Diarrhoea: Causes and Treatments
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Questions and Answers

What happens to intestinal absorption when motility increases?

It leads to less time for absorption.

Identify two red flag symptoms that require referral in cases of diarrhoea.

Blood in stool and severe abdominal pain.

What is the typical duration of acute viral diarrhoea?

2-3 days.

List two lifestyle recommendations for managing acute diarrhoea.

<p>Increased fluid intake and small light meals.</p> Signup and view all the answers

What dietary options are suggested for patients experiencing diarrhoea?

<p>BRAT diet: bananas, rice, applesauce, toast.</p> Signup and view all the answers

What is a common treatment option for patients with diarrhoea?

<p>Oral Rehydration Salts (ORS).</p> Signup and view all the answers

Describe a situation that necessitates immediate referral in diarrhoea patients.

<p>Diarrhoea following recent travel to a tropical climate.</p> Signup and view all the answers

What symptoms indicate a risk of dehydration in patients with diarrhoea?

<p>Signs include persistent vomiting and signs of dehydration.</p> Signup and view all the answers

What is the recommended storage duration for reconstituted Oral Rehydration Salts (ORS) in the refrigerator?

<p>24 hours</p> Signup and view all the answers

How does loperamide affect intestinal transit time and water resorption?

<p>Loperamide reduces propulsive peristalsis, increases intestinal transit time, and enhances water and electrolyte resorption.</p> Signup and view all the answers

What is the maximum number of loperamide tablets an adult can take in 24 hours?

<p>5 tablets</p> Signup and view all the answers

What are the contraindications for the use of loperamide?

<p>Children under 12 years, known hypersensitivity, and conditions like acute dysentery or ulcerative colitis.</p> Signup and view all the answers

What is the active ingredient in Tasectan and its primary function?

<p>The active ingredient is gelatin tannate, which restores the physiological function of intestinal walls.</p> Signup and view all the answers

Describe the characteristic symptoms of gastroenteritis.

<p>Gastroenteritis is characterized by sudden onset of diarrhoea, with or without vomiting.</p> Signup and view all the answers

When should patients be advised to seek medical consultation while using loperamide?

<p>Patients should consult a doctor if diarrhea persists for more than 24 hours.</p> Signup and view all the answers

What role does Tasectan play in treating intestinal inflammation?

<p>Tasectan forms a protective mucoadhesive film that promotes healing and reduces inflammation.</p> Signup and view all the answers

What are the potential side effects that require the discontinuation of loperamide?

<p>Constipation, abdominal distension, or if the bowels are not moving.</p> Signup and view all the answers

What types of organisms can cause gastroenteritis?

<p>Viruses, bacteria, or parasites.</p> Signup and view all the answers

Explain the mechanism by which lactulose alleviates constipation and its important usage considerations.

<p>Lactulose softens stool by drawing water into the bowel, enhancing peristalsis. It requires fluid intake and can take up to 48 hours to work.</p> Signup and view all the answers

What distinguishes stimulant laxatives from bulk-forming laxatives in the treatment of constipation?

<p>Stimulant laxatives like senna and bisacodyl stimulate nerve activity in the colon, while bulk-forming laxatives increase stool mass to promote natural bowel movements.</p> Signup and view all the answers

Identify two treatment options for haemorrhoids and explain their functions.

<p>Topical astringents like zinc create a protective coat over haemorrhoids, while anti-inflammatory agents like hydrocortisone reduce swelling and alleviate pain.</p> Signup and view all the answers

Describe the action and expected timing of MICROLAX® in treating constipation.

<p>MICROLAX® acts locally in the rectum to soften hard faeces, providing relief in 5-15 minutes after administration.</p> Signup and view all the answers

What are the red flag symptoms in constipation that necessitate a referral for further evaluation?

<p>Red flag symptoms include unexplained bleeding, severe pain during defecation, and persistent changes in bowel habits in individuals over 40 years old.</p> Signup and view all the answers

What is functional constipation?

<p>Functional constipation is chronic constipation without a known cause.</p> Signup and view all the answers

What might be a common question to assess the duration of a patient's constipation?

<p>How long have you been experiencing constipation?</p> Signup and view all the answers

What are some potential causes of secondary constipation?

<p>Secondary constipation can be caused by medications or underlying medical conditions.</p> Signup and view all the answers

When should a referral be considered for a patient experiencing constipation?

