DIARRHEA

Introduction  

Diarrhea is an increase in the frequency and looseness of stool. It results when some factors impair the ability of the intestine to absorb water from stool.

Classification
According to: 1. Mechanism
Osmotic Secretory Motility

2. Origin Acute Chronic

Classification According to Mechanism 

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

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

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

Classification According to Origin 

Acute: (2-3 days and may last up to 2 weeks)
Due to:

Infection 
 

Virus (Rota) Bacteria Protozoa (Giardia lambila,entamoeba histolytica). Food allergy High fiber diet Large amount of caffeine

Diet 
 

Classification According to Origin 

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

Protozoal infection IBS Malabsorption syndrome Pancreatic disease

Drug Induced Diarrhea 
    

Antacid containing Mg Metoclopramid Bethanecol Antibiotics Blood pressure Medication Cancer drugs

DISCUSSION

1. My child always suffers from diarrhea after drinking milk or eating any dairy products, is it a serious condition, how could it be treated?   

The child is not able to digest lactose in the milk due to lactase deficiency. Lactase is responsible of the break down of lactose to glucose and galactose. Accumulation of lactose leads to osmotic diarrhea.

Lactase deficiency maybe due to:  Congenital:
occur at birth due to mutation of gene producing lactase. 

Secondary:
disease destroying the lining of small intestine along with lactase. e.g.: celiac sprue. 

Developmental:
decrease in the amount of lactase after childhood and persists into adulthood.

2. I am suffering Irritable Bowel Syndrome which makes me suffer from abdominal cramps and diarrhea, will those symptoms persist and how can I avoid them?  

IBS causes secretory diarrhea in which intestinal wall is damaged resulting in an increased secretion rather than absorption of electrolytes into intestinal tract. Also it causes motility disorder leading to decreasing contact time between fecal mass with intestinal wall. 

Medications are an important part of relieving symptoms. Your doctor may suggest fiber supplements or laxatives for constipation or medicines to decrease diarrhea, such as Lomotil or loperamide (Imodium). An antispasmodic is commonly prescribed, which helps to control colon muscle spasms and reduce abdominal pain.    

With any medication, even OTC medications such as laxatives and fiber supplements, it is important to follow your doctor¶s instructions. Medications affect people differently, and no one medication or combination of medications will work for everyone with IBS. a diet with enough fiber to produce soft, painless bowel movements. quickly can lead to swallowing air, which also leads to gas.     

Drinking six to eight glasses of plain water a day is important, especially if you have diarrhea. Drinking carbonated beverages, such as sodas, may result in gas and cause discomfort. Chewing gum and eating too quickly can lead to swallowing air, which also leads to gas . Large meals can cause cramping and diarrhea, so eating smaller meals more often, or eating smaller portions, may help IBS symptoms. Eating meals that are low in fat and high in carbohydrates such as pasta, rice, whole-grain breads and cereals (unless you have celiac disease), fruits, and vegetables may help.

3. My child is suffering from diarrhea, can he be contagious to his siblings?
Yes, he could be contagious and infection could be:
Viral Bacterial Protozoal 

Viral
Rota virus 

Affects children less than 2 years. It affects older children and adults.

Norwalk virus  

Bacterial
Toxigenic bacteria 


Caused by e-coli, shigella , staphylococcus aureus. It results from the secretory effects of the enterotoxins released in the small intestine. Caused by invasive e-coli, shigella and campylobacter. It results from invasion of colon mucosa. Stool contains pus and blood.

Invasive bacteria 
 

Protozoal
Caused by Giardia lamblia and Entamoeba histolytica. It is characterized by foul-smelling, large volume watery stool. The cause of diarrhea is the invasion of small intestine and damage to microvilli so decreases absorption of fluids.  

The microorganisms that cause infectious diarrhea are easily spread to other people. They may be spread directly to soap, wash clothes and other items that contact feces, either directly or indirectly. They could be on your toilet seat, faucet handles, shower handles ... etc ... In essence, if you touch feces, your fingers can spread the germs to anything they touch. These germs may survive for a long time, though some die quickly. 

If you prepare food ... at home or in a restaurant ... and the food in not kept hot enough to kill them, they can be in the food. It may not become obvious that you were infected for several days. Contaminated water and food are the major sources of infectious diarrhea and the major source of both is feces from some animal such as humans. Wash your hands. It's not magic but it sure helps prevent these types of diarrhea.  

Diarrhea due to metabolic or genetic issues is not contagious but washing your hands to prevent spread of fecal organisms remains a cornerstone for prevention of many other health problems. Normal fecal microbes can cause many other serious infections when they are inoculated to other anatomic locations 

4. I am traveling to the African coast next week, I am afraid of getting traveler's diarrhea. What are the possible causes, protective measures and treatment? 

