE: ROTAVIRUS DIARRHEA Insidious onset (gradual onset) Prodromal symptoms, including fever, cough, and vomiting precede diarrhea Stools are watery or semi-liquid; the color is greenish or yellowish typically looks like yoghurt mixed in water Mild to moderate dehydration Fever moderate grade

28. CLINICAL FEATURE: SHIGELLOSIS Frequent passage of scanty amount of stools, mostly mixed with blood and mucus Moderate to high grade fever Severe abdominal cramps Tenesmus : pain around anus during defecation Usually no dehydration

29. CLINICAL FEATURE: AMEBIASIS Offensive and bulky stools containing mostly mucus and sometimes blood Lower abdominal cramp Mild grade fever No dehydration

30. Approach to Patients with Diarrhea History Characteristics of the onset of diarrhea should be precisely noted (congenital, abrupt, gradual) Pattern of diarrhea should be recorded (continuous or intermittent) Duration of the symptoms Epidemiological factors (travel, exposure to contaminated food or water, illness in other contacts)

31. History Stool characteristics should be investigated (watery, bloody, fatty) Presence of fecal incontinence Presence of abdominal pain Presence of weight loss Aggravating factors (diet or stress) Mitigating factors (alteration of diet, OTC meds) Previous evaluations

32. History Iatrogenic causes (medication history, surgical history, radiation history) Factitious diarrhea (history of eating disorders, secondary gain and malingering) (hyperthyroidism, diabetes mellitus, CVD, AIDS, etc )

33. Approach to Patients with Diarrhea Physical Exam Presence of rashes or flushing mouth ulcers thyroid masses wheezing arthritis anal rectal examination

34. LABORATORY DIAGNOSIS Stool microscopy Dark field microscopy of stool for cholera Stool cultures ELISA for rotavirus Immunoassays, bioassays or DNA probe tests to identify E. coli strains

35. ASSESSMENT OF DEHYDRATION

36. ASSESSMENT OF DEHYDRATION (contd.)

37. ASSESSMENT OF DEHYDRATION (contd.)

38. TREATMENT Rehydration: replace the loss of fluid and electrolytes Antibiotics: according to the type of pathogens Start food as soon as possible

39. COMPOSITION OF ORS

40. AMOUNT OF SALT LOSS DURING DIARRHEA

41. ANTIMICROBIAL AGENTS

42. COMPLICATIONS: WATERY DIARRHEA Dehydration Electrolyte imbalances Tetany Convulsions Hypoglycemia Renal failure

43. COMPLICATIONS: DYSENTERY Electrolyte imbalances Convulsions Hemolytic uremic syndrome (HUS) Leukemoid reaction Toxic megacolon Protein losing enteropathy Arthritis Perforation

44. Acute Diarrhea Less than 2-3 weeks duration Majority of cases are mild and self limiting 4 million deaths world-wide per year in children under 5 years Categories infectious noninfectious drugs, fecal impaction, elixir diarrhea, enteral feedings, chemotherapy or radiation therapy, runner’s diarrhea

45. Diagnostic Tests for Acute Diarrhea Spot Stool Sample Culture, Ova and Parasite, C.diff toxin, fecal leukocytes Blood Tests CBC, electrolytes, SMA 7, blood culture Plain X-rays Endoscopy flex sig (  A  flexible sigmoidoscopy   ( is an exam used to evaluate the lower part of the large intestine (colon).

46. Treatment for Acute Diarrhea Symptomatic fluid replacement Oral replacemet solutions or IV fluids antidiarrheals Bismuth subsalicylate Antimicrobial therapy quinolones metronidazole Bactrim Rifaximin

47. Antidiarrheals and Infectious Acute Diarrheas Bismuth Subsalicylates (Pepto-Bismol) safe and efficacious antidiarrheal effects, antibacterial, antiinflammatory Loperamide safe in traveler’s diarrhea Kaolin-pectin, opiates, anticholingerics not effective

48. Antibiotics First Line Ciprofloxacin : effective against most enteric infections Metronidazole : if symptoms suggest Giardia Second Line Bactrim : effective second line therapy for most infectious diarrheas

49. Rifaximin Nonabsorbed Broad-spectrum antibacterial activity invitro No known drug interactions 200 mg PO TID or 400 mg PO BID comparable to cipro

50. Infectious Nosocomial Diarrheas Usually from C.difficile Salmonella, Shigella , extremely rare if diarrhea develops after 3-4 days in hospital In the immunosuppressed, viral infections are an important cause

51. Chronic Diarrhea At least 3 to 4 weeks duration A ccounts for 30% of patients in GI practices

52. Diagnostic Test for Chronic Diarrhea Blood tests CBC, ESR, Thyroid function Stool studies Spot WBCs, occult blood, O+P, culture, giardia Ag Quantitative volume/weight, electrolytes, osmolality, fat, pH

53. Diagnostic Tests Endoscopy Flex sig or colonoscopy with biopsies Upper endoscopy biopsies aspiration for bacterial counts and parasites Radiology Plain Radiographs UGI (upper gi endoscopy)/Small Bowel Series

54. Malabsorptive Diarrhea Fat Malabsorption intraluminal maldigestion mucosal malabsorption postmucosal malabsorption intestinal lymphangiectasia , vasuclitis Carbohydrate Malabsorption Protein Malabsorption ( Azotorrhea )

55. Malabsorptive Diarrheas (Fat) Intraluminal Phase Cirhosis Bile duct obstruction Bacterial overgrowth Pacreatic exocrine insufficiencyl Mucosal Phase Drugs Infectious disease Immune system dz Tropical sprue Celiac sprue

56. VACCINES An oral cholera vaccine is available, which gives immunity to 50-60% of those who take the vaccine, and this immunity lasts only a few months. No vaccines are available against shigellosis A vaccine against rotavirus diarrhea has been withdrawn recently from the market.

57. PREVENTION Safe drinking water and food “Boil it, cook it, peel it, or forget it. " Hand washing Proper sanitation