Diarrhea is an increased frequency and decreased consistency of fecal discharge as compared with an individual’s normal bowel pattern. It is often a symptom of a systemic disease. Acute diarrhea is commonly defined as shorter than 14 days’ duration. Persistent diarrhea as longer than 14 days’ duration. Chronic diarrhea as longer than 30 days’ duration. Most cases of acute diarrhea are caused by infections with viruses, bacteria, or protozoa, and are generally self-limited.

1. DIARRHEA
Dr.Raghavendra S.Hegde
D.Pharm., B.Pharm., Pharm.D., R.Ph(KSPC)
Lecturer, Dept of Pharmacy Practice
H.S.K College of Pharmacy,Bagalkot
COMMUNITY PHARMACY PRACTICE

2. Definition
• Diarrhea is an increased frequency and decreased consistency of
fecal discharge as compared with an individual’s normal bowel
pattern.
• It is often a symptom of a systemic disease.
• Acute diarrhea is commonly defined as shorter than 14 days’
duration.
• Persistent diarrhea as longer than 14 days’ duration.
• Chronic diarrhea as longer than 30 days’ duration.
• Most cases of acute diarrhea are caused by infections with
viruses, bacteria, or protozoa, and are generally self-limited.

3. Prevalence and epidemiology
• The exact prevalence and epidemiology of diarrhea is not
well known.
• This is probably due to the number of patients who do not
seek care or who self-medicate.
• However, acute diarrhoea does generate high GP
consultation rates.
• It has been reported that children under the age of 5 years
have between one and three bouts of diarrhoea per year
and adults, on average, just under one episode of diarrhoea
per year.
• Many of these cases are thought to be food related.

4. PATHOPHYSIOLOGY

5. PATHOPHYSIOLOGY
• Diarrhea is an imbalance in absorption and secretion of water
and electrolytes.
• It may be associated with a specific disease of the
gastrointestinal (GI) tract or with a disease outside the GI tract.
• Four general pathophysiologic mechanisms disrupt water and
electrolyte balance, leading to diarrhea;

6. (1) A change in active ion transport by either ↓d Na
absorption↑ cl secretion.
(2) A change in intestinal motility
(3)An ↑ in luminal osmolarity, and
(4) An ↑ in tissue hydrostatic pressure.
 These mechanisms have been related to four broad clinical
diarrheal groups:
1Secretory
2.Osmotic
3.Exudative and
4.Altered intestinal transit.
PATHOPHYSIOLOGY

7. 1.Secretory diarrhea
 Occurs when a stimulating substance
(eg, vasoactive intestinal peptide [VIP], laxatives, or bacterial
toxin) increases secretion or decreases absorption of large
amounts of water and electrolytes.
 Cholera infection stimulates the secretion of negatively
charged chloride ions.
 Sodium and water present in the secretion, help maintain the
charge balance in the gastrointestinal tract.
 In this type of diarrhea, intestinal fluid secretion is isotonic
with plasma.

8. Osmotic Diarrhea

9. Osmotic Diarrhea
• Improper digestion (in case of pancreatic disease or celiac
disease), leaves the nutrients in the lumen that draw water
into the bowel. This condition is called osmotic diarrhea.

10. • Exudative diarrhea occurs with
• Inflammatory bowel diseases, such as Crohn's disease or
ulcerative colitis
• Severe infections such as E.coli or other forms of food
poisoning.
• The stool contains blood and pus.
Exudative

11. Inflammatory
• In inflammatory diarrhea, there is damage to the mucosal lining,
leading to a passive loss of protein-rich fluids and a decreased
ability to absorb these lost fluids.
• It can be caused by
• Bacterial infections,
• Viral infections,
• Parasitic infections, or
• Autoimmune problems such as inflammatory bowel diseases.
• It can also be caused by tuberculosis, colon cancer, and enteritis
• http://www.scientificanimations.com/diarrhea-pathophysiology-
treatment-management/

12. Altered intestinal Transit
• Intestinal motility is altered by reduced contact time in the
small intestine,
• Premature emptying of the colon
• Bacterial overgrowth.

13. Dysentry
• Visible blood in the stools as a result of bowel tissue invasion,
is indicative of dysentery.
• It is often a symptom of Shigella, Entamoeba histolytica, or
Salmonella infection.
• Besides microbial infection, certain non-infectious factors
including
• Lactose intolerance.