It is subcategory of acute type of infectious diarrhea that occurs due to traveling mainly from developed to less developed country.

Protective measures 
 

Avoid eating food, drinking from street vendors. Avoid eating raw or undercooked meat, sea food and raw fruits. Always wash your hands by water with iodine or chlorine.

Treatment 
  

Self limited. We can use oral rehydration to replace lost fluids and electrolytes. Fluroquinolones is drug of choice.(3-5 days) Do not use
Trimethoprim, sulfamethoxazole and Doxycycline due to high resistance Antimotility drugs with fever or bloody diarrhea

- to increase contact time between pathogen and the intestine. - increase the severity of the disease.

5. I heard about "Stomach Flu", what is it? What are the causes, symptoms and possible treatment? 

Stomach flu: " viral gastroenteritis "
It is inflammation of stomach, small and large intestine by viruses resulting in diarrhea or vomiting or both. 

Sources:
Fecal oral routes Contaminated water and food. 

Symptoms(1-3 days)
Vomiting Headache Abdominal cramps Fever No blood or pus in the stool 

Treatment
It is not serious illness and requires no therapy except electrolyte and fluids replacement.

6. My physician prescribed Vibramycin R. It causes diarrhea, my brother also was prescribed Velosef 1000R tablets and the physician warned him from a case called "Pseudo-membranous Colitis". Could you explain, please? 

These antibiotics disturb the normal bowel bacterial flora,more extensive growth than normal of certain bacteria as Clostridium difficile producing toxins that are responsible for the diarrhea ³Pseudo-membranous colitis´. The disease is usually treated with
oral metronidazole (400 mg every 8 hours) velosef (Cephradine) 1st generation cephalosporin   

Pseudo-membranous colitis has been reported with the use of cephalosporins (and other broad spectrum antibiotics) it is important to consider its diagnosis in patients who develop diarrhea in association with antibiotic use.

7. My physician prescribed PrimperanR. Since taking it I suffered from diarrhea, why? (Mention other drugs that cause diarrhea).   

Primperan contains metoclopramide <parasympathomemitic agent> inducing motility disorder. Results in decreased contact time of fecal mass with the intestinal wall so less water is absorbed from the feces. Indication: treatment of gastro esophageal reflux disease 

Other drugs that cause diarrhea
Digitalis Quinidine Some antibiotics 

Antibiotic cause diarrhea by causing:
Intestinal irritation Increased bowel motility Altered microbial flora 

To avoid that, we can take the agent with food.

8. When diarrhea is considered chronic? What are the possible causes of chronic diarrhea? When to refer to physician? 

Acute diarrhea:
2-3 days up to 2 weeks. 

Chronic diarrhea:
More than 2 weeks.

Causes of chronic diarrhea 

Protozoal
Entamoeba histolytica Giardia lamblia 

Food
Lactose intolerance Spicy food Caffeine Sugar substituents (sorbitol and mannitol) 

  

IBS Hyperthyroidism Pancreatic disorder Medications (chronic laxative use)

When to refer to physician?  

   

Patient younger than 3 years or older than 60 years. Pregnant and breast feeding patients. Blood or mucus in stool. Fever (higher than 38 °C). Signs of dehydration. Duration more than 2 days.

9. What is the strategy that FDA recommends for treatment of diarrhea? Is it necessary to administer antibiotics to diarrhea patients? 

2 days cutoff strategy
The patient should not receive any medication in the first 2 days 

It is not necessary to take antibiotics as it is not infectious.

10. I suffer from chronic diarrhea, I am afraid of being a worse case than diarrhea. What diagnostic tests are useful for the evaluation of diarrhea? 

Fluid and electrolyte imbalance (dehydration) especially if the intake of fluids is limited. If diarrhea is accompanied with vomiting. 

Diagnostic tests for the evaluation of diarrhea  

 



Stool examination and culture (bacteria and parasites) Blood test (disease) Sigmoidoscopy (inside of rectum and lower part of the colon) Colonoscopy (entire colon) Fasting test (specific food intolerance or allergy)

11. A pregnant patient suffers from diarrhea which is not usually common in pregnancy, what could be the causes? Could it be harmful to the baby? 

Pregnant women are susceptible to viral and bacterial infection. Cause of diarrhea in pregnancy
Dietary or Hormonal changes
Sensitivity to certain foods Lactose intolerance  

No effect on the baby as the virus or the bacteria stay within the digestive tract. If the pregnant woman suffered from dehydration, then the baby will be affected. 

