Diarrhea

Diarrheais an increase in the

frequency and looseness of
stool.

Itresults when some factors

impair the ability of the intestine
to absorb water from stool.
Classification
According to:
1. Mechanism
◦ Osmotic
◦ Secretory
◦ Motility
2. Origin
◦ Acute
◦ Chronic
Classification According to Mechanism

Osmotic diarrhea:
◦ when non absorbable solute pulls excess water
into the intestinal tract.
Secretory diarrhea:
◦ When the intestinal wall is damaged, increased
secretions rather than absorption of electrolytes in
the intestinal tract.
Motility disorder:
◦ Decreased contact time of fecal mass with the
intestinal wall
Classification According to Origin
Chronic: (more than 2 weeks).
Due to:
◦ Protozoal infection
◦ IBS
◦ Malabsorption syndrome
◦ Pancreatic disease
QUESTION NO.1
 My child always suffers from
diarrhea after drinking milk or
eating dairy products is it a
serious condition ,how it could
be treated?
 Why milk ?
Milk contain lactose
which needs lactase
enzyme to be digested.
In case of lactase
deficiency undigested
lactose lingers in the
intestine and ferments
causing intestinal
discomfort.
 Treatment :
Drink milk with meals

Use lactaid

Use lactase

For infants try lactose-free infant formula

Try calcium-fortified soy milk

Yoghurt may be safe

QUESTION NO.2
 I am suffering from
Irritable Bowel syndrome
which makes me suffer
from abdominal cramps
and diarrhea, will those
symptoms persist and
how can I avoid them?
IBS( spastic colon):
Is a central or lower abdominal pain
relieved by defecation ,abdominal bloating,
altered bowel habit, tenesmus and passage
of mucus.
Causes:
After GIT infection
Young age
Prolonged fever
Anxiety
Depression
Treatment:
1) Diet
patients are hypersensitive to fats and fructose
soluble fibers e.g.: psyllium may be effective
2) Medications
 Laxative
 Antidiarrheal (opiates, opioids, loperamide)
 Serotonin (agonist or antagonist)
 Antispasmodic (hyoscyamine)
 Anti-depressants
QUESTION NO.3
 3) My child suffering from
diarrhea, can he be contagious
to his siblings?
Causes of Infectious diarrhea
1) Virus
-Rotavirus
-Astrovirus

2) Bacteria and toxins

-Campylobacter jejuni.
-Salmonella
-E.coli
-C.dificile
3) Protozoa
-Giardia lamblia
-E.histolytica
Treatment :
1) Oral rehydration solution
2) Antibiotics (Norfloxacin)
3) Anti- protozoal (Antinal)
4) Anti- secretory agents ( enkephalinase
inhibitor)
QUESTION NO.4
 I am travelling to the
African coast , the next
week . I am afraid of
getting travelers
diarrhea .What are the
possible causes ,
protective measures and
treatment?
Travelers diarrhea(TD):

• Causative agents are usually

bacterial, viral and may be giardiasis.

• TD largely is due to absence of

treated water and poor hygiene.
Treatment of traveler’s diarrhea
1)Quinolones:
-Ciprofloxacin ( Cipro®).
-Levofloxacin (Levaquin®).
2)Subsalicylate(Pepto-Bismol).
3)Alternative drugs:
-Diphenoxylate.
-Atropine (Lomotil®).
-Loperamide (Imodium®).
4)Oral fluids.
QUESTION NO.5
 I heard about
“stomach flu”, what’s
it? What are the
causes, symptoms and
possible treatment?
Stomach flu (Gastro-enteritis):
Inflammation of stomach ,small and large
intestine.
Causes:
-Viruses (Rota , Adeno, Noro , Sapo and
Astro virus).
-Not Caused by Bacteria or Parasites.
Symptoms :
-Watery diarrhea.
-Vomiting.
-Headache.
-Fever.
-Abdominal cramps (stomach ache).
Possible treatment:
-Oral rehydration solution.
QUESTION NO.6
 Vibramycin :

• Doxycyclin 100mg .

• Semi synthetic member of Tetracycline

Antibiotics .

• Inhibits protein synthesis .

• Causes stomach upset.

Velosef 1000
Cephadrine
1st generation Cephalosporin.

Bactericidalantibiotic that inhibits cell

wall synthesis.

Disrupts
normal flora causing Pseudo
-membranous colitis in some cases.
Pseudo membranous colitis or
C.Difficle colitis:
Severe inflammation of the inner lining of colon.
Antibiotic associated colitis:
caused by broad spectrum antibiotics as they
alter the normal flora by:
1) destroying normal intestinal bacteria
2) causing extensive growth of others
ex. Clostridum difficle that change to the active
infectious form producing toxins that are
responsible for diarrhea which characterizes
pseudo membranous colitis.
Characterized by:
- Offensive smelling diarrhea.
- Fever > 38’C
-Abdominal pain and cramps
-Pus in stool
-Complications : Toxic mega colon.