14. • IBS,
• Non-celiac gluten sensitivity,
• Celiac disease
• IBD
• Hyperthyroidism,
• Bile acid diarrhea and even certain drugs (laxatives), may also
lead to diarrhea.
Dysentry

15. • The clinical presentation of diarrhea is shown in Table.
• Most acute diarrhea is self-limiting, subsiding within 72 hours.
• However, infants, young children, the elderly, and debilitated
persons are at risk for morbid and mortal events in prolonged or
voluminous diarrhea.
• Many agents, including antibiotics and other drugs, cause
diarrhea (Table ).Laxative abuse for weight loss may also result
in diarrhea.
Clinical Presentation of Diarrhea

16. Clinical Presentation of Diarrhea
• General
• Usually, acute diarrheal episodes subside within 72 h of onset,
whereas chronic diarrhea involves frequent attacks over
extended time periods.
• Signs and symptoms
• Abrupt onset of nausea, vomiting, abdominal pain, headache,
fever, chills, and malaise
• Bowel movements are frequent and never bloody, and
diarrhea lasts 12–60 h.
• Intermittent peri-umbilical or lower right quadrant pain with
cramps and audible bowel sounds is characteristic of small
intestinal disease.

17. • When pain is present in large intestinal diarrhea, it is a
gripping, aching sensation with tenesmus (straining,
ineffective, and painful stooling).
• Pain localizes to the hypogastric region, right or left lower
quadrant, or sacral region.
• In chronic diarrhea, a history of previous bouts, weight loss,
anorexia, and chronic weakness are important findings.
Clinical Presentation of Diarrhea

18. • Physical examination:
• Typically demonstrates hyperperistalsis with
borborygmi and generalized or local tenderness.
• Laboratory tests:
• Stool analysis studies include examination for
microorganisms, blood, mucus, fat, osmolality
• pH, electrolyte and mineral concentration, and cultures.
• Stool test kits are useful for detecting GI viruses,
particularly rotavirus.
• Antibody serologic testing shows rising titers over a 3-
to 6-day period, but this test is not practical and is
nonspecific.
Clinical Presentation of Diarrhea

19. • Occasionally, total daily stool volume is also determined.
• Direct endoscopic visualization and biopsy of the colon may
be undertaken to assess for the presence of conditions such
as colitis or cancer.
• Radiographic studies are helpful in neoplastic and
inflammatory conditions
Clinical Presentation of Diarrhea

20. TREATMENT
• Goals of Treatment:
• To manage the diet
• Prevent excessive water, electrolyte, and acid-base
disturbances
• Provide symptomatic relief;
• Treat curable causes of diarrhea; and
• Manage secondary disorders causing diarrhea.
• Diarrhea, like a cough, may be a body defense mechanism for
ridding itself of harmful substances or pathogens.
• The correct therapeutic response is not necessarily to stop
diarrhea at all costs.
• If diarrhea is secondary to another illness, controlling the
primary condition is necessary.

21. GENERAL APPROACH TO TREATMENT
• Management of the diet is a first priority for treatment of
diarrhea
• Most clinicians recommend stopping solid foods for 24 hours
and avoiding dairy products.
• When nausea or vomiting is mild, a digestible low-residue diet is
administered for 24 hours.
• If vomiting is present and is uncontrollable with antiemetics,
nothing is taken by mouth. As bowel movements decrease, a
bland diet is begun. Feeding should continue in children with
acute bacterial diarrhea.

22.  Rehydration and maintenance of water and
electrolytes are the primary treatment
measures until the diarrheal episode ends. If
vomiting and dehydration are not severe,
enteral feeding is the less costly and preferred
method.
 In the United States, many commercial oral
rehydration preparations are available
GENERAL APPROACH TO TREATMENT

23. Drugs Causing Diarrhea

25. Follow these steps:
(1)Perform a complete history and physical examination.
(2)Is the diarrhea acute or chronic? If chronic diarrhea, go
to Fig 2
(3) If acute diarrhea, check for fever and/or systemic signs
and symptoms (ie, toxic patient). If systemic illness
(fever, anorexia, or volume depletion), check for an
infectious source. If positive for infectious diarrhea, use
the appropriate antibiotic/anthelmintic drug and
symptomatic therapy. If negative for infectious cause,
use only symptomatic treatment.
(4)If no systemic findings, use symptomatic therapy based
on severity of volume depletion, oral or parenteral
fluid/electrolytes, antidiarrheal agents (see Table ), and
diet. (RBC, red blood cells; WBC, white blood cells.)

