Treatment of diarrhea

treatment of diarrhea

1. TREATMENT OF DIARRHEA Dr.k.vishnuvardhan babu MD

2. Diarrhea Abnormal frequent passage of loose stools OR Abnormal passage of stools with increased frequency, fluidity, and weight, or with increased stool water excretion

3. Diarrhea (cont'd) Acute diarrhea Sudden onset in a previously healthy person Lasts from 3 days to 2 weeks Self-limiting Resolves without sequelae

4. Diarrhea (cont'd) Chronic diarrhea Lasts for more than 3 weeks Associated with recurring passage of diarrheal stools, fever, loss of appetite, nausea, vomiting, weight loss, and chronic weakness

5. Causes Of Diarrhea Acute Diarrhea Bacterial Viral Drug induced Nutritional Protozoal Chronic Diarrhea Tumors Diabetes Addison’s disease Hyperthyroidism Irritable bowel syndrome

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

7. COMMON CAUSES OF DIARRHEA- VIRUS Rotavirus Adenoviruses Caliciviruses Astroviruses Norwalk agents and Norwalk-like viruses

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

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

10. Drugs causing diarrhea 1) Laxatives 2) Antacids containing magnesium 3) Antineoplastic drugs 4) Antibiotics Clindamycin Tetracyclines Sulfonamides Any broad-spectrum antibiotic 5) Antihypertensives Methyldopa Angiotensin -converting enzyme inhibitors Angiotensin receptor blockers α -adrenergic receptor blockers

11. Drugs causing diarrhea (cont) 6) Cholinergic drugs Neostigmine 7) Cardiac agents Quinidine Digoxin 8) Nonsteroidal antiinflammatory drugs Misoprostol 10) Colchicine 11) Proton pump inhibitors 12) H2-receptor blockers

12. TRANSMISSION Most of the diarrheal agents are transmitted by the fecal-oral route Cholera: water-borne disease; transmitted through water contaminated with feces Some viruses (such as rotavirus) can be transmitted through air Nosocommial transmission is possible Shigellosis (blood dysentery) is mainly transmitted person-to-person.

13. ASSESSMENT OF DEHYDRATION

14. ASSESSMENT OF DEHYDRATION (contd.)

15. ASSESSMENT OF DEHYDRATION (contd.)

16. 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

17. Treatment of diarrhea Non-pharmacologic therapy: Dietary management: Discontinue consumption of solid foods and dairy products for 24 h (valuable in osmotic diarrhea) For patients who are experiencing nausea and/or vomiting, a mild, digestible, low-residue diet should be administered for 24 hours. If vomiting is present and uncontrollable with antiemetics , nothing is taken by mouth. As bowel movements decrease, a bland diet is begun. Rehydration and maintenance of water and electrolytes

18. Treatment of dehydration Increase fluid intake (fruit juice – contain glucose and potassium) Oral rehydration solution (ORS). The WHO formula contains glucose, sodium, potassium, chloride and bicarbonate in an isotonic fluid. Glucose concentrations between 80 – 120 mmol /L are needed to optimize sodium absorption in the small intestine. Sodium concentration = 75 mmol /L (higher concentrations may cause hypernatremia ) Dose in mild/moderate diarrhea for adults: 2L/first 24 h followed by 200 ml per each loose stool

19. Why Reduced osmolarity ORS? 39% reduction in need for IVF 19% reduction in stool output 29% lower incidence of vomiting Risk of hyponatremia not significant in any type of diarrhea. back 20/04/2015 Takvani 27

20. Home-Made ORS Home-made ORS: Sugar or molasses (40 g) can be used as a substitute for glucose to prepare home-made ORS. Common salt (5 g) will be added to it and dissolved in one liter of clean water. Rice-ORS: Rice powder (50 g) can replace the sugar or glucose. The amount of the other salts will remain the same. These will be dissolved in one liter of clean water to prepare rice-based ORS. Studies showed that rice-based ORS can reduce vomiting and diarrhea more in some cases compared to the conventional ORS prepared with glucose.

21. Zinc in Diarrhea Zinc has an additional modest benefit Reduces stool volume. Reduces duration of diarrhea. 20/04/2015 Takvani 30

22. Zinc in Diarrhea Dose: Elemental Zinc 20 mg/day for 6months and older for 14 days 10 mg/day Between 2-6 months. Any of zinc salts e.g ., sulphate, gluconate or acetate may be used. back 20/04/2015 Takvani 31

23. Antidiarrheal agents Indications of antidiarrheal agents: Patients with mild to moderate acute diarrhea Control chronic diarrhea caused by IBS or IBD Contraindications: Patients with bloody diarrhea, fever or systemic toxicity (risk of worsening of the underlying condition) Discontinued in patients whose diarrhea is worsening despite therapy

24. Treatment of diarrhea Pharmacologic therapy: Drugs used for the treatment of diarrhea include Antimotility agents Adsorbents Antisecretory compounds Antibiotics Enzymes Intestinal microflora .

