GIT Diarrhea and IBS Lecture 2 2020-21 PDF

College of Pharmacy ‫جبار‬‫ضياء‬  : ‫د‬.‫م‬.‫أ‬ Fourth Year. Clinical Pharmacy 2020-21  Gastrointestinal Conditions 1-Diarrh...

College of Pharmacy ‫جبار‬‫ضياء‬  : ‫د‬.‫م‬.‫أ‬ Fourth Year. Clinical Pharmacy 2020-21  Gastrointestinal Conditions 1-Diarrhea 1-Diarrhea is an increased frequency of bowel evacuation with the passage of abnormally soft or watery stools (1). Although the normal frequency of bowel movements varies with each individual, more than three bowel movements per day are considered abnormal (2). 2-Diarrhea may be acute (less than 14 days duration), persistent (14 days to 4 weeks duration), or chronic in nature (more than 4 weeks). Chronic and persistent diarrheal illnesses are often secondary to other chronic medical conditions (or treatments) and need medical care (2). Causes 1-Acute diarrhea (infective diarrhea, gastroenteritis): The most common causes of acute diarrhea are bacterial and viral infection and food toxins (3). Viral: Rotavirus responsible for causing severe diarrhea in infants and children and the most common cause of gastroenteritis among children worldwide (3). Rotavirus tends to be a seasonal infection, with peaks of gastroenteritis occurring between November and February. It is spread by the fecal-oral route (2). Associated symptoms are those of a cold and perhaps a cough. The infection starts abruptly and vomiting often precedes diarrhea. (1). Whilst in the majority the infection is usually not too severe and is self-limiting, it should be remembered that rotavirus infection can cause death. This is most likely in those infants already malnourished and living in poor social circumstances who have not been breastfed (1). Note: vaccine is available to protect against rotavirus (3). Bacterial: These are the food-borne infections (previously known as food poisoning). There are several different types of bacteria that can cause such infections: Salmonella, Shigella, pathogenic Escherichia coli,………….... The typical symptoms include severe diarrhea and/or vomiting, with or without abdominal pain (1). Antibiotics are generally unnecessary as most food-borne infections resolve spontaneously. The most important treatment is adequate fluid replacement. Antibiotics are used (by prescription only) for Shigella infections and the more severe Salmonella. Ciprofloxacin (by prescription) may be used in such circumstances (1). Protozoan: Examples include Entamoeba histolytica (amoebic dysentery) and Giardia lamblia (giardiasis). Diagnosis is made by sending stool samples to the laboratory (1). 1 2-Chronic diarrhea: There are several causes and chronic diarrhea requires medical investigation. Causes include: Irritable-bowel syndrome (IBS), inflammatory bowel disease (Crohn’s disease, ulcerative colitis), malabsorption syndromes (such as celiac disease)……… (4). Patient assessment with diarrhea A-Age Infants (1 day duration in children 2 days duration in children 3 days duration in older children and adults required referral (4). Diarrhea of more than 24 hours in people with diabetes required referral (4).idiopathic diarrhea caused by autonomic neuropathy in DM C-Severity patient Severe diarrhea (passing 6 or more unformed stool in 24 hours) required referral (2). D-Periodicity A history of recurrent diarrhea of no known cause ---------should be referred for further investigations (5). E-Associated symptoms The presence of blood or mucus in the stools is an indication for referral for further investigations (1). Diarrhea with severe vomiting or with high fever required referral for further investigations (1). Diarrhea with severe abdominal pain required referral for further investigations (5). F-Recent travel abroad Diarrhea in patient who has recently travelled abroad requires referral since it may be infective in origin (Traveler's diarrhea) (1). G-Signs of dehydration (3) Patient with signs or symptoms of debilitating dehydration required referral (table1-5). 2  Table1-5: Symptoms of dehydrations in children and adults (3) children adults Dry mouth, tongue and skin Increased thirst Fewer or no tears when crying Decreased urination Decreased urination (less than 4 wet diapers in 24 Feeling weak or hours) lightheaded Sunken eye, cheeks or abdomen Dry mouth/ tongue sunken fontanel decreased skin turgor irritability or listlessness H-Medication (1) Table1-6: Some drugs that may cause Medicines already tried: The pharmacist diarrhea (1). should establish the identity of any medication Antacids: Magnesium salts that has already been taken to treat the Antibiotics symptoms in order to assess its Antihypertensives: methyldopa; beta- appropriateness. blockers (rare) Digoxin (toxic levels) Other medicines being taken: Diuretics (furosemide) Details of any other medication being taken Iron preparations (both OTC and prescribed) are also needed, as Laxatives the diarrhea may be drug induced (Table 1-6). Misoprostol Non-steroidal anti-inflammatory drugs Selective serotonin reuptake inhibitors Treatment timescale One day in children, otherwise 2 days (1). Management A-Advices for patients suffering from diarrhea (4) 1-Drink plenty of clear fluids, such as water. 2-Avoid drinks high in sugar as these can prolong diarrhea. 3-Avoid milk and milky drinks, as a temporary lactose intolerance occurs due to damage done by infecting organisms to the cells lining the intestine, making diarrhoea worse. 