26. Recommendation for Tx of Chronic Diarrhea

27. Recommendations for treating chronic
diarrhea. Follow these steps:
(1) Perform a careful history and physical examination.
(2) The possible causes of chronic diarrhea are many. These can
be classified into intestinal infections (bacterial or protozoal),
inflammatory disease (Crohn diseas or ulcerative colitis),
malabsorption (lactose intolerance), secretory hormonal
tumor (intestinal carcinoid tumor or vasoactive intestinal
peptide [VIP]–secreting tumors), drug (antacid), factitious
(laxative abuse), or motility disturbance (diabetes mellitus,
irritable bowel syndrome, or hyperthyroidism).

28. (3) If the diagnosis is uncertain, appropriate diagnostic studies
should be ordered.
(4) Once diagnosed, treatment is planned for the underlying
cause with symptomatic antidiarrheal therapy.
(5) If no specific cause can be identified, symptomatic therapy is
prescribed. (RBC, red blood cells; WBC, white blood cells.)
Recommendations for treating chronic
diarrhea. Follow these steps:

29. PHARMACOLOGIC THERAPY
• Drugs used to treat diarrhea are grouped into several
categories:
• Antimotility,
• Adsorbents,
• Antisecretory compounds,
• Antibiotics,
• Enzymes, and
• Intestinal microflora.
• Usually, these drugs are not curative but palliative.

30. Opiates & Opiod derivatives
• Delay the transit of intraluminal content
• Increase gut capacity
• Prolonging contact and absorption.
The limitations of the opiates are
• Addiction potential (a real concern with long-term use) and
worsening of diarrhea in selected infectious diarrheas.
• Loperamide is often recommended for managing acute and
chronic diarrhea.
• Diarrhea lasting 48 hours beyond initiating loperamide
warrants medical attention.

31. Adsorbents kaolin-pectin
• Are used for symptomatic relief .
• Adsorbents are nonspecific in their action they adsorb
nutrients, toxins, drugs, and digestive juices.
• Co-administration with other drugs reduces their
bioavailability.

32. Antisecretory
• Bismuth subsalicylate is often used for treatment or
prevention of diarrhea (traveler’s diarrhea) and has
antisecretory, anti-inflammatory, and antibacterial effects.
• Bismuth subsalicylate contains multiple components that
might be toxic if given in excess to prevent or treat diarrhea.
• Lactobacillus preparation is intended to replace colonic
microflora.
• This supposedly restores intestinal functions and suppresses
the growth of pathogenic microorganisms.
• However, a dairy product diet containing 200 to 400 g of
lactose or dextrin is equally effective in recolonization of
normal flora.

33. Anticholinergic and other drugs
• Atropine, block vagal tone and prolong gut transit time. Their
value in controlling diarrhea is questionable and limited by
side effects.
• Octreotide, a synthetic octapeptide analogue of endogenous
somatostatin,
• is prescribed for the symptomatic treatment of carcinoid
tumors and other peptide secreting tumors.
• The dosage range for managing diarrhea associated with
carcinoid tumors is 100 to 600 mcg daily in two to four divided
doses, subcutaneously, for 2 weeks.
• Octreotide is associated with adverse effects such as
cholelithiasis, nausea, diarrhea, and abdominal pain.

36. EVALUATION OF THERAPEUTIC OUTCOMES
• Therapeutic outcomes are directed to key symptoms, signs, and
laboratory studies.
• The constitutional symptoms usually improve within 24 to 72 hours.
• Elderly persons with chronic illness as well as infants may require
hospitalization for parenteral rehydration and close monitoring.
• The frequency and character of bowel movements should be
checked each day along with the vital signs and improving appetite.

37. • Monitor body weight,
• Serum osmolality,
• Serum electrolytes,
• Complete blood cell count,
• urinalysis, and cultures (if appropriate).
• With an urgent or emergency situation, any change in the
volume status of the patient is the most important
outcome..
EVALUATION OF THERAPEUTIC OUTCOMES

38. • Toxic patients (those with fever, dehydration, and
hematochezia and those who are hypotensive)
• Require hospitalization
• They need IV electrolyte solutions and empiric antibiotics
while awaiting cultures. With quick management, they usually
recover within a few days
EVALUATION OF THERAPEUTIC OUTCOMES