Diarrhoea is a symptom characterized by an

abnormal increase in stool frequency (more

than 3 times daily) or liquidity (> 80% water);
The normal frequency of bowel movements
varies with each individual

Diarrhoea
 bacterial or viral infection through
ingestion of contaminated food or drink;
1. E.Coli, S.aureus toxins mucosal cells
hypersecretion of fluid watery diarrhoea
with little or no fever or other symptoms;

Diarrhoea
2. Invasive E. coli, salmonella and shigella:
directly invade mucosal epithelial cells and
cause an inflammatory reaction less fluid
diarrhoea accompanied by nausea,
vomiting, cramps and sometimes low-grade
fever

Diarrhoea
3. Viral infections, which often affect babies
and young children, also produce watery
diarrhoea
4. Non-infective causes: stress, alcohol, and
hot spicy food
5. Drugs: antibiotics all but varying
degrees. Depends on extent that drug
disrupts normal intestinal microflora
Other: laxatives, misoprostol. Olsalazine,
anticancer, antihypertensive agents

Diarrhoea
 Normal faeces contain 60-85 % water
Water loss during defecation= 70-200 mL/day

In diarrhoea: water loss 4X normal K and Na

loss fall in plasma pH (acidosis) serious
metabolic consequences
Fluid & electrolyte losses are increased if
vomiting also occurs

Diarrhoea
 In babies/children: hazardous as high
proportion of total body weight is lost and
dehydration can occur very rapidly

Elderly are also particularly sensitive to the

effects of fluid and electrolytes loss,
especially if on diuretics

Reduction in blood volume + RAS +

aldosterone (1) loss of K (hypokalemia)
(2) Excessive fluid loss reduction of renal
artery flow renal failure
Diarrhoea
If diarrhoea lasts more than:
72 hours : adults and older children
48 hours : children < 3 years old & elderly
24 hours in children < 1 year old
Refer Immediately in infants under 3 months
old

Diarrhoea
Diarrhoea
 Oral rehydration therapy
(ORT)
Opioids
Adsorpants
Dietary management
In UK: belladonna extract

Diarrhoea
 First line treatment of acute diarrhoea
the very young & elderly (particularly
important)
ORT not intended to relieve symptoms
Use of antidiarrheals (antimotility drugs or
adorbants) is regarded unnecessary and
sometimes undesirable
Use of antidiarrheals (for comfort/convenience)
is used as adjunct to ORT

Diarrhoea
Mode of action:
replace water and electrolytes lost through
diarrhoea and vomiting;
K & Na: replace ions
citrate and/or bicarbonate: correct acidosis
glucose: carrier for Na ions and hence water
across the mucosa of the small intestine

Diarrhoea
 ORT is not intended to stop diarrhoea, but
acute diarrhoea is self-limiting and normally
ceases within 24-48 hours;
ORT can be recommended for patients of any
age, even when referral to a doctor is
considered necessary

Diarrhoea
 the content of 1 sachet or 2 effervescent
tablets should be dissolved in 200-250 ml of
water (freshly bolied and cooled in case of
infants)
discard unused solution 1 hr after
reconstitution or no longer than 24 hrs (if
refrigerated)
Dose, adults: 200-400 ml after every loose
motion, or 2-4 L over 4-6 hrs

Diarrhoea
 Patients may prefer to sip 1-2 tsp every
few minutes rather than drink large
quantities less frequently
children > 2 yrs: cupful (200ml) after every
loose stool
children < 2 yrs: - cupful
Infants: 1-1.5 normal feed volume
Both breast and bottle-fed babies should
continue to be fed normally (without
dilution)
Diarrhoea
 Loperamide, Morphine, Codeine
Mode of action:
1. increase tone of both small and large bowel
and reduce intestinal motility (enhances fluid
and electrolyte reabsorption);
2. increase the sphincter tone and decrease
secretory activity along GIT

Diarrhoea
 It is a synthetic opioid agonist that has a
high affinity for, and exerts a direct action on
opiate receptors in the gut wall;
also has a high first-pass metabolism so very
little reaches the systemic circulation;
effective in reducing the duration of diarrhea
(25 vs 40 hrs with placebo)

Diarrhoea
Indications:
travellers diarrhoea
non-specific acute diarrhoea
chronic diarrhoea associated with
inflammatory bowel disease
AAP does not recommend use in children <
6 years old

Used when patient is afebrile or have mild

fever and does not have bloody stool

Diarrhoea
Dosage & Administration
dosage forms: caplets (2 mg), and liquid (1
mg/5ml)
Dose: 4 mg initially, then 2 mg after each
loose stool/ Do not exceed 16 mg/day
Consult product instructions for pediatric
dose

Diarrhoea
 Contraindication
Loperamide should not be used in patients
with fecal leukocytes, high fever, or blood or
mucus in the stool (dysentery);
Loperamide may cause paralytic ileus in
patients with desentery

Paralytic ileus: paralysis or inactivity of the intestine that prohibits the

passage of material within the intestine. May be a result of anticholinergic
drugs, injury or surgery

Diarrhoea
 Kaolin: a natural hydrated aluminum
silicate. Not absorbed from GIT, 90%
metabolized in gut and excreted in faeces
Attapulgite is another naturally occur clay
mineral, consisting of hydrous Mg-Al-
silicate;
kaolin & attapulgite have varying and
relatively weak adsorptive properties in
respect to diarrhoea producing bacteria

Diarrhoea
 Pectin is a purified carbohydrate obtained
from the rind of citrus fruit of pomace
(crushed apple); its mode of action is
uncertain;
Bismuth subsalicylate: claimed to pocess
adsorbent properties; large doses are
required and salicylate absorption may occur
(be cautious!)

