Pharmaceutical guidelines of patients with pathology of digestive organs. SYMPTOMATIC TREATMENT OF DIARRHEA

DIARRHEA

becoming more frequent (more than 3 times for the last 24 hours, for breast-feeding children more than 5-7 times) or / and dilution of feces

Diarrhea is an increase in the frequency of bowel movements or a decrease in the form of stool (greater looseness of stool). Although changes in frequency of bowel movements and looseness of stools can vary independently of each other, changes often occur in both.

Doctors classify diarrhea as "osmotic," "secretory," or "exudative"

Osmotic - something in the bowel is drawing water from the body into the bowel ("dietetic candy" or "chewing gum" diarrhea, in which a sugar substitute, such as sorbitol, is not absorbed by the body but draws water from the body into the bowel, resulting in diarrhea).

Secretory - occurs when the body is releasing water into the bowel when it's not supposed to. Many infections, drugs, and other conditions cause secretory diarrhea.

Classification (cont’d)

Exudative diarrhea refers to the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and several infections

Distinguish acute and chronic diarrhea

acute (duration less than 2-3 weeks) chronic (duration longer than 3 weeks)

It is important to distinguish between acute and chronic diarrhea because they usually have different causes, require different diagnostic tests, and require different treatment

POSSIBLE CAUSES OF DIARRHEA

In patients with diseases of the gastrointestinal tract

Ulcerative colitis As part of irritable bowel syndrome or other

chronic diseases of the large intestine Crohn's disease (ileitis terminal) intestinal infections Shortened guts syndrome Endocrine dyskinesia Chronic gastritis with decreased secretion

POSSIBLE CAUSES OF DIARRHEA

In healthy individuals Drinking milk in patients with lactase

deficiency Violation of the diet (an abrupt change of diet,

water composition, the use of unripe fruit, overeating)

Scare ("bear's disease") The use of drugs (antibiotics, antacids

containing magnesium salts, potassium preparations, sulphonamides, anticoagulants, digitalis, cholestyramine, sorbitol, mannitol)

Pathogenesis

During normal digestion, food is kept liquid by the secretion of large amounts of water by the stomach, upper small intestine, pancreas, and gallbladder.

Food that is not digested reaches the lower small intestine and colon in liquid form. The lower small intestine and particularly the colon absorb the water, turning the undigested food into a more-or-less solid stool with form.

Increased amounts of water in stool can occur if the stomach and/or small intestine secretes too much fluid, the distal small intestine and colon do not absorb enough water, or the undigested, liquid food passes too quickly through the small intestine and colon for enough water to be removed.

More than one of these abnormal processes may occur at the same time.

Pathogenesis (cont’d)

Some viruses, bacteria and parasites cause increased secretion of fluid, either by invading and inflaming the lining of the small intestine (inflammation stimulates the lining to secrete fluid) or by producing toxins (chemicals) that also stimulate the lining to secrete fluid but without causing inflammation.

Inflammation of the small intestine and/or colon from bacteria or from ileitis/colitis can increase the rapidity with which food passes through the intestines, reducing the time that is available for absorbing water.

Conditions of the colon such as collagenous colitis can block the ability of the colon to absorb water

Clinical symptoms

Sudden onset of bowel frequency associatedwith crampy abdominal pains, and a fever will point to aninfective cause; bowel frequency with loose blood-stained stools to an

inflammatory basis; the passage of pale offensive stools that float, often

accompanied by loss of appetite and weight loss, to steatorrhoea.

Nocturnal bowel frequency and urgency usually point to an organic cause.

