Diarrhea Management Essentials

Management of Diarrhea

• The presentation is on the management of diarrhea, covering various aspects from definition and classification to treatment approaches.
• The course is PHARM 345 taught by Dr. René Breault.
• The presentation uses slides adapted from Dr. Tara Leslie and Dr. Nese Yuksel.
• Various resources for further reading on the topic are mentioned.

Definition of Diarrhea

• Diarrhea is defined as the frequent (≥3 per day) passage of loose, watery stools.
• Normal stool output ranges from 100 to 300 grams daily.
• More than 300 grams of stool output per day is considered diarrhea.
• Diarrhea is classified as acute (<14 days), persistent (>14 days), or chronic (>30 days) depending on its duration.

Bristol Stool Chart

• The chart provides visual examples of different stool types, from separate hard lumps (type 1) to entirely liquid (type 7).
• Understanding stool consistency and color can help healthcare professionals diagnose the cause of diarrhea.

Complications of Diarrhea

• Complications include dehydration and electrolyte imbalances, which can be particularly severe in infants, young children, and the elderly.
• Complications can also include conditions like renal failure, cardiovascular disease, fever, abdominal pain, flatulence and weight loss.
• Presence of blood, mucus, or pus in stools may indicate a specific underlying cause.
• Hemorrhoids are possible complications.

Types of Diarrhea

• Osmotic diarrhea results from poorly absorbed substances drawing water into the bowel.
• Secretory diarrhea involves a disruption in fluid and electrolyte transport in the intestines, causing increased secretion of water and electrolytes.
• Exudative/inflammatory diarrhea relates to inflammation and compromised intestinal lining.
• Increased gut motility leads to reduced transit time in the intestines, contributing to diarrhea due to premature emptying and bacterial overgrowth.

Common Causes of Acute Diarrhea

• Infectious agents are a common cause, including bacterial pathogens (e.g., E. coli, Salmonella, Shigella, C. difficile) and viral pathogens (e.g., rotavirus, norovirus).
• Food toxins can cause diarrhea, particularly in regions with inadequate hygiene standards.
• Diarrheal illnesses in developing countries can sometimes become chronic.

Drugs Commonly Associated With Diarrhea

• Certain medications, such as laxatives, antacids (containing magnesium), antibiotics, and cholinergic drugs, are frequently associated with diarrhea.
• Other factors that cause diarrhea include promotility agents, prostaglandins, SSRIs, and anti-hypertensives.

Medical Conditions Associated With Diarrhea

• Poorly or non-absorbed carbohydrates, lactose intolerance, malabsorption syndromes, and celiac disease are osmotic diarrheas causes.
• Bacterial infections, excessive bile, and hormone-producing tumors are factors linked to secretory diarrhea.
• Inflammatory bowel disease (IBD) and other types of colitis are causes of inflammatory diarrhea.
• Irritable bowel syndrome (IBS), hyperthyroidism, and certain medications can be causes of increased gut motility.

Clostridium difficile Infections (CDI)

• Clostridium difficile is an anaerobic bacterium that causes infections primarily in individuals who have been taking antibiotics.
• Fluoroquinolones, cephalosporins, clindamycin, and carbapenem are common antibiotics linked to CDI.
• Symptoms range from severe diarrhea to absence of symptoms.
• CDI can range from asymptomatic to very serious illness

Traveller's Diarrhea

• Traveler's diarrhea is often caused by ingesting contaminated food or water.
• Infections associated with traveler's diarrhea can be caused by bacteria (e.g., Escherichia coli, Campylobacter, Shigella, Salmonella), parasites (e.g., Giardia), and viruses (e.g., Norovirus, Rotavirus).
• Symptoms are typically self-limiting (lasting less than 7 days).

Patient Assessment (Diarrhea)

• Thorough patient assessment is crucial, focusing on symptoms, history, red flags, and possible complications.
• The presentation includes a flow chart that outlines a systematic approach to evaluate and address potential diarrhea causes, including the presence of complications with different severities and risk factors that may present.

Approach to Diarrhea

• A three-step approach is used to manage cases of diarrhea, initially focusing on the consequences, such as dehydration and electrolyte imbalances, then identifying possible causes and factors like the presence of red flags, and finally treatment or management.
• Self-care measures such as maintaining hydration and avoiding specific foods and drugs may be necessary.

