DIARRHOEA & CONSTIPATION

No organ in the body is so misunderstood, so slandered and maltreated as the colon!

Sir Arthur Hurst, 1935

PRESENTATION BY ASWATHY.T.D

M PHARM PART- I PHARMACY PRACTICE

Introduction

Epidemiology

Etiology

Pathophysiology

Clinical manifestations

Diagnosis

Treatment

Role of pharmacist

Conclusion

References

CONTENTS

INTRODUCTION

Diarrhoea and constipation are common clinical complaints that negatively affect quality of life, reduce work productivity and lead to considerable health-care expenditure.

They are non specific symptoms that may be caused by diet, stress, medication, inadequate fluid intake, a neuromuscular disorder, an endocrine disorder (e.g.,diabetes, thyroid or parathyroid disease) or rarely cancer

About 8-9% of people suffer from chronic constipation and about 4-5% Chronic Diarrhoea .

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DIARRHOEA

What is Diarrhoea ? An increase in the frequency of bowel

movements or a decrease in the form of stool (greater looseness of stool)

Changes in frequency of bowel movements and looseness of stools can vary independently of each other, changes usually occur in both

Diarrhoea in the 21st Century Second most common

cause of morbidity and mortality worldwideWHO estimation (2002), diarrhoeal disease results in:

2.5 million people die annually, mostly children

1.6 million children <5yrs old (in developing countries)

Types of diarrhoea

Chronic diarrhoea

Acute diarrhoea

Generally lasts > 3 weeksMost of the causes are non-infectiousIBS, AIDS, bacterial outgrowth of small int., Colon cancer, Chron’s disease

sudden onset and lasts less than two weeks

90% are infectious in etiology

10% are caused by medications, toxin ingestions, and ischemia

IMPORTANT !!!distinguish between acute and chronic

diarrhoea>>>different diagnostic tests, different

treatments

What are common causes of diarrhoea?

.

Dietary abuse

Food intolerance

Infection by bacteria, virus & parasites

Reaction to medicine

Intestinal disease

Causative PathogensBacterial

Campylobacter jejuni

Salmonella sp.

Shigella

Escherichia coli

Staphylococcal enterocolitis

Bacillus cereus

Clostridium perfringens

Clostridium botulinum

Gastrointestinal tuberculosis

E. Coli bacteria

Salmonella typhimunium

Shigella bacteria

Campylobacter bacteria

Viral

RotavirusNorovirusAdenovirus

Rotavirus

Protozoa

•Entamoeba histolytica• Cryptosporidium • Giardia intestinalis• Schistosomiasis

High Risk Groups

1. Travelers

2. Consumers of certain foods

3. Immunodeficient person

4. Daycare participants

5. Institutionalized person

Why does diarrhoea develop?

Increased secretion or impaired absorption of fluid with in the lumen.

What are the pathohysiologic mechanisms leading to diarrhoea?

a. Change in active ion transport by either decreased sodium absorption or increased chloride absorption.

b. Change in intestinal motility

c. Increase in luminal osmolarity

d. Increase in tissue hydrostatic pressure

Clinical diarrhoeal group

Secretory diarrhoea

Osmotic diarrhoea

Exudative diarrhoea

Altered intestinal transit

Clinical Features

Stools

LooseBlood stainedOffensive smellSteatorrhea (floating, oily, difficult to

flush)

Sudden onset of bowel frequency

Crampy abdominal pain

Urgency

Fever, Nausea, +/- Vomiting

Loss of appetite

Loss of weight

Complications of Diarrhoea

•Dehydration

•Electrolyte deficiency

•Hypovolemia

•Irritation to anus

•Shock

•Cardiovascular collapse

•Hypokalemia

•Metabolic acidosis

Diagnosis

Physical examination

Stool culture

Stool examination, microscopy for ova, cysts, parasites and fecal WBC

Blood tests

Review of your medications

ELISA test

** For unresolved diarrhoea: sigmoidoscopy, rectal biopsy and radiological studies to rule out other organic causes

TREATMENT

Nonpharmacologic managementDiet

Discontinuing consumption of solid foods and diary products for 24 hrs

Frequent feedings of fruit drinks, tea, "flat" carbonated beverages, and soft, easily digested foods (eg, soups, crackers) are encouraged

Rehydration

* Oral rehydration with fluids containing glucose, Na+, K+, Cl–, and bicarbonate or citrate is preferred in most cases to intravenous fluids

* Fluids should be given at rates of 50–200 mL/kg/24 h depending on the hydration status.

