Dr.k.

vishnuvardhan babu
MD
Abnormal frequent passage of loose
stools
OR
Abnormal passage of stools with
increased frequency, fluidity, and
weight, or with increased stool water
excretion
Acute diarrhea
 Sudden onset in a previously healthy person

 Lasts from 3 days to 2 weeks

 Self-limiting

 Resolves without sequelae

Chronic diarrhea
 Lasts for more than 3 weeks

 Associated with recurring passage of

diarrheal stools, fever, loss of appetite,
nausea, vomiting, weight loss, and chronic
weakness
Acute Diarrhea Chronic Diarrhea
Bacterial Tumors
Viral Diabetes
Addison’s disease
Drug induced
Hyperthyroidism
Nutritional
Irritable bowel syndrome
Protozoal
◦ Vibrio cholera
◦ Shigella
◦ Escherichia coli
◦ Salmonella
◦ Campylobacter jejuni
◦ Yersinia enterocolitica
◦ Staphylococcus
◦ Vibrio parahemolyticus
◦ Clostridium difficile
•Rotavirus
•Adenoviruses
•Caliciviruses
•Astroviruses
•Norwalk agents and Norwalk-like
viruses
•Entameba histolytica
•Giardia lamblia
•Cryptosporidium
•Isospora
• Metabolic disease
Hyperthyroidism
Diabetes mellitus
Pancreatic insufficiency
• Food allergy
Lactose intolerance
• Antibiotics
• Irritable bowel syndrome
1) Laxatives
2) Antacids containing magnesium
3) Antineoplastic drugs
4) Antibiotics
a) Clindamycin

b) Tetracyclines

c) Sulfonamides

d) Any broad-spectrum antibiotic

5) Antihypertensives
a) Methyldopa

b) Angiotensin-converting enzyme inhibitors

c) Angiotensin receptor blockers

d) α-adrenergic receptor blockers

 6) Cholinergic drugs
1. Neostigmine

7) Cardiac agents
1. Quinidine

2. Digoxin

8) Nonsteroidal antiinflammatory drugs

9) Misoprostol

10) Colchicine
11) Proton pump inhibitors
12) H2-receptor blockers
 Most of the diarrheal agents are transmitted
by the fecal-oral route
 Cholera: water-borne disease; transmitted
through water contaminated with feces
 Some viruses (such as rotavirus) can be
transmitted through air
 Nosocommial transmission is possible
 Shigellosis (blood dysentery) is mainly
transmitted person-to-person.
 Dehydration
Mild Moderate Severe
Appearance irritable, irritable, lethargy,
thirsty very coma, or
thirsty unconscious
Anterior normal depressed markedly
Fontanelle depressed
Eyes normal sunken sunken
 Dehydration
Mild Moderate Severe
Tongue normal dry very dry,
furred
Skin normal slow very slow
retraction retraction
Breathing normal rapid very rapid
 Dehydration
Mild Moderate Severe
Pulse normal rapid and feeble or
low imperceptible
volume
Urine normal dark scanty
Weight < 5% 6 - 9% 10% or more
loss
 Stool microscopy
 Dark field microscopy of stool for cholera
 Stool cultures
 ELISA for rotavirus
 Immunoassays, bioassays or DNA probe
tests to identify E. coli strains
 Non-pharmacologic therapy:
Dietary management:
1. Discontinue consumption of solid foods and dairy
products for 24 h (valuable in osmotic diarrhea)
2. For patients who are experiencing nausea and/or
vomiting, a mild, digestible, low-residue diet
should be administered for 24 hours.
3. If vomiting is present and uncontrollable with
antiemetics, nothing is taken by mouth. As bowel
movements decrease, a bland diet is begun.
Rehydration and maintenance of water and
electrolytes
 Increase fluid intake (fruit juice – contain glucose
and potassium)
 Oral rehydration solution (ORS). The WHO formula
contains glucose, sodium, potassium, chloride and
bicarbonate in an isotonic fluid.
 Glucose concentrations between 80 – 120 mmol/L
are needed to optimize sodium absorption in the
small intestine.
 Sodium concentration = 75 mmol/L (higher
concentrations may cause hypernatremia)
Dose in mild/moderate diarrhea for adults: 2L/first
24 h followed by 200 ml per each loose stool
 39% reduction in need for IVF
 19% reduction in stool output
 29% lower incidence of vomiting
 Risk of hyponatremia not significant in any
type of diarrhea.
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 Home-made ORS: Sugar or molasses (40 g)
can be used as a substitute for glucose to
prepare home-made ORS. Common salt (5 g)
will be added to it and dissolved in one liter of
clean water.
 Rice-ORS: Rice powder (50 g) can replace the
sugar or glucose. The amount of the other
salts will remain the same. These will be
dissolved in one liter of clean water to prepare
rice-based ORS. Studies showed that rice-
based ORS can reduce vomiting and diarrhea
more in some cases compared to the
conventional ORS prepared with glucose.
• Zinc has an additional modest benefit
• Reduces stool volume.
• Reduces duration of diarrhea.

