Diaherra, N&V

• The presentation is about nausea, vomiting, and diarrhea
• The presentation was given on 01/28/2025

Objectives

• Identify counseling points for pharmacological and non-pharmacological treatments
• Determine if a patient is a candidate for self-care
• Select appropriate therapy

Diarrhea

• Diarrhea is a global burden and a common cause of death worldwide
• Usually affects those younger than 5 years old
• Diarrhea occurs when stools push through the bowel before the water is reabsorbed
• Symptoms include cramping, nausea, vomiting, and fever
• It is characterized by:
  • More than 3 bowel movements per day
  • Increase in stool: frequency, liquidity, or weight
• Acute Diarrhea: lasts less than 2 weeks
• Persistent Diarrhea: lasts 2-4 weeks
• Chronic Diarrhea: lasts more than 4 weeks

Classifications of Diarrhea

• There are four clinical classifications of the condition

Osmotic

• Mechanism involves unabsorbed solutes which increase the osmotic load and brush border damage
• Common causes are viruses, bacteria, lactose deficiencies

Secretory

• Mechanism involves stimulation of crypt cells, flow of electrolytes, and fluids into the intestines
• Common causes are viruses, bacteria, ileal resection, and thyroid cancer

Inflammatory

• Mechanism involves inflammation of the intestinal mucosa, resulting in a leaking of mucus, blood and pus
• Common causes include ulcerative colitis and Crohn's disease

Motor

• Mechanism involves reduced contact time due to a decrease in intestinal transit time
• Commmon causes are irritable bowel syndrome and diabetic neuropathy

Classification and Causes of Diarrhea

• Diarrhea can be classified by its duration and cause

Acute Diarrhea

• Lasts less than 2 weeks
  • Viral causes: Norovirus, rotavirus
  • Bacterial causes: Campylobacter, E. coli, Salmonella, Shigella
  • Parasitic Causes: Cryptosporidium enteritis, Entamoeba histolytica, Giardia lamblia
  • Foodborne causes: Traced back to bacteria or viruses (E. coli, Salmonella)
  • Food-induced causes: intolerance to fatty, spicy, or lactose foods, and high fiber diets

Persistent Diarrhea

• Lasts 2-4 weeks
  • Can be caused by medications

Chronic Diarrhea

• Lasts more than 4 weeks
  • Irritable bowel syndrome, inflammatory bowel diseases, celiac disease, malabsorption, chronic infections, tumors, and medication side effects
• Medications can cause acute and chronic diarrhea and referral to a medical provider is usually needed

Medications that Cause Diarrhea

• Antacids containing magnesium
• Many antibiotics can cause infectious C. difficile
• Laxatives (mineral oil, docusate, senna)
• Metformin and GLP-1 agonists
• Prokinetic drugs (metoclopramide, cisapride)
• Antineoplastics (irinotecan, capecitabine, fluorouracil, methotrexate, TKIs)
• Acetylcholinesterase inhibitors (donepezil)
• Other medications to consider: Colchicine, misoprostol, quinidine, roflumilast, nelfinavir)

Self-Treatment Goals of Diarrhea

• Prevent or correct fluid and electrolyte imbalances
• Control symptoms
• Identify and treat the cause of diarrhea
• Prevent acute morbidity and mortality

Dehydration Symptoms

• Dehydration symptoms include: dry mouth, excessive thirst, weight loss, and decreased urination
• Other symptoms include: Decreased skin turgor, lack of tears or sweat, sunken eyes, and dark yellow urine
• Other symptoms include: Dizziness, high heart rate, confusion, changes in mental status, falls, and difficulty walking

Assessment of Dehydration

• Assessment is needed to differentiate between self-treatable and non-self-treatable dehydration

Self-Treatable

• Normal mental status and fatigue
• Normal pulse and breathing
• Dry skin and slightly sunken eyes
• Less than 6 stools per day
• Afebrile with a fever less than 102.2° F
• Thirsty and able to drink
• Less than 10% loss of body weight

NOT Self-Treatable

• Apathetic, lethargic, or unconscious
• Low blood pressure, dizzy, tachycardic, and weak pulse
• Dry skin that is parched, has more than 2 seconds to recoil, and sunken eyes
• More than 6 stools per day
• Febrile with a fever greater than 102.2° F
• Unable to drink or drinks poorly
• More than 10% loss of body weight

Exclusion to Self-Treatment

• Young age less than 6 months or less than 8 kg
• Frail patients older than 65 years old
• Persistent fever greater than 102.2 degrees Fahrenheit
• Blood, pus, or mucus in stool
• High output and volume of diarrhea
• Persistent vomiting
• Not responding well to oral rehydration
• Signs of severe dehydration
• Severe abdominal pain/distress
• Immunosuppressed
• Pregnancy
• Chronic (more than 4 weeks) or persistent (2-4 weeks)

Self-Care Treatment of Diarrhea

• Oral rehydration therapy if dehydrated
• Symptomatic drug therapy

Symptomatic Drug Therapy

• Bismuth subsalicylate
• Digestive enzymes
• Loperamide
• Probiotics
• Zinc
• If diarrhea does not resolve or greatly improve after 72 hours, see a provider