* Intravenous fluids (lactated Ringer's solution) are preferred acutely in patients with severe dehydration.

ORS

Ingredients Standard WHO- ORS Mmols/L

Reduced osmolarity ORS Mmols/L

Glucose 111 75

Na 90 75

K 20 20

Cl 80 65

Citrate 10 10

Osmolarity 311 245

Pharmacologic therapyOpiates & their derivatives

A. Loperamide: 4 mg initially, then 2 mg after each loose stool (maximum: 16 mg/d)

B. Diphenoxylate With Atropine: One tablet three or four times daily

C. Codeine, Paregoric:. 15–60 mg every 4 hours as needed; the dosage of paregoric is 4–8 mL after each liquid bowel movement

Adsorbents

Kaolin- pectin mixture: 30-120 mL after each loose stool

Attapulgite: 1200- 1500 mg after each loose bowel movements or every 2 hrs; up to 9000 mg/dayAntisecretory agents

Bismuth subsalicylate: 2 tablets or 30 mL every 30 min to 1 hr as needed up to 8 doses/day

In immunocompromised patients

Octreotide: Initial 50mcg s/c 1-2 times/day & titrate dose based on indication up to 600mcg/day in 2-4 divided doses

Antimicrobial therapy

Shigella- TMP-SMZ, Cipro, Norflox

Salmonella-Quinolones, Ceftrixone

V.cholerae - Doxycycline, Tetracycline, Erythromycin

E. coli-Cipro, norflox

C. difficile-Metronidazole, Vanco

Cryptosporidium- Paromomycin

Isospora- TMP-SMZ, Cyclospora-TMP-SMZ

ROLE OF PHARMACIST

• Avoid dehydration; drink clear fluids, preferably those containing electrolytes and an energy source such as glucose.

• Good hygiene, particularly washing your hands thoroughly after going to the toilet, is essential in case the diarrhea is infectious.

• Do not prepare food for other people, especially babies and old people, while you have acute diarrhea. 

• A carbohydrate diet that includes boiled potatoes or boiled rice may help.

• If the diarrhea does not resolve after a few days, seek medical advice.

Good nutrition and hygiene can prevent most diarrhoea.

SEE YOU………

CONSTIPATION

What is constipation?

Constipation is generally defined as infrequent and/or unsatisfactory defecation fewer than 3 times per week.

Patients may define constipation as passing hard stools or straining, incomplete or painful defecation.

Constipation is a symptom, NOT a disease.

Epidemiology

2-27% of the population has constipation

Constipation affects twice as many women as men

Constipation is more prevalent in non-White persons than in White persons (non-White:White ratio range 1.13--2.89)

Causes of constipation Diet

Lack of exercise

Age

Irregular bowel habits

Drug induced

Disease States/Conditions

Spasam of sigmoid colon

Dysfunction of myenteric plexus

PATHOPHYSIOLOGYA variety of pathogenetic mechanisms can cause constipation:

•Abnormal intrinsic motility

•Lack of luminal factors (stretching, chemical and tactile stimuli)

•Medications •Hormones (very rarely, e.g., in pheochromocytoma)

•Lack of extrinsic innervation (in paraplegia)

•Impaired defecation

symptoms of constipationInfrequent defecation

Nausea

Vomiting

Anorexia

Feeling full quickly

Stools that are small, hard, and/or difficult to evacuate

Rectal bleeding

Weight loss (in chronic constipation)

Diagnosis

Good history is enough for most cases (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs)

Basic laboratory tests: CBC, BS, BUN, Cr, TSH

Structural: Barium enema, Sigmoidoscopy, Colonoscopy

I’m constipated, now what?

Two approaches to consider:

Non-drug Approach Drug Approach

1. Exercise - Fibre in the diet - Fluid Intake

No evidence that increased exercise is beneficial

in severe constipation

Aim for 25-30g fibre/day

Unless dehydrated, increasing fluid does not

relieve chronic constipation and may increase

the risk of fluid overload eg heart or renal failure

The kitchen can help!

