diarrhea.pdf

‫د عبير الجبوري‬.‫م‬.‫أ‬ Diarrhoea Background Diarrhoea can be defined as an increase in frequency of the passage of soft or watery stools relative to the usual bowel habit for that individual. It is not...

‫د عبير الجبوري‬.‫م‬.‫أ‬ Diarrhoea Background Diarrhoea can be defined as an increase in frequency of the passage of soft or watery stools relative to the usual bowel habit for that individual. It is not a disease but a sign of an underlying problem such as an infection or gastrointestinal disorder. It can be classed as acute (less than 7 days), persistent (more than 14 days) or chronic (lasting longer than a month). Most patients will present to the pharmacy with a self-diagnosis of acute diarrhoea. Significance of questions and answers Age Particular care is needed in the very young and the very old. Infants (younger than 1 year) and older people are especially at risk of becoming dehydrated. Duration Most cases of diarrhoea will be acute and self-limiting. Because of the dangers of dehydration, it would be wise to refer infants with diarrhoea of longer than 1 day’s duration to the doctor. Severity The degree of severity of diarrhoea is related to the nature and frequency of stools. Symptoms Acute diarrhoea arising from infection is rapid in onset and produces watery stools that are passed frequently. Abdominal cramps, flatulence and weak- ness or malaise may also occur. Nausea and vomiting may be associated with diarrhoea, as may fever. Another important question to ask about diarrhoea in infants is whether the baby has been taking milk feeds and other drinks as normal. Reduced fluid intake predisposes to dehydration.  ‫د عبير الجبوري‬.‫م‬.‫أ‬ The pharmacist should question the patient about food intake and also about whether other family members or friends are suffering from the same symptoms, since acute diarrhoea is usually due to an infection. The presence of blood or mucus in the stools is an indication for referral. Diarrhoea with severe vomiting or with a high fever would also require medical advice. Previous history A previous history of diarrhoea or a prolonged change in bowel habit would warrant referral for further investigation, and it is important that the phar- macist distinguish among acute, persistent and chronic conditions. Persistent diarrhoea (of more than 2 weeks’ duration) may be caused by bowel condi- tions such as Crohn’s disease, irritable bowel syndrome or ulcerative colitis and requires medical advice. Chronic diarrhoea is diarrhoea that goes on for 5 weeks or longer. Recent travel abroad Diarrhoea in a patient who has recently travelled abroad requires referral since it might be infective in origin. Giardiasis should be considered in travellers recently returned from South America or the Far East. Causes of diarrhoea Infections Most cases of diarrhoea are short lived, the bowel habit being normal before and after. In these situations, the cause is likely to be infective (viral or bacterial). Viral Viruses are often responsible for gastroenteritis. The two main viruses are rotavirus and norovirus: Rotavirus: In infants, the virus mainly gains entry via the faecal–oral route or sometimes through the air from sneezing and coughing. The infection starts abruptly and fever and vomiting often precedes diarrhoea. The acute  ‫د عبير الجبوري‬.‫م‬.‫أ‬ phase is usually over within 2–3 days, although diarrhoea may persist for up to a week. The virus is read- ily spread by contact with another person, through contaminated food, or surfaces contaminated with vomit. After an incubation of up to 48 h, the illness begins suddenly with profuse vomiting, diarrhoea and flu-like symp- toms. It usually settles in 2–3 days and treatment includes the usual advice on fluid replacement. Bacterial These mostly take the form of food-borne infections, previously known as food poisoning. There are several different types of bacteria that can cause such infections: Staphylococcus, Campylobacter, Salmonella, Shigella, pathogenic Escherichia coli, Bacillus cereus and Listeria monocytogenes. The typical symp- toms include severe diarrhoea and/or vomiting, with or without abdominal pain. The two most commonly seen infections are Campylobacter and Salmonella, which are often associated with contaminated poultry, although other meats have been implicated. Contaminated eggs have also been found to be a source of Salmonella. Bacillary dysentery is caused by Shigella. B. cereus is usually associated with cooked rice, especially if it has been kept warm or has been reheated. E. coli infections are less common but can be severe with toxins being released into the body, which can cause kidney failure. L. monocytogenes can cause gastroenteritis or a flu-like illness. Antibiotics are generally unnecessary to treat infectious diarrhoea as most food-borne infections resolve spontaneously. The most important treatment is adequate fluid replacement. Ciprofloxacin has often been used in sever cases.In Giardia lamblia (giardiasis). Diagnosis is made by sending stool samples to the laboratory. Treatment is usually with metronidazole.  ‫د عبير الجبوري‬.‫م‬.‫أ‬ Persistent or chronic diarrhoea Persistent, chronic or recurrent diarrhoea may be due to an irritable bowel or, more seriously, a bowel tumour, an inflammation of the bowel (e.g. ulcerative colitis or Crohn’s disease), an inability to digest or absorb food (malabsorption, e.g. coeliac disease) or diverticular disease of the colon. Antibiotics and Clostridium difficile Diarrhoea is commonly seen with antibiotics,the antibiotic kills off other flora in the gut and allows the C. difficile to flourish. Some strains of C. difficile produce a toxin that damages the large bowel lining, which results in profuse watery diarrhoea. These strains can get passed to other patients if scrupulous handwashing and careful hygiene practice is not followed. In hospitals this is called nosocomial spread. Factors that increase the risk of C. difficile infection include advanced age and underlying morbidity such as abdominal surgery, cancer and chronic renal disease. Recently it has been recognised that an important risk factor is use of PPIs in these people because it may trigger recurrence. Antidiarrhoeal medica- tion such as loperamide should not be used as this can aggravate the condi- tion. If the diagnosis is confirmed using a stool sample to test for C. difficile toxin, an antibiotic such as metronidazole, which C. difficile is sensitive to, may be used. When to refer Diarrhoea of greater than 1 day’s duration in children younger than 1 year 2 days’ duration in children under 3 years and elderly patients 3 days’ duration in older children and adults Persistent diarrhoea after course of antibiotics Association with severe vomiting Feverish, high temperature Suspected outbreak of ‘food poisoning’ Recent travel abroad  ‫د عبير الجبوري‬.‫م‬.‫أ‬ Suspected drug-induced reaction to prescribed medicine History of change in bowel habit Presence of blood or mucus in the stools Pregnancy Management Oral rehydration therapy Rehydration may still be initiated even if referral to the doctor is advised. Factors associated with high risk of dehydration, and where referral should be considered, are the following: Children younger than 1 year of age, particularly younger than 6 months Infants who were of low birth weight Children who have passed more than five diarrhoeal stools in the previous 24 h Children who have vomited more than twice in the previous 24 h Children who have not been offered, or have not been able to tolerate, sup- plementary fluids before presentation Infants who have stopped breastfeeding during their illness Children with signs of malnutrition Sachets of powder for reconstitution are available; these contain sodium as chloride and bicarbonate, along with glucose and potassium. The absorption of sodium is facilitated in the presence of glucose. A variety of flavours are available. Patients should be reminded that only water should be used to make the solution (never fruit or carbonated drinks) and that boiled and cooled water should be used for children younger than 1 year. Boiling water should not be used, as it would cause the liberation of carbon dioxide. The solution can be kept for 24 h if stored in a refrig- erator. Fizzy, sugary drinks should never be used to make rehydration fluids, as they will produce a  ‫د عبير الجبوري‬.‫م‬.‫أ‬ hyperosmolar solution that may exacerbate the prob- lem. The sodium content of such drinks, as well as the glucose content, may be high. Home-made salt and sugar solutions should not be recommended, since the accuracy of electrolyte content cannot be guaranteed, and this accu- racy is essential, especially in infants, young children and elderly patients. Loperamide Loperamide is a synthetic opioid analogue and is thought to exert its action via opiate receptors slowing intestinal tract time and increasing the capacity of the gut. It is an effective antidiarrhoeal treatment for use in older children and adults. Diphenoxylate/atropine (co-phenotrope) Co-phenotrope can be used as an adjunct to rehydration to treat diarrhoea in those aged 16 years and over. Kaolin Kaolin has been used as a traditional remedy for diarrhoea for many years. Its use was justified on the theoretical grounds that it would absorb water in the GI tract and would absorb toxins and bacteria onto its surface, thus removing them from the gut. Probiotics A systematic review concluded that, when used with rehydration, probi- otics appear to reduce stool frequency and shorten the duration of infectious diarrhoea. There is some evidence that specific strains of probiotics (Lactobacillus rhamnosus or Saccharomyces boulardii) can help prevent diarrhoea caused by antibiotics.