Pre-Oral Rehydration Solution

Mild Dehydration

• Less than 3% weight loss
• Mild symptoms
• Healthy adult/child
  • Likely do not need ORS products
  • Try water, soups, sports drinks
  • Try complex carb-rich foods
  • Consider ORS if symptoms progress and fluid loss

Oral Rehydration Solution

• Provides electrolytes and fluids lost during acute diarrhea and minimal dietary intake
• For mild-moderate dehydration in children 6 months to 5 years, 3-9% weight loss with no exclusion to self-care
• Drink ORS 50-100 mL/kg over 3-4 hours
• Continue until rehydrated (usually 4-6 hours) and add 10 mL/kg for each loose stool thereafter
• Weigh the patient if possible
• Vomiting is not a contraindication
• Small volumes (1-2 tsp every 1-2 minutes) may be tolerated by a vomiting child and can be enough to maintain hydration

Oral Rehydration Solution (ORS)

• MOA is fluid and electrolyte replacement
• Dosing is based on the patient's fluid status

Rehydration Phase

• Over 3-4 hours to quickly replace water and electrolyte deficits and restore normal body composition

Maintenance Phase

• Maintain normal body composition until adequate dietary intake is established

Inappropriate Products

• For children less than 5 years old: sports drinks, colas, ginger ale, apple juice, and tea

ORS Example

• Tommy, 5-year-old, 20 kg patient example

• Symptoms: diarrhea for 2 days, not eating much, afebrile, clammy, tired

• Appropriate ORS treatment:

  • Drink ORS 50-100ml/kg in 3-4 hours
  • 50 x 20kg=1000 to 100 x 20kg=2000 maximum
  • 1000 – 2000 mL over 3-4 hours

• An example regimen would be

  • 500 mL/hour until rehydrated plus extra 200 mL for each loose stool

Available ORS Products

• Pedialyte
• Hydralyte
• Ceralyte 70

ORS Electrolyte Content

• A comparison of multiple brands includes varying contents of:
  • Sodium
  • Potassium
  • Chloride
  • Carbs
  • Serving size in fl oz

ORS Patient Example

• Tommy, 5-year-old, 20 kg patient example
• Symptoms: diarrhea for 2 days, not eating much, afebrile, clammy, tired
  • 1000-2000 mL over 3-4 hours (50-100 mL/kg)
• An appropriate regimen would be:
  • 500 mL/hour until rehydrated
  • Extra 200 mL for each loose stool)
• 1 Pedialyte bottle is about 1 L (1000 mL)
• Tommy needs roughly 2 bottles of Pedialyte for replacement over 4 hours plus an additional 200 mL for each loose stool thereafter

Bismuth Subsalicylate (Pepto-Bismol)

Mechanism

• Exhibits antisecretory and antimicrobial actions
• May provide some anti-inflammatory actions
• Reacts with HCl in stomach to form bismuth oxychloride and salicylic acid

Indications

• Acute diarrhea for age 12 and older

Dose

• 524 mg (30mL/2 tabs) every 30-60 minutes as needed
• Or 1,050 mg (60 mL/4 tabs) every 60 minutes as needed
• Maximum dose 4,200 mg/day for up to 2 days

Contraindications

• Salicylate allergy, use with other salicylates, ulceration, bleeding problems, black or bloody stools, and pregnancy

Side Effects

• Reactions such as black tongue, black stool that are temporary and harmless
• Salicylate toxicity if used excessively (early signs and symptoms include tinnitus, nausea, vomiting, increased respiratory rate, diaphoresis

Interactions

• Many interactions, including aspirin and anticoagulants, like warfarin, apixaban, heparin, and rivaroxaban, that cause a toxicity risk for bleeding
• A trivalent cation that binds medications like tetracycline antibiotics

Notes

• Caution in renal insufficiency
• Children and teenagers who are recovering from the flu, chickenpox, or other viral infections should not use due to the risk of Reye syndrome

Digestive Enzymes (Lactase)

Mechanism

• Provides lactase enzymes to help with the digestion of milk products

Indications

• Patients with lactose deficiency or milk intolerance

Dose

• If consuming dairy, use 1-3 tablets at first bite
• If continuing consumption, take another serving after 30-45 minutes

Side Effects

• None recorded

Loperamide (Imodium A-D)

Mechanism

• Binds to the opiate receptors in the gut wall
• Inhibits the release of acetylcholine and prostaglandins
• Reduces peristalsis
• Increases intestinal transit time

Indications

• Acute diarrhea for adults 12 years and older

Dose

• 4 mg orally once, followed by 2mg after each loose stool
• Maximum OTC dose is 8 mg/day or 16 mg/day under healthcare supervision

Contraindications

• Children under 2 years of age
• Acute dysentery, bloody diarrhea, high fever
• Bacterial enterocolitis (E. coli, Shigella, Salmonella)
• Pseudomembranous enterocolitis