Treated by:
Metronidazole 400 mg/ 8 hours to
restore the balance of bacteria in colon.
Antibiotic-induced diarrhea:

1) intestinal irritation / stomach upset.

2) increased bowel motility.

3) disruption of normal bacterial flora .

QUESTION NO.7
Primpran® ( Metoclopramide )
Uses:
Anti-emetic, Nausea, and GERD.
Causes Diarrhea as it is a prokinetic
drug increasing the gastro-intestinal
motility by stimulating the GIT muscles
via ACH/ DA receptors.
Other drugs causing Diarrhea:

1) Motility diarrhea: decreased contact time of feces in intestine,

low water absorption.
Example: Prokinetics – D2 Antagonists: Domperidone ( motilium )
- Parasympathomimetics: Bethanichol,
Digitalis and Quinidine

2) Secretary diarrhea: intestinal wall damage, resulting in

increased secretion of electrolytes into the intestinal tract.
Examples : - Antibiotics - Chemotherapeutic agents - Colchicine
(gout) – PGs ( secretagouges)

3) Osmotic Diarrhea: extra water is pulled into the intestine.

Examples - laxatives (lactulose -> Laxolac)
- Mg antacids
QUESTION NO.8
When is diarrhea considered chronic?

Acute diarrhea:
◦ Self-limiting in 2-3 days.

Chronic diarrhea:
◦ Loose stool that lasts for more than 2
weeks.
Refer to a Physician when:
Patient is younger than 3 years or
older than 60 years.
Pregnant and breast feeding patients.
Blood or mucus in stool.
Fever (higher than 38 °C).
Weight loss and signs of dehydration.
Duration more than 2 days with no
response to common medication.
Causes of chronic diarrhea:
 Protozoal infection
◦ Entamoeba histolytica
◦ Giardia lamblia
 Diet induced
◦ Lactose intolerance
◦ Spicy food
◦ Caffeine
◦ Fibers
 Pancreatic disease (pancreatitis or pancereatic cancer)
 Endocrine disease (Hyperthyrodism or addisons
disease)
 Intestinal Disorder (IBS or inflammatory bowel disease)
 Medications (chronic laxative abuse or Mg Antacids)
QUESTION NO.9
FDA strategy :
The 2 days cutoff strategy
• The patient should not receive any medication
in the first 2 days.
• Antibiotics are administered rarely as diarrhea
most likely is of viral origin; however, in severe
cases and if stool examination proves the
presence of bacterial or parasite infection
antibiotics are used.
Overuse encourages development of resistance.
 Treatment

Pharmacological 1.kaolin
Non-pharmacological
2.bisthmus subsalicylate
(Fluid replacement)
3.loperamide
Complications of diarrhea:
Dehydration: Dryness, coma,
electrolyte imbalance and kidney
failure.

Occurs due to excessive loss of fluids

and minerals, especially if the intake of
fluids is limited and if diarrhea is
accompanied by vomiting.
QUESTION NO.10
Diagnostic tests for the evaluation of
diarrhea:
 Stool examination and culture (bacteria,
toxins, parasites, and blood)
 Blood test (full blood count, antibodies, and
electrolytes)
 Colonoscopy (to examine entire colon lining )
and sigmoidoscopy (inspection of lower colon
and rectum)
 Fasting test (test for food intolerance or
allergy)
 Barium enema via anus (Barium sulphate to
highlight colon and rectum in X-rays)
QUESTION NO.11
A pregnant patient
suffers from diarrhea
which is not usually
common in pregnancy,
what could be the
causes? Could it be
harmful to the baby?
 Pregnant women are susceptible to viral and
bacterial infection.

Diarrhea in pregnancy:
•Hormonal changes
•Sensitivity to certain foods
•Lactose intolerance
•Certain antibiotics and antacids can cause it
sometimes
•Gastrointestinal problems like inflammatory
bowel disease, irritable bowel syndrome.
 The biggest concern for pregnant women
with diarrhea is the risk of severe
dehydration, which can affect the baby.