Diarrhoea
Mode of action:
1. adsorb the microbial toxins and micro-
organisms to their own surfaces
drugs not absorbed from the GIT toxins
and MOs are excreted in stool;
2. Hydrophilic adsorbents (e.g. pectin and
bulk-forming agents; ispaguala, methylcellulose, and
sterculia), bind water within the intestine
causing watery stool to become more
formed
Diarrhoea
 the main constituents in the antidiarrhoeal
preparations for young children (whom
opiates and antimuscarinics are
contraindicated);
not absorbed from GIT harmless and safe
to use
Debate: reduce evacuation of faeces-
prolong presence of pathogens/toxins in
bowel. Adsorption: non-specific process
(medicines)

Diarrhoea
 Traditionally: withdrawal of feedings, initiation
of clear liquids, with a slow reintroduction of
feedings over several days
However, oral intake does not worsen
diarrhoea, clinically significant nutrient
malabsorption is uncommon (80-95% CHO, 70%
of fat and 75% of the nitrogen from protein) in acute
diarrhoea and bowel rest is generally not
necessary

Diarrhoea
 Early refeeding in combination with
maintenance ORS therapy, improves
outcomes of acute diarrhoea in children by
reducing the duration of diarrhoea, reducing
stool output and improving weight gain

Diarrhoea
 most infants and children with diarheoa can
tolerate full-strength breats milk and cows
milk;
The familiar BRAT (bananas, rice, apple sauce
and toast) is frequently prescribed-
insufficient calories, protein and fat especially
in strict or prolonged use and is not
recommended by AAP

Diarrhoea
Diet should include:
complex carbohydrate-rich foods (e.g. rice,
potatoes, bread, cereals)
Yogurt
lean meats
Fruits and vegetables

Diarrhoea
Avoid:
fatty foods
foods rich in simple sugars that may cause
osmotic diarrhoea
spicy foods that may cause GI upset
Caffeine (WHY??)

Diarrhoea
 diphenoxylate (with atropine), a weak
analog of meperidine .may induce
sedation

Difenoxin: active metabolite of

diphenoxylate available as prescription
medication
Loperamide.less sedationmay not
cross BBB.

Diarrhoea
 should not be used in patients with severe
ulcerative colitis, since toxic megacolon may
be precipitated
may prolong duration of diarrhea in patients
with Shigella or Salmonella infection
in patients with irritable bowel syndrome
with predominant diarrhea, loperamide in
doses of 2-4 mg QID may lead to
substantial clinical improvement (combined
with fiber, use of anticholinergic agents, &
supportive counseling)
Diarrhoea
 Kaolin & pectin are also widely used.
adsorb compounds from solution,
binding potential intestinal toxins.
are much less effective than
antidiarrheals
may interfere with absorption of other
medications.

Diarrhoea
Diarrhoea
34
Probiotics are live organisms that are ingested
to provide therapeutic or preventative benefit
for the host. The most commonly used are
the lactic acid-producing bacteria
bifidobacteria and lactobacilli. Probiotics also
include the yeast Saccharomyces boulardii.
Probiotics are commonly promoted to
strengthen the immune defenses.

Diarrhoea
35
 Beneficial microbes such as bifidobacteria live in
the intestinal ecosystem with potentially
pathogenic bacteria. Beneficial microbes prevent
the overgrowth of bad bacteria by producing
antimicrobial agents. Additionally, beneficial
microbes competitively limit pathogenic bacterial
overgrowth by occupying receptor sites and vying
for space and nutrients. Beneficial microbes may
also increase intestinal production of mucin,
which stimulates the production of mucus,
forming a protective barrier on the intestinal
lining

Diarrhoea
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37
Bifidobacteria are anaerobic, rod-shaped,
gram-positive bacteria. Bifidobacteria are the
most prominent beneficial microbes in the
colon. Bifidobacteria produce antimicrobial
substances that have a broad spectrum of
antimicrobial activity

Diarrhoea
38
 Bifidobacteria that are commonly used as
probiotics include Bifidobacterium longum, B.
breve, B. infantis, B. bifidum, B. lactis, and B.
adolescentis. Bifidobacteria supplements are
most commonly combined with other
probiotics. Lactobacilli are a group of gram-
positive rods that are obligate and facultative
anaerobes. Lactobacilli are in the colon in
much lower numbers than bifidobacteria.
Lactobacilli also produce a range of
antimicrobial agents. Lactobacilli that are
commonly used as probiotics are Lactobacillus
rhamnosus, L. acidophilus, L. casei, L. reuteri,
and L. bulgaricus. Lactobacilli supplements are
Diarrhoea
39
 Other bacteria sometimes used as probiotics
include Streptococcus thermophilus and
Leuconostoc species. The yeasts
Saccharomyces boulardii and S. cerevisiae are
also used

Diarrhoea
40
 Probiotics may be useful as adjunctive treatment
of adults and children with infectious diarrhea.
Several species of Lactobacillus seem to reduce
the duration of diarrhea, particularly in rotaviral
infections. For antibiotic-associated diarrhea,
Lactobacillus rhamnosus GG, S. boulardii, and
probiotic mixtures appear to be effective
prophylactic agents. Given along with antibiotics,
these probiotics can reduce the incidence of
diarrhea by about 60% to 65%. The effectiveness
of probiotics on treatment of antibiotic-
associated diarrhea is less clear.

Diarrhoea
41
 Results of studies looking at
probiotics for travelers diarrhea have
been mixed. Studies using
Lactobacillus species have shown very
modest or no effect. Combination
treatment with L. acidophilus, L.
bulgaricus, B. bifidum, and S.
thermophilus may be better for
reducing the frequency of diarrhea, but
there have been no head-to-head
comparisons with single agents. S.
boulardii also may modestly reduce
Diarrhoea
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