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).
 Diet
 Food allergy
 High fiber diet
 Large amount of caffeine
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.
I am suffering Irritable Bowel Syndrome .2
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.
My child is suffering from diarrhea, can .3
?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.
 Norwalk virus
 It affects older children and adults.

 Bacterial
 Toxigenic bacteria
 Caused by e-coli, shigella , staphylococcus aureus.
 It results from the secretory effects of the enterotoxins
released in the small intestine.
 Invasive bacteria
 Caused by invasive e-coli, shigella and campylobacter.
 It results from invasion of colon mucosa. Stool contains pus
and blood.
 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.
I heard about "Stomach Flu", what is it? .5
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.
My physician prescribed Vibramycin R. It .6
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 “Pseudo-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.
When diarrhea is considered chronic? What .8
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.
What is the strategy that FDA recommends for .9
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.
I suffer from chronic diarrhea, I am afraid of .10
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)
A pregnant patient suffers from diarrhea .11
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.
My infant suffers from diarrhea, what could .12
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)
Dehydration is a serious complication of .13
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
What is ORS according to .14
?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

 What types of OTC drugs that treat .15
?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
I have been suffering from diarrhea two days .16
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.
LomotilR is contraindicated in some .17
?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.
I am taking LanoxinR for CHF. Lately I .18
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.
I am taking Bismuth salicylate for diarrhea. I .19
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.
I suffered from diarrhea and I was prescribed .20
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