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DIARRHOEA

Alkaline

Acid

Alkaline

Gastrointestinal system

Food passes into the upper part of the small intestine,

called the duodenum, where digestion and absorption of

nutrients continues

Unabsorbed portion then moves down into

the large intestine, and removed from the

body as faecal matter

The Digestive Process

Peristalsis

The Small Intestine

Duodenum

Jejunum

Ileum

The small intestine receives digestive juices

from the liver and the pancreas, completes

the digestion of the nutrients in food,

absorbs the different products of digestion,

and moves the remaining residues to the

large intestine for excretion

The Small Intestine

Gastritis

vs

Gastroenteritis?

The Large Intestine

Caecum

Ascending

colon

Transverse colon

Descending colon

Sigmoid

colon

Rectum

Anal canal

•The reabsorption of water and

electrolytes (e.g. sodium,

potassium, and chloride)

•The formation of faeces

(‘stools’)

•Peristalsis moves bolus towards

rectum

•The storage of (solid) faeces

The Large Intestine

Electrolytes

H2O

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Enterocyte / intestinal

absorptive cells – have a

secretory role. Control ion,

water, lipid, sugar uptake.

Secrete mucin which dissolves in

Water to form mucus

Produce hormones

such as serotonin

The Large Intestine

Constipation vs Diarrhoea

Excess H2O

reabsorbed

Peristalsis

sluggish

Constipation

Constipation vs Diarrhoea

Less H2O

reabsorbed

Peristalsis

rapid

Diarrhoea

Diarrhoea – some facts

Greek διάρροια, meaning "flowing through”

Western society

• Adults: 100 – 200g/day

• Children: 10g/kg/day

Diarrhoea – stool weight >200g/day (subjective analysis!)

Complications

• Dehydration & Electrolyte loss (hypoK, hypoMag)

• Infant mortality

• Vascular collapse (cholera)

99% of all fluid intake (+ GI secretions) are absorbed

• Small changes can cause diarrhoea

In most diarrhoea, >1 mechanism at work

• Osmotic load, secretions, less time/surface area 12

Unabsorbable dietary

material

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ACUTE vs CHRONIC Diarrhoea

ACUTE CHRONIC

Viral infection Drugs

Bacterial infection Irritable Bowel Syndrome (IBS)

Parasitic infection Diet (CHO intol.)

Food poisoning Inflammatory Bowel Disease

Drugs Surgery

Malabsorption syndromes

Tumours

Endocrine tumours

Endocrine disorders

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Dietary factors

DIETARY FACTOR SOURCE

Caffeine Coffee, tea, cola, headache OTC’s

Fructose (> gut’s capacity)

Juice (apple, pear), grapes, honey, dates, nuts, figs, fruit soft drinks, prunes

Hexitols, sorbitols, mannitol

Sugar-free gum, mints, sweet cherries, prunes

Lactose Milk, ice cream, frozen yoghurt, yoghurt, soft cheeses

Magnesium (Mg) Antacids

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Type of diarrhoea Definition

Acute watery diarrhoea Presence of ≥ 3 loose, watery stools within the

past 24 hours

Acute bloody diarrhoea

(or dysentery)

Presence of visible blood and mucous in

diarrhoeal stools

Persistent diarrhoea Episodes of diarrhoea that last for > 14 days

Defined by the WHO as having three or more loose or liquid stools per day, or as having

more stools than is normal for that person

Types of Diarrhoea

Osmotic Diarrhoea

Too much water is drawn into the colon

Drinks with high sugar or salt are highly osmotic

Stops when offending agent stops (alcohol, milk)

Caused by excess magnesium or vitamin C, or undigested

lactose (bowel distension)

• HypoMg = tetany

Lactose intolerance from very high dairy product intake

Excess fructose intake (in fructose malabsorption) – use

fructose foods with a high glucose content (less diarrhoea)

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Secretory Diarrhoea

Increase in active secretion; inhibition of absorption

Cholera toxin the most common cause (chloride ions; Cl-)

Sodium (Na+) follows, and then H2O

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Exudative Diarrhoea

Presence of blood and pus in the stool. This occurs with

inflammatory bowel diseases, such as Crohn's disease

or ulcerative colitis, and other severe infections such as

E. coli or other forms of food poisoning

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Motility-related Diarrhoea

Rapid movement of food through the intestines

(hypermotility)

Hyper-peristalsis

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Inflammatory Diarrhoea

Damage to the mucosal lining or brush border, which

leads to a passive loss of protein-rich fluids and a

decreased ability to absorb these lost fluids.

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Dysentery

Generally, if there is blood visible in the stools, it is not

diarrhoea, but dysentery

Blood indicates invasion of bowel tissue

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Infectious Diarrhoea (‘gastroenteritis’)

Viruses and parasites

• Norovirus the most common cause of viral diarrhoea in adults

• Rotavirus is the most common cause in children under 5 years

• Also Adenovirus and astroviruses

Bacterial diarrhoea

• Campylobacter spp. Salmonella spp. (chicken!) are common causes

• Shigella spp. and some strains of Escherichia coli (both mechanisms)

In the elderly, a toxin produced by Clostridium difficile often

causes severe diarrhoea

Mild, self-limiting (infants vulnerable)

Traveller’s Diarrhoea

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Tissue-damaging Toxin-secreting

Inflammatory Bowel Disease

The two overlapping types here are of unknown origin:

Ulcerative colitis – chronic bloody diarrhoea and

inflammation mostly affects the distal colon near the rectum.