Side Effects

• Abdominal cramping, constipation, and Nausea

Interactions

• Some drugs can cause increased concentrations

Notes

• There are opioid effects, such as sedation, respiratory depression, with doses above the standard recommendation
• Box warning of cardiac issues, cardiac arrest, and death at high doses
• Self-treatment should not be more than 48 hours

Probiotics

Mechanism

• Thought to reach the bowel
• Suppress the germs that are causing diarrhea
• Help the body fight infection

Indications

• Preventing and treating mild, uncomplicated diarrhea
• Functions as dietary supplement, so it cannot cure or treat a disease

Notes

• Reduction of diarrheal duration
• Can be caused by rotavirus
• Most evidence with lactobacillus rhamnosus GG and saccharomyces boulardii
• Caution with immunocompromised patients

Zinc

Background

• Aids in reducing diarrhea
• 10-day tablets treat diarrhea
• Helps prevent future bouts of condition

Mechanism

• Inhibits cAMP-induced fluid secretion
• Enhances the absorption of water and electrolytes
• Improves regeneration
• Enhances the immune response

Primary Use

• Prescribed for acute and persistent diarrhea in children, mostly in developing countries

Recommended Dose

• 20 mg for 10-14 days in children 6 months and older, 10 mg for children younger than 6 months

Side Effects

• Some reactions include Taste disturbances

Interactions

• Iron, tetracycline, & fluoroquinolones (administer zinc 2 hours before or 4 hours after)

Traveler's Diarrhea

Prophylaxis

• Eat hot food that is cooked and served
• Avoid buffet style food
• Drink bottled water
• Boil tap water for approximately 1 minute
• Avoid ice
• Wash all produce before consuming
• Eat at known restaurants
• Wash hands frequently

Treatments

• Mild loperamide
• Bismuth subsalicylate
• Hydration

Counseling Points

• Contact a healthcare provider if you have a fever (greater than 101°F), severe abdominal pain, and/or blood in stool that does not get better in 2 days
• If pregnant, contact a health provider
• Stay hydrated by drinking fluids with electrolytes

Diarrhea Summary

• Inclusion/Exclusion of self-treatment assessment.
• Distinguishing patients that will require external or internal treatment.
• Understanding commonly used medications for diarrhea.
• Select an appropriate drug.
• Know key interactions and exclusions with any medications that are provided

Nausea and Vomiting

• 2.5 million people visit emergency rooms for vomiting each year (USA)
• Mostly affect children
• Usually present in pregnant women
• Involves three main processes: Nausea, Retching, Vomiting
• Nausea: Need to vomit
• Retching: Involuntary contractions
• Vomiting: Sudden expulsion of GI tract

Chemoreceptor Trigger Zone

• The mechanism by which the CTZ is triggered by neurotransmitters
• Etiology of N/V is complex
• CTZ located outside the BBB
• Stimulates vomiting center
• GI tract release serotonin to activate centers

Primary Causes

• GI Tract
• CNS Disorder
• Other Disorders

Self-Treatment Goals

• Provide symptomatic relief by:
  • Identify any underlying causes for diarrhea
  • Prevent from re-occurrence
  • Correct complications

Exclusion List

• The Exclusion list provides a detailed description of both children and pregnant women who may need to see a medical provider. This list includes, but is not limited to:
  • Low blood pressure or signs of severe dehydration
  • Inability to keep fluids down
  • Diabetics
  • Those who have recently had a head injury

Appropriate Treatments

• If patient has NOT met exclusions, may be able to treat at home
• Limiting intake, in many cases, can be effective.
• The following can sometimes be treated with self-care:
  • Overeating
  • Food poisoning-related vomiting
  • Anxiety

Self-Care Treatment Options

• Salts
• Bismuth Subsalicylate
• Antihistamines, Dimenhydratrate, Diphenhydramine, Doxylamine, and Meclizine
• Phosphorated Carbohydrate Solution
• Extra Vitamin B6 and Ginger can resolve Nausea and Vomiting

Motion Sickness

• Avoid reading during travel
• Look towards the horizon (straight ahead)
• Stay where motion is least experienced
• Avoid strong odors
• Drive the vehicle(s) if possible!
• A non-prescribed antihistamine can alleviate motion sickness

Pregnancy-NVP

• NVP is generally known as morning sickness
• Affects 50-90% of pregnant women
• All Pregnant symptoms should be screened and discussed with a primary health physician (HCP)
• Self-Care OTC, can generally be used with the following, Doxylamine 10-12.5mg, Pyridoxine, Ginger, and Vitamin B

How to treat Pregnancy-NVP

• First, find fresh hair or open a window in the room where you sleep
• When moving from a drowsy position, do so very slowly. As you get up from bed, eat several crackers and recline for 10-15 minutes
• Do not overload when eating. Eat smaller foods more frequently
• Avoid greasy or fatty foods as they can be harmful.
• If necessary, consume chilled foods as they tend to be less nauseating
• If comfortable, try Motion sickness acupuncture or use acupressure band.

Oral Rehydration Solution (ORS)

Indicates for

• Overeating and disagree foods, and food poisoning or viral
• Self-limiting N&V's status
• Important for status for fluid loss!