<p>Referral is needed for patients over 40 with sudden bowel changes or those with symptoms like severe abdominal pain.</p> Signup and view all the answers

What lifestyle changes can help alleviate constipation?

<p>Increasing dietary fiber, fluid intake, and regular exercise can help relieve constipation.</p> Signup and view all the answers

What is the peak age for the incidence of constipation in children?

<p>The peak incidence occurs around toilet training, typically at ages 2 to 3.</p> Signup and view all the answers

How should laxatives be administered in relation to stool consistency?

<p>Bulk-forming laxatives should be first; if stools remain hard, switch to an osmotic laxative.</p> Signup and view all the answers

What must be monitored when using laxatives for constipation treatment?

<p>It's important to avoid excessive doses to prevent misuse, abuse, and electrolyte disturbances.</p> Signup and view all the answers

What is a common parental misconception regarding childhood constipation?

<p>Parents often do not recognize the link between soiling and constipation.</p> Signup and view all the answers

What action should be taken if obstruction is suspected in a constipated patient?

<p>Laxatives should not be administered if obstruction is suspected.</p> Signup and view all the answers

What is one effective scheduled toileting strategy for children experiencing constipation?

<p>Encouraging the child to try to open their bowels at pre-planned intervals, such as after each meal.</p> Signup and view all the answers

Why is it important to avoid recommending unprocessed bran for children with constipation?

<p>It may cause bloating and flatulence, and reduce the absorption of micronutrients.</p> Signup and view all the answers

What types of foods should be included in a diet to treat constipation in children?

<p>High-fiber foods such as fruits, vegetables, high-fiber bread, baked beans, and wholegrain breakfast cereals.</p> Signup and view all the answers

In addition to dietary changes, what role do encouragement and reward systems play in treating constipation?

<p>They help praise good behavior, such as visiting the toilet, reinforcing positive habits.</p> Signup and view all the answers

What is the mechanism by which bulk-forming laxatives help alleviate constipation?

<p>They retain fluid within the stool, increase fecal mass, and stimulate peristalsis.</p> Signup and view all the answers

What precaution should be observed while taking bulk-forming laxatives, such as Fybogel?

<p>Increase fluid intake to prevent intestinal obstruction.</p> Signup and view all the answers

What advice should be given regarding the use of osmotic laxatives?

<p>They increase fluid in the large bowel by retaining fluid and drawing it from the body.</p> Signup and view all the answers

What is one suggested physical activity for babies under 6 months to alleviate constipation?

<p>Engaging in bicycle motion exercises or warm baths and massage.</p> Signup and view all the answers

How long after taking bulk-forming laxatives should one expect to see effects?

<p>The effects typically start within 12-24 hours.</p> Signup and view all the answers

What should be done if there is no bowel movement after taking laxatives for three days?

<p>Consult a doctor if no movement occurs after three days.</p> Signup and view all the answers

Study Notes

Increased Intestinal Motility

  • Leads to less time for absorption
  • Associated with various types of diarrhoea

Specific Questions to Consider

  • Frequency and nature of stools
  • Duration and severity of symptoms
  • Onset of symptoms
  • Timing of diarrhoea
  • Recent change of diet
  • Signs of dehydration

Red Flag Symptoms

  • Symptoms of dehydration, blood in stool, persistent vomiting, abdominal tenderness, weight loss, nocturnal symptoms, fever, treatment failure

Diarrhoea

  • Acute Diarrhoea
    • Mainly viral or bacterial, but try to ascertain the underlying cause
    • Rapid onset
    • Possibly nausea and vomiting
    • Cramping, flatulence, tenderness of abdomen
    • 2-3 days (viral) or 3-5 days (bacterial)
    • Should resolve itself, keeping an eye out for dehydration symptoms
  • Treatment Options
    • Oral Rehydration salts (ORS) and increased fluid intake
    • Loperamide
    • Tasectan
    • Lifestyle - Small light meals and adequate fluids.
    • BRAT diet is easy to digest - banana, rice, applesauce, toast
    • Hydrating Snacks and Fluids

Referral Required

  • Change in bowel habit (long-term) in patients over 50 years.
  • Stools are blood stained.
  • Diarrhoea following recent travel to a tropical climate
  • Dehydration (children, elderly)
  • Presence of blood or mucus in the stool
  • Severe abdominal pain
  • Fever
  • Steatorrhoea
  • Does not respond to treatment