4-Babies should continue to be fed as normal, whether by breast or bottle. B-Oral rehydration therapy 1-The risk of dehydration from diarrhea is greatest in babies, and rehydration therapy is considered to be the standard treatment for acute diarrhea in babies and young children (1). 2-Oral rehydration sachets may be used with antidiarrheals in older children and adults (1). 3-Rehydration may still be initiated even if referral to the doctor is advised (1). 3 A premixed solutions (2) or Sachets of powder for reconstitution are available; these contain sodium as chloride and bicarbonate, glucose and potassium. The Table1-7:Amount of rehydration (1) absorption of sodium is facilitated in the solution to be offered to patients.. presence of glucose (1). Age Quantity of solution 4-Table1-7 provides the volumes (per watery stool) (1) required per watery stool. Under 1 year) 50 mL (quarter of a glass 5-Reconstitution of ORS: Only water 1–5 years 100 mL (half a glass) should be used to make the solution and 6–12 years 200 mL (one glass) that boiled and cooled water should be Adult 400 mL (two glasses (1) used for children < 1 year. 6-Stability of ORS after reconstitution: To avoid risk of possible exposure to further infection, the solution should be discarded not later than 1hour after reconstitution, or it may be kept for up to 24 hours if stored in a refrigerator. (9). 7- If the child is vomiting, give 1 teaspoon of ORS every few minutes (2). C-Antimotility Drugs: 1-Loperamide, and Co-phenotrope (Diphenoxylate+Atropine) [Atropine is included at a subtherapeutic dose to discourage abuse (unpleasant antimuscarinic effects will be experienced if higher than recommended doses are taken)] (4). 2-Loperamide is considered an OTC drug only for patient of > 12 years old (1). Adult dose: Initially 2 tablets (4 mg) followed by 1 tablet (2 mg) after each loose stool (max. 8 tablets / day) (6). 3-Co-phenotrope is considered an OTC drug only for patient of > 16 years old (1, 6). B-Adult doses: 4 tablets initially followed by 2 tablets every 6 hours (6). D-Adsorbents: Like Pectokaolin® (pectin +kaolin) Adsorbents such as kaolin are not recommended for acute diarrheas (6). Extra-Notes: A-Probiotics (dietary supplement): Probiotics are dietary supplements containing bacteria (including several Lactobacillus species) that may promote health by enhancing the normal microflora of the GI tract while resisting colonization by potential pathogens (7). Probiotics have been shown to decrease the duration of infectious and antibiotic-induced diarrhea (AAD) in adults and children (however; the use of probiotics to treat and prevent AAD is controversial (8). B-Use of zinc in children with diarrhea: Several large studies performed in developing countries have shown that daily zinc supplementation in young children with acute diarrhea reduces both the duration and severity of diarrhea (2, 3). The WHO/UNICEF recommends that children with acute diarrhea also receive zinc (10 mg of elemental zinc/day for infants younger than 6 months; 20 mg of elemental zinc/day for older infants and children) for 10 to 14 days (2, 3). 4 References 1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 8th edition. 2018. 2-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self- Care. 18th edition. 2016. 3-Canadian American pharmacists association (CPhA). CTMA: Compendium of Therapeutics for Minor Ailments. 2014. 4-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 5-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 5th edition. 2021. 6-BNF-80 7-Marie A. Chisholm-Burns.Pharmacotherapy Principles & Practice. 4th edition. 2016. 8-Joseph T. DiPiro, Robert L. Pharmacotherapy: A Pathophysiologic Approach, 11th edition. 2021.. 2-Irritable Bowel Syndrome (IBS) 1-Irritable Bowel Syndrome is defined as: a functional bowel disorder in which abdominal pain is associated with abdominal distention and a change in bowel habit (diarrhea and constipation may occur; sometimes they alternate) (1, 2). 2-The two main classifications of IBS are IBS with constipation predominant (IBS-C) and IBS with diarrhea predominant (IBS-D). Some patients may also have IBS with alternating diarrhea and constipation (IBS-A) (3). Adult prevalence rates in Western countries are reported to be between 10% and 20%, with approximately twice as many women than men affected (2). 3-The cause is unknown (1). Some possible causes include genetic mutations, abnormal GI motility, enhanced gut pain sensation (visceral hypersensitivity), or psychological changes. Most likely a combination of these factors leads to IBS (3). Patient assessment with IBS A-Age: Because of the difficulties in the diagnosis of abdominal pain in children (1), it is best to refer children less than 16 years (2). IBS often develop in young adult life (1). If an older (above 45(2)) person presenting with for the first time with no previous history of bowel problems, referral should be made (1). Figure1-9: The position of pain associated with irritable bowel B-Symptoms: syndrome (2). IBS has three Key symptoms: abdominal pain, abdominal distention/bloating and disturbance of bowel habit (1). 1-Abdominal pain: The pain can occur anywhere in the abdomen. It is often central or left sided and can be severe (1) (pain normally located in the left lower quadrant) (figure1-9) (2). 