Passage of frequent small-volume stools (often formed) points to a functional cause

Threatening symptoms of diarrhea

1. The presence of blood in the stool 2. Feces in the form of "rice broth" 3. Increased body temperature 4. Nausea and vomiting 5. Diarrhea accompanied by severe abdominal pain 6. Diarrhea occurs in several family members 7. Diarrhea lasts for a few weeks 8. Diarrhea is accompanied by loss of consciousness 9. Diarrhea accompanied by severe thirst, dry mouth,

dry skin 10. Diarrhea is accompanied by a small amount of

urine 11. Diarrhea in pregnancy

Signs of dehydration:

Dark urineSmall amount of urineRapid heart rateHeadachesDry skinIrritabilityConfusion

Signs of dehydration in young children :

Dry mouth and tongueSunken eyes or cheeksNo or decreased tear productionDecreased number of wet diapersIrritability or listlessnessSkin that stays pinched instead of

flattening out after being pinched

Acute diarrhea Diarrhea of sudden onset is very common, often short-lived and

requires no investigation or treatment. This type of diarrhea is seen after dietary indiscretions, but diarrhea due to viral agents also lasts 24–48 hours

Travellers’ diarrhea, which affects people travelling outside their own countries, particularly to developing countries, usually lasts 2–5 days;

Clinical features associated with the acute diarrheas include fever, abdominal pain and vomiting. If the diarrhea is particularly severe, dehydration can be a problem;

The very young and very old are at special risk from this. Investigations are necessary if the diarrhea has lasted more than 1

week. Stools (up to three) should be sent immediately to the laboratory for culture and examination for ova, cysts and parasites.

If the diagnosis has still not been made, a sigmoidoscopy and rectal biopsy should be performed and imaging should be considered.

Acute diarrhea (cont’d)

Oral fluid and electrolyte replacement is often necessary. Special oral rehydration solutions (e.g. sodium chloride and glucose powder) are available for use in severe episodes of diarrhea, particularly in infants.

Antidiarrheal drugs are thought to impair the clearance of any pathogen from the bowel but may be necessary for short-term relief (e.g. Codeine phosphate 30 mg four times daily, or loperamide 2 mg three times daily). Antibiotics are sometimes given depending on the organism.

Antibiotics in adult acute bacterial gastroenteritis

Chronic diarrhea

Always needs investigation. All patients should have a sigmoidoscopy and rectal biopsy.

whether the large or the small bowel is investigated first will depend on the clinical story of, for example, bloody diarrhoea or steatorrhoea.

When difficulties exist in distinguishing between functional and organic causes of diarrhoea, hospital admission for a formal 72-hour assessment of stool weights is helpful and will also assist in the diagnosis of factitious causes of diarrhoea.

Antibiotic-associated diarrhea(pseudomembranous colitis)

Pseudomembranous colitis may develop following the use of any antibiotic.

Diarrhoea occurs in the first few days after taking the antibiotic or even up to 6 weeks after stopping the drug.

The causative agent is Clostridium difficile. It is a Gram-positive, anaerobic, spore-forming bacillus and is found as part of the normal bowel flora in 3–5% of the population and even more commonly (up to 20%) in hospitalized people.

Antibiotic-associated diarrhea(pseudomembranous colitis) (cont’d) Pathogenesis

C. difficile produces two toxins: toxin A is an enterotoxin while toxin B is cytotoxic and causes bloody diarrhoea.

It causes illness either after other bowel commensals have been eliminated by antibiotic therapy or in debilitated patients who have not been on antibiotics.

Almost all antibiotics have been implicated but the present increase has been attributed to the overuse of quinolones (e.g. ciprofloxacin).

Hospital-acquired infections remain high, partly due to increased person-to-person spread and from fomites. In recent years new strains of C. difficile with greater capacity for toxin production have been reported. There have been a number of hospital outbreaks with a high mortality.

Clinical features

C. difficile diarrhoea can begin anything from 2 days to a month after taking antibiotics.

Elderly hospitalized patients are most frequently affected. It is unclear as to why some carriers remain asymptomatic.

Symptoms can range from mild diarrhoea to profuse, watery, haemorrhagic colitis, along with lower abdominal pain.

The colonic mucosa is inflamed and ulcerated and can be covered by an adherent membrane-like material (pseudomembranous colitis). The disease is usually more severe in the elderly and can cause intractable diarrhoea, leading to death.

Treatment

metronidazole 400 mg three times daily or

oral vancomycin 125 mg four times daily Causative antibiotics should be

discontinued if possible.

Travellers’ diarrhea

Travellers’ diarrhea is defined as the passage of three or more unformed stools per day in a resident of an industrialized country travelling in a developing nation.