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• Dose: Elemental Zinc
20 mg/day for 6months and older for 14 days
10 mg/day Between 2-6 months.
• Any of zinc salts e.g., sulphate, gluconate or
acetate may be used. back

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 Indications of antidiarrheal agents:
1. Patients with mild to moderate acute diarrhea
2. Control chronic diarrhea caused by IBS or IBD

Contraindications:
Patients with bloody diarrhea, fever or systemic
toxicity (risk of worsening of the underlying
condition)
Discontinued in patients whose diarrhea is
worsening despite therapy
 Pharmacologic therapy:
Drugs used for the treatment of diarrhea
include
1. Antimotility agents
2. Adsorbents
3. Antisecretory compounds
4. Antibiotics
5. Enzymes
6. Intestinal microflora.
Opioids agonists:
Action in the GIT (mediated by binding to opioid
receptors)
1. Increase segmentation and a decrease
propulsive movement → ↑ intestinal transit
time → ↑ absorption of water and electrolyte →
feces become more solid
2. Antisecretory
3. ↑ tone of the internal anal sphincter
4. ↓ response to the stimulus of a full rectum (by
their central action)
Mechanism of opioid action:

Inhibition of presynaptic cholinergic nerves in

the submucosal and myenteric plexuses
Opioid agonist that has no analgesic properties in standard doses.
Higher doses have central opioid actions. Used in combination with
a subtherapeutic dose of atropine (to prevent abuse)
Contraindications:
1. Children below 2 y (toxicity at lower doses than adults)
2. Obstructive jaundice
Drug interactions:
1. Potentiate the effects of CNS depressants
2. Co-administration with MAO inhibitors→ hypertensive crises
Adverse effects:
1. Caused by the atropine in the preparation and include anorexia,
nausea, pruritus, dizziness, and numbness of the extremities.
2. Prolonged use of high doses may cause dependence
Opioid agonist that does not cross the blood-
brain barrier and has no analgesic properties
and no potential for addiction
Adverse effects:
Abdominal pain and distention, constipation,
dry mouth, hypersensitivity, and nausea and
vomiting.
Adsorbents
 Coat the walls of the GI tract
 Bind to the causative bacteria or toxin, which
is then eliminated through the stool
 Examples: bismuth subsalicylate (Pepto-
Bismol), kaolin-pectin, activated charcoal,
attapulgite (Kaopectate)
1. Kaolin and Pectin:
Kaolin (hydrated magnesium aluminum silicate),
often combined with pectin (indigestible
carbohydrate).
Mechanism of action:
Adsorb bacterial toxins and fluid
Indications:
Acute diarrhea (given after each loose bowel
movement)
Adverse effects:
Not absorbed and has no adverse effects.
2. Bismuth subsalicylate:
Insoluble complex of bismuth and salicylate
Mechanism of action:
Bismuth: antimicrobial
Salicylate: antisecretory
Adverse effects: blackening of tongue and
stools
Mechanism of the anti-diarrheal action:
1. It inhibits the secretion of many GIT hormones,
including gastrin, cholecystokinin, glucagon,
insulin, secretin, pancreatic polypeptide, vasoactive
intestinal peptide, and 5-HT3.
2. It reduces intestinal fluid secretion and pancreatic
secretion.
3. It slows gastrointestinal motility and inhibits
gallbladder contraction.
4. It induces direct contraction of vascular smooth
muscle, leading to a reduction of portal and
splanchnic blood flow.
 Indications in diarrhea:
1. Secretory diarrhea due to carcinoid tumor

2. Diarrhea due to vagotomy

3. Diarrhea caused by short bowel syndrome or

AIDS.
 Adverse effects:
1. Steatorrhea leading to fat-soluble vitamin deficiency (due to
impaired pancreatic secretion)
2. Nausea, abdominal pain, flatulence, and diarrhea due to
alterations in gastrointestinal motility
3. Gall bladder sludge, gall stones or cholecystitis due to
inhibition of gallbladder motility
4. Hyperglycemia
5. Bradycardia.
Anticholinergics
 Decrease intestinal muscle tone and
peristalsis of GI tract
 Result: slowing the movement of fecal matter
through the GI tract
 Examples: belladonna alkaloids (Donnatal),
atropine
Anticholinergics
 Urinary retention, hesitancy, impotence

 Headache, dizziness, confusion, anxiety,

drowsiness

 Dry skin, rash, flushing

 Blurred vision, photophobia, increased

intraocular pressure
 Nonpathogenic micro-organisms.
 Exert a positive influence on the health or
physiology of the host.
 They consist of either yeast or bacteria,
Lacto-bacillus Acidophilus

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 Mechanisms:
1. Protect the intestine by competing with
pathogens for attachment.
2. Strengthening tight junctions between
enterocytes
3. Enhancing the mucosal immune
response to pathogens.

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Indications:

1. Patients with +ve stool culture

2. Patients presented with dysentery

3. Patients with suspected exposure to

bacterial infection.
• Cotrimoxazole has been recommended as the
first line drug for acute bloody diarrhea.
• High resistance of shigella to cotrimoxazole
has been reported.

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 Resistance rates to cotrimoxazole exceed 30%
 Cefixime 20mg/kg/day 5-7 days should be used
instead of quinolones.
 If No response to cefixime in 3 days:;
Ceftriaxone 50-100mg/kg od for 2-5 days.

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 Metronidazole/Tinidazole should be used
when cases of acute dysentery fail to respond
to second line drugs for dysentery such as
cefixime or when a stool examination has
confirmed trophozoites of Entamoeba
hystolitica.

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 Adsorbents decrease the absorption of many
agents, including digoxin, clindamycin,
quinidine, and hypoglycemic agents

 Adsorbents cause increased bleeding time

when given with anticoagulants

 Antacids can decrease effects of

anticholinergic antidiarrheal agents