25. Antimotility agents ( opioids ) Opioids agonists: Action in the GIT (mediated by binding to opioid receptors) Increase segmentation and a decrease propulsive movement → ↑ intestinal transit time → ↑ absorption of water and electrolyte → feces become more solid Antisecretory ↑ tone of the internal anal sphincter ↓ response to the stimulus of a full rectum (by their central action)

26. Antimotility agents (cont) Mechanism of opioid action: Inhibition of presynaptic cholinergic nerves in the submucosal and myenteric plexuses

27. Opioiods - Diphenoxylate Opioid agonist that has no analgesic properties in standard doses. Higher doses have central opioid actions. Used in combination with a subtherapeutic dose of atropine (to prevent abuse) Contraindications: Children below 2 y (toxicity at lower doses than adults) Obstructive jaundice Drug interactions: Potentiate the effects of CNS depressants Co-administration with MAO inhibitors→ hypertensive crises Adverse effects: Caused by the atropine in the preparation and include anorexia, nausea, pruritus , dizziness, and numbness of the extremities. Prolonged use of high doses may cause dependence

28. Opioids - Loperamide Opioid agonist that does not cross the blood-brain barrier and has no analgesic properties and no potential for addiction Adverse effects : Abdominal pain and distention, constipation, dry mouth, hypersensitivity, and nausea and vomiting.

29. Antidiarrheals: Mechanism of Action Adsorbents Coat the walls of the GI tract Bind to the causative bacteria or toxin, which is then eliminated through the stool Examples: bismuth subsalicylate (Pepto-Bismol), kaolin-pectin, activated charcoal, attapulgite (Kaopectate)

30. Adsorbents 1. Kaolin and Pectin: Kaolin (hydrated magnesium aluminum silicate), often combined with pectin (indigestible carbohydrate). Mechanism of action: Adsorb bacterial toxins and fluid Indications: Acute diarrhea (given after each loose bowel movement) Adverse effects: Not absorbed and has no adverse effects.

31. Adsorbents (cont) 2. Bismuth subsalicylate: Insoluble complex of bismuth and salicylate Mechanism of action: Bismuth: antimicrobial Salicylate : antisecretory Adverse effects: blackening of tongue and stools

32. Octreotide ( somatostatin analogue) Mechanism of the anti-diarrheal action: 1. It inhibits the secretion of many GIT hormones, including gastrin, cholecystokinin, glucagon, insulin, secretin, pancreatic polypeptide, vasoactive intestinal peptide, and 5-HT3. 2. It reduces intestinal fluid secretion and pancreatic secretion. 3. It slows gastrointestinal motility and inhibits gallbladder contraction. 4. It induces direct contraction of vascular smooth muscle, leading to a reduction of portal and splanchnic blood flow.

33. Octreotide ( somatostatin analogue) Indications in diarrhea: Secretory diarrhea due to carcinoid tumor 2. Diarrhea due to vagotomy 3. Diarrhea caused by short bowel syndrome or AIDS.

34. Octreotide ( somatostatin analogue) Adverse effects: Steatorrhea leading to fat-soluble vitamin deficiency (due to impaired pancreatic secretion) Nausea, abdominal pain, flatulence, and diarrhea due to alterations in gastrointestinal motility Gall bladder sludge, gall stones or cholecystitis due to inhibition of gallbladder motility Hyperglycemia Bradycardia .

35. Antidiarrheals: Mechanism of Action (cont'd) Anticholinergics Decrease intestinal muscle tone and peristalsis of GI tract Result: slowing the movement of fecal matter through the GI tract Examples: belladonna alkaloids (Donnatal), atropine

36. Antidiarrheal Agents: Side Effects (cont'd) Anticholinergics Urinary retention, hesitancy, impotence Headache, dizziness, confusion, anxiety, drowsiness Dry skin, rash, flushing Blurred vision, photophobia, increased intraocular pressure

37. Intestinal Flora Modifiers( Probiotics ) Nonpathogenic micro-organisms. Exert a positive influence on the health or physiology of the host. They consist of either yeast or bacteria, Lacto-bacillus Acidophilus 20/04/2015 Takvani 46

38. Probiotics in the Treatment of Diarrhea Mechanisms: Protect the intestine by competing with pathogens for attachment. Strengthening tight junctions between enterocytes 3. Enhancing the mucosal immune response to pathogens. 20/04/2015 Takvani 47

39. Antimicrobials Indications: Patients with + ve stool culture Patients presented with dysentery Patients with suspected exposure to bacterial infection.

40. Antibiotic in Acute Dysentery Cotrimoxazole has been recommended as the first line drug for acute bloody diarrhea. High resistance of shigella to cotrimoxazole has been reported. 20/04/2015 Takvani 49

41. Antibiotic in Acute Dysentery Resistance rates to cotrimoxazole exceed 30% Cefixime 20mg/kg/day 5-7 days should be used instead of quinolones . If No response to cefixime in 3 days:; Ceftriaxone 50-100mg/kg od for 2-5 days. 20/04/2015 Takvani 50

42. Antibiotic in Acute Dysentery Metronidazole/Tinidazole should be used when cases of acute dysentery fail to respond to second line drugs for dysentery such as cefixime or when a stool examination has confirmed trophozoites of Entamoeba hystolitica. 20/04/2015 Takvani 51

43. Antidiarrheal Agents: Interactions Adsorbents decrease the absorption of many agents, including digoxin , clindamycin , quinidine , and hypoglycemic agents Adsorbents cause increased bleeding time when given with anticoagulants Antacids can decrease effects of anticholinergic antidiarrheal agents