PF1011 Gastrointestinal Symptoms_Diarrhoea & Constipation 24.25 PDF

PF1011: Pharmacy Practice I Gastrointestinal Tract – Part 2 Dr. Harriet Bennett-Lenane [email protected] Lecture Layout Diarrhoea Constipation Haemorrhoids Two of the most common disorders of the gastro-intestinal (GI) tract. Can be considered to be either a symptom or a disorder...

PF1011: Pharmacy Practice I Gastrointestinal Tract – Part 2 Dr. Harriet Bennett-Lenane [email protected] Lecture Layout Diarrhoea Constipation Haemorrhoids Two of the most common disorders of the gastro-intestinal (GI) tract. Can be considered to be either a symptom or a disorder, depending on how long they last. May be a symptom of another, more serious disorder. Varying levels of morbidity Both can be drug induced. Diarrhoea A symptom of which there are many causes. Increase in frequency of the passage of soft or watery stools relative to the individual's usual bowel habit. Acute (14 days) vs Chronic (>1 month) Possible Causes: Infection (called gastroenteritis) Medicinal side effects (NSAIDs, PPIs, beta blocker, antibiotics, some medicines to treat diabetes) Irritable bowel syndrome (IBS) Coeliac disease/ lactose intolerance Faecal impaction* Ulcerative Colitis or Crohn’s disease Colorectal Cancer Causes of Diarrhoea: Acute – e.g. Virus, bacteria, parasites, drugs, anxiety, food allergies, alcohol misuse. Chronic – e.g. IBS, IBD, microscopic colitis, coeliac, diverticular disease, colorectal cancer. *Faecal impaction is actually constipation, but may present as diarrhoea → Important to take full history.  Diarrhoea Pathophysiology Increased osmotic load = Osmotic Diarrhoea Ingestion of poorly absorbed substance, such as mannitol/sorbitol, or magnesium-containing antacids Malabsorption of solute, such as lactose or gluten Will resolve with fasting. Increase in secretion = Secretory Diarrhoea Water is secreted into the lumen, but is normally reabsorbed. If secretion>reabsorption, then diarrhoea occurs. Causes: Cholera, E.coli, some laxatives, some drugs e.g. antidepressants, caffeine, some toxins. Will not resolve with fasting.  Diarrhoea Pathophysiology Inflammation of the Intestinal Lining Disruption to/destruction of the epithelium due to infection with: Bacteria: Salmonella, E. coli, Campylobacter Viruses: rotaviruses, coronaviruses, parvoviruses (canine and feline), norovirus Protozoa: coccidia species, Cryptosporium, Giardia Inflammatory processes → activation of white blood cells, cytokines/inflammatory mediators leads to increased secretion AND destruction of epithelial cells. Increased Intestinal Motility Leads to less time for absorption Observed in many types of diarrhoea Specific Questions to Consider Frequency and nature of the 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 --> Referral Diarrhoea Acute Diarrhoea Mainly viral or bacterial, but try to ascertain the underlying cause. Rapid onset Possibly nausea and vomiting also Cramping, flatulence, tenderness of abdomen 2-3 days (viral) or 3-5 days (bacterial) Should resolve itself, keeping an eye out for dehydration symptoms – co-treat. 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. Diarrhoea 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 – Giardiasis (protozoan infection) Dehydration (children, elderly) – cannot maintain hydration. Presence of blood or mucus in the stool Severe abdominal pain Fever Steatorrhoea Does not respond to treatment. Diarrhoea persists for >3-4days or does not respond to treatment.  Lassitude Anorexia, nausea Light-headedness Postural hypotension Mild Usually no signs Apathy/tiredness Reduced skin elasticity Dizziness Postural hypotension Muscle cramps Tachycardia Pinched face Moderate Dry tongue or sunken eyes Oliguria Profound apathy Tachycardia Weakness Peripheral vasoconstriction Confusion leading to coma Systolic blood pressure < 90 mmHg Severe Shock Oliguria or anuria Signs of Dehydration Dehydration Risk Particular caution when there is an increased risk of dehydration… Infants younger than 1 year of age, and especially if younger than 6 months. Infants who were of low birthweight. Infants who have stopped breastfeeding during their illness. Children who have passed six or more diarrhoeal stools in the past 24 hours. Children who have vomited three times or more in the past 24 hours. Dehydration Management Prevention