Add dry, fresh or canned fruit to cereal

Add legumes to soups casseroles

Include grated vegetables in rissoles,

soups

Choose fruit desserts

Use high fibre snacks, raisin bread, date

scones, carrot, muffins EASY FIBRE SUPPLEMENT

3 TBS unsweetened apple puree1 TBS unprocessed bran2-3 TBS prune juice

Use 1 TBS on breakfast cereal

Psyllium (Metamucil®), Sterculia (Normacol®), Ispaghula

(Fybogel®)

Improve stool consistency and frequency with regular use

Ensure good fluid intake to prevent faecal impaction

Onset of action 2-3 days

Side Effects may include bloating, flatulence, distension

2. Bulk Forming Laxatives

Docusate (Coloxyl®), Paraffin oil (Agarol®)

Efficacy of docusate is controversial

May be useful with anal fissures of

haemorrhoids or when straining is a hazard

Liquid paraffin is not recommended for

treatment of constipation

- risk of aspiration and lipid pneumonia

- long term use may result in depletion of

Vitamins A, D, E and K

3. Stool Softeners & Lubricants

4. Stimulant Laxatives

Senna (Senokot®), bisacodyl (Durolax®,

Bisalax®)

Increase intestinal motility by stimulating colonic nerves

Useful with opioids

Onset of action 8-12 hours

Development of tolerance is reported to be uncommon

Generally considered 2nd line therapy in elderly due to risk of

electrolyte disturbances

Other adverse effects include cramping, diarrhoea, dehydration

5. Osmotic LaxativesLactulose (Duphalac®), Sorbitol (Sorbilax®), PEG products (Movicol®)

Lactulose/Sorbitol

- equally effective at improving stool frequency

- onset of action – up to 48 hours

- metabolised by bacteria flatulence

Movicol® - improves stool frequency and consistency

- iso-osmotic and therefore water and

electrolyte loss is limited

Some precautions with osmotic laxatives

Lactulose contains absorbable sugars and

may adversely affect glycamic control in

diabetics

Overuse may result in dehydration

Monitor for any signs of electrolyte

disturbances

- oedema

- shortness of breath

- increasing fatigue

- cardiac failure

6. Enemas & Suppositories

Used when rapid relief from faecal loading is

required

Induce bowel movements by distension of the

rectum and colon

Frequent use may cause poor rectal tone and

may exacerbate incontinence

Tap water enemas are safest for regular use

Phosphate enemas (Fleet®) increase the risk

of hyperphosphataemia in renal impairment

Glycerine suppositories stimulate rectal

secretion by osmotic action

Helping to prevent constipation

Patient education

Diet and Fluid Intake

Exercise

Effective Bowel Habits

Toileting Facilities

Ensure a laxative is

prescribed with opioids

Imaginative ways to increase fibre:-

• Add dry, fresh or canned fruit to cereal

• Add legumes to soups and casseroles

• Include grated vegetables in rissoles & soups

• Choose fruit desserts

• High fibre snacks eg raisin bread, date scones, carrot muffins

An Effective Fibre Supplement

3 TBS unsweetened apple puree

1 TBS unprocessed bran

2-3 TBS prune juice

Add 1 TBS to breakfast cereal

CONCLUSION

Diarrhoea and constipation are common disorders of GIT that are often self reported by older adults.

Pharmacist is essential in counseling patients on self management of constipation & diarrhoea.

Good nutrition and hygiene can prevent most diarrhoea.

Patients should be instructed to increase fluid intake and participate in regular exercise to prevent constipation.

REFERENCES

o Davidson’s Principle and Practice of Medicine 20th edition by Nicholas.N.Boon, Niki. R.colledge, Brain. R. Walker Page No:677-692

o Harrison’s Principle of Internal Medicine 18th edition, Vol 1 by Longo, Fauci Kasper, Hasper, Jamesoli Page No: 247-255

o Text book of therapeutics- Drug and Disease Management, 7th edition by Eric. T. Herfintal, Dick .R.Gourley; Page No:571-585

o Clinical Pharmacy and Therapeutics, 4th edition by Roger Walker, Cate Whitelsia Page No: 824- 832

owww.authorstreamcomowww.hope.comowww.stueckpharmacy.omowww.healthguiadence.orgowww.nhs.uk/condition..../diarrhoeaowww.bums.ac.ir/..../constipation

Contd…..

THANK YOU