12. My infant suffers from diarrhea, what could be the causes, prevention measures, and how to treat it? 

Infectious
Viral (Rota virus) Bacterial ( E.coli) Protozoal (Entamoeba histolytica) 

Non infectious
Food allergy. Lactose intolerance. 

Prevention measures
Health education. Breast feeding. Clean surfaces. Washing hands of infants and parents. 

Treatment
Rehydration therapy. Symptomatic treatment (antispasmodic and antidiarrheal)

13. Dehydration is a serious complication of persistent diarrhea, especially in infants as it could be lethal. How could this imbalance be corrected? How can it be avoided?   



Dehydration more severe in infants due to their small body mass. Mild to moderate dehydration (ORS) containing glucose and electrolytes. Severe dehydration (IV therapy). Rehydration fluids must be used once opened.

What can be done to prevent dehydration?  

keep replacing the fluid and body salts. At the first sign of diarrhea, you must give ORS to the patient. You must give this drink after every loose motion. If you have diarrhea or vomiting, or if you are not drinking very much, force yourself to begin drinking liquids before you become dehydrated.

What can be done to prevent dehydration?  

Children with frequent stools ,fever ,or vomiting should stay at home and avoid school and day-care until these symptoms go away. This allows the child to rest and recover and prevents other children from being exposed to virus or bacteria

14. What is ORS according to WHO/UNICEF definition? 
 

Oral Rehydration Solution Any increase in administered fluid content: sodium chloride, potassium chloride, sodium bicarbonate, glucose and water. ORS is safe but has no effect on duration of diarrhea, it acts as fluid replacement. 

Fluids

to be avoided in ORS

Hypertonic fruit juices Drinks (apple juice and powdered drink mixes) Carbonated beverages Caffeine containing drinks

15. What types of OTC drugs that treat diarrhea? 

The FDA classified 3 agents as category 1 (safe and effective)
Kaolin Bismuth subsalicylate Loperamide 

FDA reclassified attapulgite and polycarbophil from category 1 to category 3 due to insufficient effectiveness data.

Types of OTC treating diarrhea 

ANTISEPTICS
1. Antinal(nifuroxazide 200mg)   



HAS wide bactericidal activity against gram+ve and gram-ve bacteria Ensures rapid clinical response reducing the risk of dehydration Effective against antibiotic resistant bacteria no remarkable contraindication&safe in pregnancy

2. Entocid
Contains 3 active ingredients 1. di-iodohydroxylquinolone which is an organic quinolone derivative with high iodine content is specifically amebicidal and active against other protozoal infections which may produce diarrhea 2. phthalylsulfa thiazole :sulphonamide with very poor absorbability attains a high conc in the bowels and it is a bacteriostatic to the majority of pathogenic 3. streptomycin sulphate ,not absorbed orally, no systemic effect or toxicity produced  

While this route of administration is reserved for the local sterilization of the gut specially in diarrhea and other gastrointestinal infections Contraindicated for patients:
hypersensitive to iodine or halogenated hydroxyquinolone Patient with impaired renal and liver functions

3. Streptoquin
Combines the effect of 4 component as entocid +homatropine methylbromide which is antimuscarinic agent antispasmodic action on intestinal smooth muscles 

ANTIAMOEBIASIS
1. Flagyl 2. Imodium tablets (loperamide) 

ABSORBENTS
1. Kapect

16. I have been suffering from diarrhea two days ago, would you recommend ImmodiumR or LomotilR? 


ImmodiumR (loperamide) LomotilR (diphenoxylate, atropine)

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

ImmodiumR 

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.

LomotilR     

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

17. LomotilR is contraindicated in some cases? 
  



Allergy to diphenoxylate or atropine. Presence of jaundice. Diarrhea associated with pseudo-membranous enterocolitis. Diarrhea caused by antibiotic treatment. Diarrhea caused by enterotoxin producing bacteria.

18. I am taking LanoxinR for CHF. Lately I suffered diarrhea and started to take KapectR. What do you recommend? 

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. 

19. I am taking Bismuth salicylate for diarrhea. I noticed some annoying effects. What are the adverse effects and contraindications?
Adverse effects 


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 
   

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.

20. I suffered from diarrhea and I was prescribed Lacteol fortR which caused me flatulence. Is it necessary to continue the treatment? 

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.  

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. 

QUIZ

QUIZ
Mark (T) for true or (F) for false: 

Accumulation of lactose leads to osmotic diarrhea ( )  

 

IBS causes secretory diarrhea ( )
Chronic diarrhea lasts more than 2 weeks ( ) Pregnant women usually suffer from diarrhea ( ) Bismuth salicylate is contraindicated in pregnancy ( )

THANK YOU

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