5  The site of pain can vary from person to person and even for an individual (1). Sometimes the pain comes on after eating and can be relieved by defecation (1) or the passage of wind (2). 2-Bloating: A sensation of bloating is commonly reported. Sometimes it is so severe that clothes have to be loosened (1). 3-Bowel habit: Diarrhea and constipation may occur; sometimes they alternate. A morning rush is common, where the patient feels an urgent desire to defecate several times after getting up in the morning and following breakfast, after which the bowel may settle.There, may be a feeling of incomplete emptying after a bowel movement. The motion is often described as loose and semiformed rather than watery. Sometimes it is like pellets or rabbit dropping, or pencil shaped. There may be a mucus but never blood (1). 4-Other symptoms: Some patients may also complain of nausea, and other unrelated symptoms such as: backache, feeling tiered, urinary urgency, and the need to pass urine during the night. Patient with unexplained weight loss, or with signs of bowel obstruction (like vomiting) required referral for further investigation (1). When to refer (1, 2) C-Periodicity: -Children IBS tend to be episodic. The patient -Older person with no previous history of IBS might have a history of being well -Pregnant women for a number of weeks or months in -Blood in stools between bouts of symptoms (2). -Unexplained weight loss -Caution in patients aged over 45 years with D-Previous history: changed bowel habit To know whether the patient has -Signs of bowel obstruction consulted the Dr. about the -Unresponsive to appropriate treatment symptoms and if so, what they were -Fever. told. Any history of previous bowel surgery would suggest a need for referral (1). episodic pain occur at usually irregular intervals E-Aggravating factors: Stress appears to play an important role and can precipitate and exacerbate symptoms. Also some types of food may aggravate IBS (1). F-Pregnant women: required referral for further investigation (1). G-Medication (1): To know: 1-What had been tried to treat the condition and whether it produced an improvement. (Unresponsive to appropriate treatment required referral). 2-Other medicines (IBS is associated with depression and anxiety in many patients ). 6 Treatment timescale Symptoms should start to improve within a week (1). Management A-Diet: Patient with IBS should follow the recommendation for a healthy diet (low fat, low sugar, high fiber). In addition patient should avoid any food they know to exacerbate their symptoms (1). Various foods such as beans, and fatty meals, and gas-producing foods such as legumes, may aggravate symptoms in some patients. This has led many patients to exclude these suspected aggravating foods from their diet although the effectiveness of such practices remains controversial (3). B-Antispasmodics: Antispasmodics (table1-14) (2) are the main stay of OTC treatment of IBS. They work by a direct effect on the smooth muscle of the gut, causing relaxation and thus reducing abdominal pain. The patient should see an improvement within a few days of starting treatment (1). 1-Mebeverine: It is given in a dose of 135 mg (1 tablet) three times a day, preferably 20 minutes before meals (1). 2-Alverine citrate: Alverine citrate is given in a dose of 60–120 mg (one or two capsules) up to three times a day (1). 3-Pippermint oil capsules: Capsules containing 0.2 mL of the oil are taken in a dose of one or two capsules three times a day, 15–30 min before meals (1). 4-Hyoscine butylbromide: The recommended dose for adult is one tablet(10 mg) three times a day , although this can be increased to two tablets four a day if necessary (2). Table 1-14: Practical prescribing: Summary of IBS medicines (2) Name of Likely side Drug interactions Patients in which medicine effects of note care is exercised Hyoscine Constipation Tricyclic Glaucoma, and dry antidepressants, myasthenia mouth neuroleptics, gravis and prostate antihistamines and enlargement disopyramide Mebeverine None None None Peppermint oil Heartburn None None Alverine Rash None None 7 C-Laxatives and antidiarrheals: 1-In addition, Bulk-forming and stimulant laxatives can be used to treat constipation predominant (IBS-C) (2). Insoluble fiber (e.g. bran) may exacerbate symptoms and its use should be discouraged (4). 2-Use of OTC antidiarrheals such as loperamide is appropriate only on an occasional, short-term basis (1). D-Compound preparations: Bulking agents are also available in combination with antispasmodics (1). e.g. Fybogel® Mebeverine: effervescent Granules (in sachets), contain ispaghula husk (Bulk-forming laxatives) and mebeverine hydrochloride (4). Dose: 1 sachet in water, morning and evening 30 minutes before food; an additional sachet may also be taken before the midday meal if necessary (4). E-Probiotics: Probiotics such as lactobacillus and Bifidobacterium have also been promoted for IBS. The studies showed that probiotics appear to be effective however the size of the effect need to be established (2). References: 1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 8th edition. 2018. 2-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 5th edition. 2021. 3-Tracey JC, Carmela AW, Tomasz Z J. Irritable Bowel Syndrome Treatment Options. US Pharm. 2012;37(12):45-48. 4-BNF-80. 8