Crohn's disease typically affects fairly well demarcated

segments of bowel in the colon and often affects the end of

the small bowel

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Irritable Bowel Disease (IBS)

Abdominal discomfort relieved by defecation and

unusual stool (diarrhoea or constipation) for at least 3

days a week over the previous 3 months

Approx 30% of patients with diarrhoea-predominant IBS

have bile acid malabsorption

Manage with a combination of dietary changes, soluble

fibre supplements, and/or medications such as

loperamide or codeine

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Warning!

Blood or pus

Abdominal tenderness

Fever

Signs of dehydration

Chronic diarrhoea

Weight loss

Tachycardia

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Aggression factors in diarrhoea

Action on escherichia coli - Rateau study (rabbit model)

• 1/3 of the goblet cells became degranulated

• Accelerated mucus degradation

• Leak of water and electrolytes

• Brush border enzymes were most affected

Mucus

H2O Na+ CI- HCO3-

Saccharase

Ileum infected

by E.Coli

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Restoration of brush border

Action on escherichia coli - Rateau study

- Reduces degranulation of the goblet cells

- Re-establishes a positive absorption balance

- Reverses the fluid flow

- Protects

membrane

enzymes Reduction in cell abnormalities

Reduction in water electrolyte leakage

Maintenance of

enzyme activity

Ileum protected

by anti-diarrhoeal

Diagnostic approach

Diarrhoea in the following situations may require further

investigation:

In infants

Moderate or severe diarrhoea in young children

Presence of blood

Lasts >2 days

Associated non-cramping abdominal pain, fever, weight

loss, etc

Travelers

Food handlers (infect others)

Hospitals, child care centres, geriatric/ convalescent homes

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Management of Diarrhoea

Replacing lost fluid, salts (ORS/ORT) usually sufficient

Intravenously in severe cases (Ringer’s)

Anti-infective agents (mostly viral)

Research does not support the limiting of milk to children

(no effect on duration of diarrhoea)

• WHO recommends that children continue to eat as sufficient

nutrients to support continued growth and weight gain

Continuing eating aids recovery of normal intestinal function

Antidiarrhoeals

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Fluids

Oral Rehydration Solution (ORS) (NaCl) help prevent

dehydration

• 400ml ORS after each bowel movement

• Salted rice water, salted yoghurt drinks, vegetable and chicken

soups with salt

• Water in which cereal has been cooked, unsalted soup, green

coconut water, weak tea (unsweetened), and unsweetened fresh

fruit juices with salt

• Clean plain water can also be given

Drinks high in simple sugars (soft drinks, fruit juices) are

not recommended in children under 5 years of age as

they may increase dehydration

• Rich solution in the gut draws water from the rest of the body,

just as if the person were to drink sea water

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Medications

Antibiotics are beneficial only in specific types of acute

diarrhoea

Antibiotic-associated diarrhoea is a common drug S/E

Bismuth compounds reduce bowel movements in

travellers' diarrhoea, but not the length of illness

Anti-motility agents reduce the duration of diarrhoea

Codeine slows down peristalsis and the passage of

faecal material through the bowels

Codeine, loperamide have antisecretory actions

ABsorbents & ADsorbents

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Diarrhoea in children

Breastfed infants – loose stools common

Gastroenteritis the most common cause

Common mechanisms:

• Osmotic, Secretory, Inflammatory, Malabsorptive

Causes of Acute diarrhoea:

• Antibiotics, bacteria, food (allergy, poisoning), parasites, viruses

Causes of Chronic diarrhoea:

• Anatomic abnormalities, dietary (lactose intol.), immunocompromise,

inflammatory disorders, malabsorption disorders

Certain drugs are not recommended

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Physico-chemical characteristics of

Diosmectite

Diosmectite

• A powder, the particles of which are tiny (+ 1µ)

• Each particle consists of a pile of lamellae or leaves

Stacked layers Layer structure

1 nm

1 of 3 µ

Silica Alumina Silica

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Physico-chemical characteristics of

Diosmectite

Because of its physico-chemical characteristics, Diosmectite has a:

• High aDsorption capacity

• Potent coating capacity

The key physico-chemical properties are:

• The tiny size of the particles

• Their formation into sheets

• Their layer structure

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Physico-chemical characteristics of

Diosmectite

Diosmectite’s Binding Capacity

Staphylococcus haemolytic toxin

Staphylococcus cytotoxic toxin

Strychnine

Study of binding capacity of diosmectine for different toxins

Diosmectite binding sites

Escherichia coli toxin

1

2

3

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Physico-chemical characteristics of

Diosmectite

The adsorption (binding) capacity is due to :

• The ionic structure

• The specific polar nature of diosmectite ‒ In the gastrointestinal tract, the negative electrical charges of clay's

mineral surfaces attract selectively the positively charged toxic molecules, preventing them from crossing the intestinal epithelium and entering the bloodstream.

These interactions may occur at three different sites:

1. Within the layers for single ions

2. Between the layers for flat or small molecules

3. On the periphery for macromolecules

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Physico-chemical characteristics of

Diosmectite

Plastic viscosity:

thixotropism

Liquid state : rupture of bonds

Agitation

Basal

State of raised plastic viscosity

New bonds which contract the molecules together in suspension in an immobile liquid

Semi-solid gel state

Spreading

Agitation

This presentation contains forward-looking statements about the company’s operations

and financial conditions. They are based on Litha Healthcare Group Limited’s best

estimates and information at the time of writing. They are nonetheless subject to

significant uncertainties and contingencies many of which are beyond the control of the

company. Unanticipated events will occur and actual future events may differ materially

from current expectations due to new business opportunities, changes in priorities by the

company as well as other factors. Any of these factors may materially affect the

company’s future business activities and its ongoing financial results.

DISCLAIMER

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