Because it can cause :

•Contractions
• Lack of water in the third trimester can also
cause premature labor.
Premature labor can have many health risks
to the newborn baby.
Q
U
E
S
T
I
O
N
NO
.1
2
My infant suffers from diarrhea,
what could be the causes,
prevention measures, and how to
treat it?
Infectious
Viral (Rota virus , Adenovirus, Calicivirus,
Astrovirus, and Influenza
Bacterial ( E.coli , Salmonella, Shigella,
Staphylococcus,Campylobacter)
Protozoal (Entamoeba histolytica )
Ear infection

Non infectious
◦ Food allergy: Milk protein allergy
◦ Lactose intolerance.
◦ Teething and change in mother's diet if
the baby is breastfed.
Prevention measures
1. Health education.
2. Breast feeding.
3. Clean surfaces.
4. Washing hands of infants and parents.
Treatment
5. Rehydration therapy
6. Symptomatic treatment (antispasmodic
and antidiarrheal)
7. BRAT diet
QUESTION NO.13
Dehydration is a serious complication of
persistent diarrhea, especially in infants
as it could be lethal. How could this
imbalance be corrected? How can it be
avoided?
Dehydration more severe in infants due to their
small body mass.
Mild to moderate dehydration  ORS containing
glucose and electrolytes.
Severe dehydration  IV therapy.

Signs of dehydration.
- Dry mouth and tongue
- Crying with no tears.
- High fever.

Avoid certain foods and drinks

QUESTION
NO.14
 What is ORS according
toWHO/UNICEF definition?
 Oral Rehydration Solution

ORS is safe but has no effect on duration of

diarrhea, it acts as fluid replacement.

Fluids to be avoided in ORS

1. Hypertonic fruit juices
2. Drinks (apple juice and powdered drink mixes)
3. Carbonated beverages
4. Caffeine containing drinks
QUESTION

NO.15
What types of OTC
drugs that treat
diarrhea?
 The FDA classified 3 agents as category 1
(safe and effective)

1- Antiprestaltic drugs: Loperamide

(Imodium®).
2- Adsorbents: Kaolin & Pectin (Kapect®).
3- Miscellaneous drugs:
- Bismuth subsalicylate
( Kaopectate®, Pepto-Bismol®).
- Smecta®
- Lacteal fort®
- Entocid®
- Antinal® & Diax®
QUESTION
NO.16
I have been suffering from diarrhea two
days ago, What would you recommend
Immodium ® or Lomotil ®?
ImmodiumR (loperamide)
LomotilR (diphenoxylate , atropine)

They are antiperistaltic contraindicated in

acute bacterial diarrhea as they:
- Decrease clearance of the organism.

- Enhance systemic invasion.

 ImmodiumR
 Precaution:
◦ Pregnancy,Nursing mothers,and with hepatic
impairment.
◦ Allergy to loperamide
◦ If you have stools that are bloody, black, or if you
have diarrhea that is caused by taking an antibiotic.
◦ Drink extra water while you are taking this medication
to keep from getting dehydrated
◦ Talk with your doctor if your symptoms do not improve
after 10 days of treatment.
◦ Imodium can cause side effects that may impair your
thinking or reactions.
 LomotilR
 Its active ingredients are diphenoxylate and
atropine.
 Diphenoxylate is anti-diarrheal and atropine
is anticholinergic.
 Diphenoxylate is chemically related to the
narcotic drug .
 A sub therapeutic amount of atropine sulfate is
present to discourage deliberate overdosage.
 Atropine has no anti-diarrheal properties, but
will cause tachycardia when overused.
QUESTION NO.17
Lomotil® is contraindicated in some
cases?
Lomotil® is contraindicated in the
following cases:
1. Allergy to diphenoxylate or atropine.
2. Presence of jaundice.
3. Diarrhea associated with pseudo-
membranous enterocolitis.
4. Diarrhea caused by antibiotic treatment.
5. Diarrhea caused by enterotoxin producing
bacteria.
QUESTION NO.18
I am taking Lanoxin® for CHF. Lately I
suffered diarrhea and started to take
Kapect®. What do you recommend?
KapectR adsorb drug from GIT

So it is recommended that this product not to

be given within 3 hours of other medication
because it may decrease the absorption of
other orally administered drugs.
QUESTION NO.19
 I am taking Bismuth salicylate for
diarrhea. I noticed some annoying effects.
What are the adverse effects and
contraindications?
Adverse effects:
Grayish charcoal coloring of stool or tongue.
Ringing in the ears (tinnitus).

Some of the risks of salicylism can apply to

the use of bismuth subsalicylate.
 Contraindications:

Pregnant or breast feeding patients.

Patients with black or bloody stool.
Patients with allergy to salicylate.
Patients on anticoagulants should be monitored
closely if taken these products.
It should not be given to children or teenagers
during or after recovery of chickenpox or flu.
QUESTION NO.20
20. I suffered from diarrhea and I was
prescribed Lacteol fort®which caused
me flatulence. Is it necessary to
continue the treatment?
Lactobacillus product containing non-toxin
strains of lactobacillus acidophilus.

Intended to replace the normal bacteria

flora that is lost during the administration
of oral antibiotic.
However, there is little information
to show that these products are
useful.

For antibiotic induced diarrhea as

with increase in bowel organism
patient experience flatulence.