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ANTIDIARRHOEAL AGENTS

DIARRHORA- is defined as the passage of loose,


liquid or watery stool usually more than 3 times a
day. Recently consistency &Character of stool more
important than frequency.
.Extremely common presenting problem
. Also called gastroenteritis
.Major cause of morbidity & mortality among
young & children especially developing
countries.
.Usually due to foeco-oral transmission of
bacterial toxin, viruses, bacterials or protozoal
organisms.
MAIN AIM & OBJECTIVES OF TREATMENT

1.Preservation of fluid & electrolytes – main aim


of treatment
2.Treatment of diarrhoeal cause
ACUTE DIARRHOEA
According to WHO/ UNICEF acute diarrhoea is
defined as an attack of sudden onset with
passage of loose, liquid or watery stools which
usually last for 3-7 days but may last upto 10 -
14 days .

The term “ gastroenteritis “ is most frequently


used to describe acute diarrhoea .
CAUSES OF ACUTE DIARRHOEA

1.Viruses – Rota, adeno, astro, corona, calci, enterovirus.


2.Bacteria – E.coli, C. jejuni, Shigella, Sulmonella, V.cholerae,
Cl. Difficile, V. parahaemolyticus
3. Toxin mediated – Bacillus cereus, Staph enterotoxin,
Cl.enterotoxin
4.Protozoal – E. histolytica, G. lamblia, Trichuria, Intestinal
worms
5. Systemic illness – Sepsis, pneumonia, malaria
6. Drugs – NSAIDS, cytotoxic agents, Antibiotics, plant toxins,
heavy metals.
7. Gastrointestinal – IBD, Malignancy, PID, acute diverticulitis
8. Metabolic upset – diabetic ketosis, Uraemia
CHRONIC DIARRHOEA
Diarrhoea lasting > 3wks

CAUSES
. Giardiasis .Enteropathic E.coli . Strongiloydosis .Tropical sprue
.Ch.calcaefic
pancreatitis . HIV enteropathy .Intestinal flukes .Ch.Intestinal
schistosomiasis.

CAUSES OF BLOODY DIARRHOEA


A.INFECTIOUS - . Campylobacter . Shigella dysentery, Non typhoid sulmonella
Enterohaemorrhagic E.coli, Entero invasive E.coli, Cl. Difficile, E. histolytica
V. parahaemolyticus
B. NON INFECTIOUS – IBD, Diverticulitis, Ca rectum or colon, Anal fissure
Bleeding haemorrhoid, ischemic colotis, Intussusception.
ASSESSSMENT OF PT WITH ACUTE DIARRHOEA
DEHYDRATION –
Degree of dehydration measured by -. Skin turgor .BP -
decrease .Pulse – Rapid & feeble .Tongue – dry . Fontanelle –
depressed . Urine flow –decreased
MANAGEMENT OF ACUTE DIARRHOEA
.Most diarrhoea are self limiting.
. Management depends on establishing the underlying cause &
Instituting specific therapy.
1.Correction of fluid & electrolyte balance – most imp
2.Antimicrobial agents
3. Adjunctive -antidiarrhoeal, antimotility, antisecretory
agents.
4. Zinc suppliment .
1.CORRECTION OF FLUID & ELECTROLYTES
. Most imp management to replace fluid loss.
May be life saving..
.Normal daily intake of fluid is – 1-2 litrs
.Fluid loss in diarrhoea is isotonic.
. So a source of electrolytes in either continued food intake fluid
replacement is needed. The absorption of electrolytes from
the gut is an active process Requiring energy. Infected bowl
mucosa can transport Fluid & electrolyte very fast if an energy
source is available. During diarrhoea a source of
carbohydrate either starch or sugar is required to absorb
fluid & electrolytes
.This is the basis of oral Rehydration salt( ORS).
ORAL REHYDRATION SALTS (ORS)

1.ORS WITH HYPEROSMOLARITY ( Standard , 310 mOsm/ L )