Infection is usually food- or water-borne, and younger travellers are most often affected (probably reflecting behaviour patterns).

Reported attack rates vary from country to country, but approach 50% for a 2-week stay in many tropical countries.

The disease is usually benign and self-limiting: treatment with quinolone antibiotics may hasten recovery but is not normally necessary.

Prophylactic antibiotic therapy may also be effective for short stays, but should not be used routinely.

Purgative abuse

This is most commonly seen in females who surreptitiously take high-dose purgatives and are often extensively investigated for chronic diarrhea.

The diarrhea is usually of high volume (> 1 L daily) and patients may have a low serum potassium.

Sigmoidoscopy may show pigmented mucosa, a condition known as melanosis coli. Histologically the rectal biopsy shows pigment-laden macrophages in patients taking an anthraquinone purgative (e.g. senna).

Melanosis coli is also seen in people regularly taking purgatives in normal doses.

In advanced cases a barium enema may show a dilated colon and loss of haustral pattern.

Phenolphthalein laxatives can be detected by pouring an alkali (e.g. sodium hydroxide) on the stools, which then turn pink; a magnesium-containing purgative will give a high faecal magnesium content.

Anthraquinones can also be measured in the urine. If the diagnosis is suspected, a locker or bed search (while the patient is out of the ward) is occasionally necessary. Management is difficult as most patients deny purgative ingestion.

Purgative abuse often occurs in association with eating disorders and all patients needs psychiatric help. It is sometimes safer not to confront the patient with their diagnosis.

Diarrhoea in patients withHIV infection

Chronic diarrhoea is a common symptom in HIV infection, but HIV’s role in the pathogenesis of diarrhoea is unclear.

Cryptosporidium is the pathogen most commonly isolated. Isospora belli and microsporidia have also been found.

The cause of the diarrhoea is often not found and treatment is symptomatic.

Functional diarrhea In this form of functional bowel disease, symptoms

occur in the absence of abdominal pain and commonly are:

■ The passage of several stools in rapid succession usually first thing in the morning. No further bowel action may occur that day or defecation only after meals.

■ The first stool of the day is usually formed, the later ones mushy, looser or watery.

■ Urgency of defecation. ■ Anxiety, uncertainty about bowel function with

restriction of movement (e.g. travelling). ■ Exhaustion after the ‘morning rush’.

Treatment of functional diarrhea

loperamide often combined with a tricyclic antidepressant prescribed at night (e.g. clomipramine 10–30 mg).

Drugs for treatment of diarrhea

Anastaltic (loperamide) enzyme agents (creon, festal, enzymtal,

enzystal, pancreatin) drugs for oral rehydration (gastrolit, rehydron) Antidiarrheal microbial products, probiotics

(bifidumbacterin, bificol, bifiform, colibacterin, lactobacterin, hilak)

drugs of other pharmacological groups (smecta, antispasmodics)

Pharmaceutical guardianship for diarrhea

When diarrhea is a loss of fluid and electrolytes, so you need prescriptions for oral rehydration

Loperamide administered with caution to patients with impaired liver function

If you experience constipation reception anastaltic drugs must be stopped immediately

In the appointment of loperamide may appear a pain in the lower abdomen, fatigue, lethargy, headache

Pharmaceutical guardianship for diarrhea (cont’d)

On the background of antimicrobial therapy may use probiotics or drugs linex or bifiform because they contain antibiotic-resistant strains of the intestinal flora

Unacceptably to add sugar in oral rehydration solutions (increased osmolarity of the solution and as a result - increased diarrhea)

Since Smecta has adsorbent properties, and may slow or reduce absorption of simultaneously taken drugs. It is recommended to comply with the interval between smecta doses and other drugs

Pharmaceutical guardianship for diarrhea (cont’d)

Simethicone, which is part of enzimtal, pangrol, reduces flatulence

Drugs hilak & hilak forte should not take with milk and other dairy products

Concomitant use of hilak and hilak forte with antacids is unacceptable

Laktobacterin is recommended to drink milk