Oral Rehydration Therapy (ORT)

• ORS solutions contain the appropriate proportions of electrolytes, such as sodium, potassium, glucose, and dextrose.
• Examples include Gastrolyte, Pedialyte, WHO-ORS, and Hydralyte.
• Commercial ORS solutions are normally preferred compared to homemade preparations.
• Specific dosing guidelines are based on the patient's age and the severity of diarrhea.

Therapeutic Approach: Non-Pharmacologic

• Discontinue medications and foods that may be contributing to the diarrhea issue.
• Ensure adequate rehydration with oral fluids and, if appropriate, oral rehydration therapy.
• Maintain hydration by consuming clear fluids such as water and avoiding fruit juice or carbonated drinks.

Treatment Approaches: Non-Pharmacologic Diet

• Stop consuming carbohydrates that are poorly absorbed, like sorbitol and mannitol.
• In most cases, a BRAT (banana, rice, apple, toast) diet is no longer recommended.
• A regular diet can often be resumed after one or two days.

Therapeutic Approach: Pharmacologic Options

• Different pharmacologic treatments for diarrhea, such as opiates and their derivatives, and adsorbent and antisecretory agents, are presented

Opiates and their Derivatives

• Loperamide (Imodium®) is an over-the-counter (OTC) agent that reduces gut motility.
• Diphenoxylate + atropine (Lomotil®) is a prescription drug acting centrally and peripherally on the gastrointestinal tract and is less effective than loperamide.

Adsorbent Agents (e.g., Attapulgite)

• These medications can absorb water, nutrients, toxins, and bacteria.
• They are often effective in mild diarrhea cases.

Hydrophilic Bulking Agents (e.g., Psyllium)

• These agents increase stool size and bulk, helping to relieve symptoms of mild diarrhea.

Antisecretory Agents (e.g., Bismuth subsalicylate)

• Bismuth subsalicylate, mechanism is unclear but it is believed to potentially have antimicrobial effects.
• It reduces the attachment of bacteria to the gut lining and has anti-inflammatory/anti-secretory effects.

Other Agents

• Zinc supplementation is useful in developing countries to manage childhood diarrhea.

Prescription Drugs to Treat Diarrhea

• Antibiotics may be necessary in severe diarrhea cases, or when caused by Clostridium difficile (CDI) and/or other infections. 
• Other prescription drugs that can treat diarrhea include agents that lower the levels of bile acids in the body.

Choosing Antidiarrheals

• Loperamide is for moderate to severe diarrhea cases.
• Bismuth is for mild to moderate diarrhea.
• Attapulgite/psyllium treatment is for mild diarrhea.
• Patients with severe diarrhea or red flags need to be referred to a physician.

Treatment of Chronic Diarrhea

• Treat the specific cause of chronic diarrhea.
• Medications that may worsen diarrhea should be discontinued if possible.
• Maintain hydration.
• Consider loperamide or adsorbents like attapulgite.
• Specific prescription drugs may be needed.

Pregnancy/Breastfeeding

• Certain medications shouldn't be used, like diphenoxylate/atropine and bismuth subsalicylate.
• Adsorbents and loperamide are considered safe options.

Probiotics

• Probiotics are microorganisms that can re-establish the balance of intestinal microorganisms.
• Probiotics are used for the treatment of diarrhea.
• Many strains are effective for treating antibiotic-associated diarrhea and other bacterial diarrheal infections.

Probiotics - Safety Considerations

• Probiotics are usually considered safe, but populations at high risk (such as those with compromised immune systems) should consult their physician.
• The evidence for dosage and effectiveness for different probiotic strains requires further research.
• Standardization across probiotic products can be inconsistent.

How to Choose a Probiotic

• Consider the probiotic strain's mechanism and efficacy based on its genus, species, and strain.
• The recommended dosage of a probiotic product varies based on its composition and the intended use.

###Additional Notes

• The presentation includes a list of resources that can be used to further understand the topic.
• Information about a flow chart and questions/answers mnemonic are likely included in the presentation.
• Many topics were summarized based on the mentioned resources and information from the slides displayed throughout the presentation slides.