Oral Rehydration Salts (ORS)

  • Reconstitute with 200ml water
  • Once reconstituted, use within one hour or store in fridge for 24hrs

Loperamide

  • Binds to the opiate receptor in the gut wall, reducing propulsive peristalsis, increasing intestinal transit time and enhancing resorption of water and electrolytes
  • Loperamide increases the tone of the anal sphincter
  • In adults and children 12 years and older:
    • As an adjunct in the management of acute diarrhoea, together with appropriate fluid and electrolyte replacement
    • The usual dose is 2 tablets (4mg) initially, followed by 1 tablet (2mg) after each further episode of diarrhoea up to a maximum of 5 tablets in 24 hours
    • Patients should be advised to consult their doctor if diarrhoea persists for more than 24 hours
  • Not suitable in pregnancy or breastfeeding

Loperamide Contraindications

  • Children under 12 years of age
  • Known hypersensitivity to loperamide hydrochloride or to any of the excipients
  • In patients with acute dysentery, which is characterised by blood in the stools and high fever
  • In patients with acute ulcerative colitis
  • In patients with bacterial enterocolitis caused by invasive organisms including Salmonella, Shigella and Campylobacter (will go on for longer than 48 hours)
  • Discontinue if constipation, abdominal distension or bowels not moving.

Tasectan

  • Active Ingredient: Gelatin tannate
  • Medical device used to restore the physiological function of the intestinal walls
  • Powder/Sachet for Recon.or Capsule form – children and adults
  • Acts mechanically - Protects inflamed intestinal mucosa due to its ability to form a protective, protein-based mucoadhesive film which forms a complex with the mucoproteins responsible for local inflammation and promotes their precipitation and elimination in the faeces.
  • 1-2 sachets/capsules every 6 hours.
  • Not in Pregnancy or Breastfeeding

Gastroenteritis

  • Common illness in infants and young children
  • Transient disorder due to enteric infection with viruses, bacteria, or parasites
  • Inflammation of stomach, small and large intestines
  • Characterized by the sudden onset of diarrhoea, with or without vomiting

Constipation

  • Difficult stool passage
  • Incomplete defecation
  • Stools are often dry and hard and may be abnormally large or abnormally small
  • Functional constipation is chronic constipation without a known cause
  • Secondary constipation is constipation caused by a drug or medical condition

Specific Questions to Ask

  • Change of diet or routine?
  • Pain on defecation?
  • Presence of blood? Specks or melaena
  • Duration?
  • Lifestyle changes?
  • Psychological factors?
  • Medications e.g. iron, opioid pain relief, antacids, etc.
  • Appearance of stool?

Referral Required

  • Pain on defecation causing the patient to suppress defecation reflex
  • Patients aged over 40 years with sudden change in bowel habit with no obvious cause
  • Greater than 14 days with no identifiable cause
  • Recurrent abdominal pain
  • Mucus in stool
  • Tiredness
  • Dark blood in stools
  • Unexplained Weight loss
  • Fever
  • Nocturnal Symptoms
  • Children for longer than 7 days
  • Watch for abuse/misuse
  • Treatment Failure

Constipation in Children

  • Prevalence of childhood constipation is 1–20%
  • ~5% will have constipation lasting more than 6 months
  • Peak incidence of constipation is at the time of toilet training (typically around 2–3 years of age)
  • Can also occur at weaning and at school age
  • Constipation is largely under-reported as the signs and symptoms frequently go unrecognized
  • Parents may not be aware of the link between soiling and constipation

Constipation Treatment - Algorithm

  • Community Pharmacy, Symptoms, Diagnosis and Treatment, 4th Edition

Constipation Treatment

  • Aim to restore normal bowel function
  • Adjust any constipating medication, if possible
  • Not to take laxatives if obstruction is suspected
  • Advise the person about increasing dietary fibre, adequate fluid intake, and exercise
  • Offer oral laxatives if dietary measures are ineffective, or while waiting for them to take effect
  • Start treatment with a bulk-forming laxative (adequate fluid intake is important), then add or switch to an osmotic laxative if stool is still hard.
  • If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, add a stimulant laxative.
  • If constipation due to opioid medication? Advise the person that laxatives can be stopped once the stools become soft and easily passed again.
  • Avoid excessive doses of laxatives - subject to misuse and abuse, can lead to diarrhoea and electrolyte disturbances.
  • Timing of administration.