COMPOSITION
Nacl – 3.5gm/L
Kcl – 1.5gm/L
Trisodium citrate or dehydrate – 2.9gm/L
or
Sodium bicarbonate ( NaHCO3) – 3.5gm/L
Glucose anhydrous – 20gm

..Trisodium citrate made the solution more stable & resulted in less
stool output.
..Trisodium citrate increases intestinal absorption of Na & H2O.
..Hyperosmolarity of this solution can cause adverse effects.
.. So now not used.
2.NEW ORS FORMULATION ( ORS with ↓osmolarity 245m mol/L)
COMPOSITION
Nacl – 2.6gm/L
Kcl – 1.5gm/L
Trisodium citrate or dehydrate – 2.9gm/L
Glucose anhydrous- 13.5g / L

This ORS preparation is


.safe . Effective . ↓stool output .↓osmolarity – avoid possible
adverse
effects of hypertonicityor net fluid absorption . So↑efficacy
& causes
.↓I/V therapy- 33% . ↓stool output – 20% .. ↓Vomiting –
30%
RATIONALS OF ORS TREATMENT
. Best
. Simple
. Safe
. Cheap
. Easily available
. Very effective
.Reliable .Only ORS can control vast majority of watery
diarrhoea
. Not designated to stop diarrhoea but to restore
&maintain hydration, electrolyte & pH balance – until
diarrhoea stops spontaneously ( mostly).
B. PARENTERAL THERAPY
. Given I/V . Especially given to children .Recommended only
when fluid loss severe > 10% body wt or unable to take
enough oral fluid due to shock, vomiting, weakness.
WHO recommended I/V fluids are –
1. RINGER LACTATE SOLUTION ( Hartmanns solution) – Best
Na - 130 m mol /L
CL- - 109 mmol/L
K+ - 4mmol/
Lactate – 28 mmol/L
Lactate yields bicarbonate for correction of acidosis.
2.DIARRHOEA TREATMENT SOLUTION (DTS)
.Nacl – 4gm /L
.sodium acetate – 6.5 g/L
KCL – 1g /L
. Glucose - 10 g /L
.
CALCULATION OF APPROPRIATE VOLUME FOR REPLACEMENT OF FLUID
1.Replacement of established losses
..In an adult average losses of fluid in moderate diarrhoea ( 6-10 time stool/
24hrs) with 48hrs duration – 1-2 litrs
.. Any associated vomiting – extra fluid
So Fluid – 1-2 litrs given rapidly as ORS or parenteral.
+

2. Replacement of ongoing losses –


.in an adult average loss of fluid / diarrhoeal stool – 200 ml of isotonic fluid.
. So ongoing loss should be calculated( new 200 ml packet available)

3. Replacement of normal daily requirement


. Minimal daily requirement of average adult – 1- 1.5 litrs
2. Antimicrobial agents
. Should not be routinely used.
. Used only in specific infections.
DRUGS : .Quinolones . Cotrimoxizole . Ampicillin . Doxycycline
. Tetracycline . Erythromycin. Metronidazole . Diloxanide furoate.
3. Adjunctive therapy
.In general these agents are not recommended.
. Contraindicated in the management of infective or potentially infective
gastroenteritis.
.. Antimotility agents – Loperamide, Diphenoxylate – Dangerous
For children.
.. Antisecretory agents – Bismuth, anticholinergic agents.
.. Antispasmodic agents – Atropine
.. Adsorbants – kaolin or charcoal – no value
4. Zinc suppliment - . ↓duration .↓ severity .↓ incidence of diarrhoea in the
following 2-3 months.
Dose- WHO/ UNICEF recommended.infant under 6 month – 10mg/D
Children > 6 month- 20mg/ D for 10- 14 days.
BLOODY DIARRHOEA / BLOODY DYSENTERY
. Antimicrobial agents
. ORS

AMOEBIC DYSENTERY

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