or correction of dehydration with its associated electrolyte disturbance AND maintenance or resumption of adequate nutritional intake. Based on the discovery that glucose stimulates sodium transport in the small intestine, oral rehydration solutions (ORS Hydration, Dioralyte) have become widely available. Popular soft drinks are hyperosmolar and may provoke an osmotic diarrhoea. Rehydration in Children Give the ORS solution frequently and in small amounts. Avoid giving solid food until dehydration is corrected. Seek urgent medical advice if the child is unable to drink, or vomits persistently. Must keep drinking – offer after they vomit. After rehydration, advise parents to: Encourage the child to drink plenty of their usual fluids, including milk feeds. Avoid giving the child fruit juices and carbonated drinks until the diarrhoea has stopped. Reintroduce the child's usual diet. Oral Rehydration Salts Oral Rehydration Salts (ORS) Reconstitute with 200ml water Once reconstituted, use within one hour or store in fridge for 24hrs  Loperamide 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 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 Gastroenteritis is a common illness in infants and young children. Gastroenteritis is a transient disorder due to enteric infection with viruses, bacteria, or parasites. Inflammation of stomach, small and large intestines. It is characterized by the sudden onset of diarrhoea, with or without vomiting Common infectious acute self-limited illness. Gastroenteritis Infection Control Encourage the child to wash their hands thoroughly after going to toilet, and before eating. Thoroughly clean the potty or toilet using disinfectant after each episode of diarrhoea and vomiting. Wash hands regularly, particularly after changing a nappy or cleaning a potty – prevent transmission. Do not share child's towels, flannels, cutlery or eating utensils with other members of the household. Do not allow the child to return to nursery or school until 48 hours have passed since their last episode of diarrhoea and vomiting. Do not allow the child to enter a swimming pool for the first two weeks after their last episode of diarrhoea - even though they are free of symptoms, research has found that the rotavirus can spread to other children via the pool water. Commence eating as soon as they want. Babies: breast-feeding and bottle-feeding should be continued. Preventing Gastroenteritis Food Hygiene Practising good food hygiene will help children avoid getting gastroenteritis as a result of food poisoning. Some ways of achieving this include: regularly washing your hands, surfaces and utensils using hot, soapy water never storing raw and cooked foods together making sure that food is kept properly refrigerated always cooking food thoroughly never eating food that is past its expiry date Rotavirus Vaccine Rotavirus disease is prevented by vaccination. All children born on or after 1 October 2016 are given rotavirus oral vaccine at 2 and 4 months of age. Rotavirus oral vaccine should not be given to infants who are 8 months older or it will not be effective. Follow-Up for Diarrhoea in Children Advise parents or carers to seek advice from a healthcare professional if their child's symptoms do not resolve within the following time frames: Diarrhoea: the usual duration is 5–7 days, and in most children it stops within 2 weeks. Vomiting: the usual duration is 1 or 2 days, and in most children it stops within 3 days. Provide a 'safety net', advising the parents or carers on how to: Recognize developing features of dehydration and shock (for example the child appears unwell or is deteriorating, or is irritable, lethargic, or less responsive). Access further medical help if red flag features are identified Constipation Defecation that is unsatisfactory, reduction in normal bowel habit Infrequent stools. Excessive straining. 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. Constipation 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? Constipation 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 The 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 < 6months, 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 Dosing: Children >3 to adults –one to be administered as necessary Children 7 days). Bowel habits 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