Treating Constipation in Children

  • Offer advice on behavioural interventions should be consistent with the child's age and stage of development and may include:
    • Scheduled toileting - encourage the child to try and open their bowels at pre-planned intervals or activities, such as after each meal for five minutes, or before bedtime.
    • Use of a bowel habit diary - to track the frequency and consistency of stool.
    • Use of encouragement and rewards systems - such as star charts incorporated into toileting routines, to help praise good behaviour such as visiting the toilet.
  • Give diet and lifestyle advice and information on recommended fluid intake if needed, in combination with advice on the early use of laxatives and behavioural interventions.
  • Foods with a high fibre content include fruit, vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals.

Treating Constipation in Children

  • Recommend a balanced diet with sufficient fibre (in all children who have been weaned).
  • Foods with a high fibre content include fruit, vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals.
  • Do not recommend unprocessed bran (which may cause bloating and flatulence and reduces the absorption of micronutrients) or fibre supplements.
  • Do not switch formula feed or start a cows' milk exclusion diet unless advised by specialist services.
  • Advise normal daily physical activity that is tailored to the child or young person's stage of development and ability.
  • Babies < 6 months, warm baths and massage, bicycle motion.
  • See HSE guides: Constipation in Children, Constipation in Babies (0-6 months)

Constipation

  • Bulk-forming laxatives
    • e.g. ispaghula husk (Fybogel®), sterculia (Normacol®)
    • Act by retaining fluid within the stool and increasing faecal mass, leading to stimulation of peristalsis.
    • They also have stool-softening properties.
    • Increase fluid intake while taking (to prevent intestinal obstruction).
    • Fybogel – Adults and Children (6+)
      • The effects start 12-24 hours later.
      • Consult doctor if no movement in 3 days.
      • Taken during the day at least ½ -1 hour before or after intake of other medicines and should not be taken immediately before going to sleep.

Constipation

  • Osmotic Laxatives
    • Act by increasing the amount of fluid in the large bowel, by retaining fluid in the bowel, and by drawing fluid from the body into the bowel.
    • Fluid accumulation in the lower bowel produces distension, leading to stimulation of peristalsis.
    • Stool-softening properties.
    • Lactulose
      • Takes 48 hours to work.
      • Suitable in infants, pregnancy and breastfeeding
      • Fluid intake important while taking.

Constipation

  • Stimulant Laxatives
    • Cause peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl).
    • e.g. bisacodyl (Dulcolax®), senna (Senokot®), glycerol suppositories

Constipation

  • Enema
    • MICROLAX® is a fast-acting micro-enema.
    • Provides very fast relief during constipation within 5-15 minutes.
    • Works locally in the rectum, without irritating the intestine.
    • Faecal softening and lubricant
    • Softens hard faeces by releasing bound water
    • Limiting any absorption of active ingredients from rectum

Enema - Dosing

  • Children >3 to adults –one to be administered as necessary
  • Children 7 days).

Bowel habits

  • Important to monitor.
  • Encourage regular toileting times.

Haemorrhoids

  • Referral Required
    • Over 40 yrs and persistent change in bowel habit
    • Unexplained bleeding
    • Severe pain associated with defecation
    • Blood mixed in the stool
    • Fever
    • Treatment failure > 7 days

Haemorrhoids - Treatment

  • Diet
    • Provide lifestyle advice to minimise constipation and straining.
    • Recommend a laxative if needed.
    • A bulk-forming laxative is preferred.
    • Lactulose alternative.
    • Stimulant laxatives without stool softening activity (e.g.senna) are less preferred - do not soften stools & stimulant effect may worsen symptoms.
  • Provide symptomatic relief
    • Analgesia e.g. paracetamol
    • Topical products - Soothing preparations containing mild astringents, emollients or lubricants are usually preferred.
    • Topical preparations containing corticosteroid &/or local anaesthetic may be considered for treating perianal inflammation and pain.

OTC - Treatment Options

  • Anaesthetics e.g. lidocaine, benzocaine - numb the area, provide short term relief from itching and pain
  • Astringents e.g. zinc, bismuth – produce a protective coating over the haemorrhoid. Also have antiseptic properties
  • Anti-inflammatory e.g. hydrocortisone – steroid, which reduces swelling of the haemorrhoid.
  • Referral – sclerotherapy, rubber band ligation or a haemorrhoidectomy

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