Acute & Chronic Diarrhea and Constipation: Approach to Management

1. GASTROENTEROLOGY:
ACUTE & CHRONIC
DIARRHOEA and CONSTIPATION
By
Dr Kemi Dele
Dept. Family Medicine
Dora Nginza Hospital

2. Disorders of the
Gastrointestinal
Tract

4. DIARRHOEA

5. Introduction
• Diarrhoea is a variation from normal bowel movements with stools of
increased frequency and/or decreased consistency.
• Increase in frequency (> 3 loose stools/day),
• Increase in volume/size (>200 g /day) or
• loosening of bowel movements.

6. Epidemiology
• Diarrhoea is a common complaint that affects nearly all patients at
some point in their lives.
• It has a higher incidence of morbidity and mortality in patients at the
extremes of age and in immunosuppressed populations.
• It is commonly categorized as merely a bothersome symptom,
however, it can be fatal if not properly managed.
• Each year an estimated 2 billion cases of diarrheal disease and 2.5
million deaths due to diarrhoea-related illness occur worldwide

7. Classification of Diarrhoea: FREQUENCY
• FREQUENCY CLASSIFICATION
• Acute diarrhoea: up to 14 days in duration
• Persistent diarrhoea: >14 days in duration(2-4 weeks)
• Chronic diarrhoea: >30 days in duration

8. Mechanism:
Secretory
Diarrhoea
Occurs when a substance either
decreases absorption or increases
secretion of large quantities of water and
electrolytes in the gastrointestinal tract
i.e. Disordered electrolyte transportation
Leads to large stool volume (>1 L/d)
May be caused by bacterial toxins,
laxatives, or excess bile salts

9. Mechanism:
Osmotic
Diarrhoea
Occurs when a poorly absorbed
substance retains intestinal fluids and
leads to an influx of water and
electrolytes into the lumen
May be caused by lactose intolerance or
ingestion of magnesium-containing
antacids or poorly soluble
carbohydrates (lactulose); Sulphate,
Phosphate Mannitol, Sorbitol, Lactase
Deficiency, Lactulose
Unlike other mechanisms, fasting causes
diarrhoea to stop

10. Mechanism:
Exudative
Diarrhoea
Occurs when an inflammatory process in
the GI tract causes discharge of mucous,
serum proteins, and blood into the gut,
and discharged substances are excreted
in the stool
Absorption, secretory, or motility
functions are altered to accommodate
large stool volume

11. Mechanism:
Motor
Occurs when altered intestinal motility leads
to:
reduction in contact time of chyme (semifluid
combination of gastric fluids and partially
digested food) in the small intestine;
premature emptying of the colon;
and bacterial overgrowth.

12. Other
mechanisms
Diarrhoea may also be caused by increased
contact time, which leads to overgrowth of
faecal bacteria and rapid dumping of chyme
into the colon that is unable to absorb water
It may occur with bypass surgery, intestinal
resection, or administration of
metoclopramide
It is important to rule out faecal
incontinence

13. Causes of Diarrhoea: Secretory
• Bacterial toxins
• Abnormal motility
• DM-related dysfunction
• IBS
• Post-vagotomy diarrhea
• Medications, stimulant laxative
abuse, toxins
• Malignancy
• Colon CA
• Lymphoma
• Rectal villous adenoma
• Idiopathic
• Epidemic (Brainerd)
• Sporadic

14. Causes of Diarrhoea: Secretory, cont.
• Diverticulitis
• Ileal bile acid malabsorption
• Vasculitis
• Congenital chloridorrhea
• Inflammatory
• Microscopic colitis
• Endocrinopathies
• Hyperthyroidism
• Adrenal insufficiency
• Cardinoid syndrome
• Gastrinoma, VIPoma,
Somatostatinoma
• Pheochromocytoma

15. Causes of Diarrhoea: Osmotic
• Ingestion of poorly absorbed agent
• Carbohydrate malabsorption (eg, lactase deficiency, diet high in
fructose or sugar alcohols)
• Osmotic laxatives (Mg, PO4, SO4)
• Loss of nutrient transporter (eg, lactase deficiency)

16. Causes of Diarrhoea:
Inflammatory/Exudative
• IBD (Crohn’s, UC)
• Ischemic colitis
• Malignancy
• Colon CA
• Lymphoma
• Diverticulitis
• Radiation colitis
• Infectious
• Invasive bacterial (Yersinia, TB)
• Invasive parasitic (Amebiasis,
strongyloides)
• Pseudomembranous colitis (C diff
infection)
• Ulcerating viral infections (CMV, HSV
• Protozoal:
• Cryptosporidium

18. Common medications and toxins associated
with diarrhoea
• Antibiotics
• Anti-neoplastic agents
• Antiretrovirals
• Metformin
• NSAIDs, ASA
• Acid-reducing agents (H2 blockers, PPIs)
• Colchicine
• Theophylline
• Caffeine
• Alcohol
• Anti-arrhythmics (eg, digitalis, quinidine)
• Beta blockers
• SSRIs
• Furosemide
• Prostaglandin analogs (ie, misoprostil)
• Amphetamines
• Levothyroxine
• Narcotic/opioid withdrawal
• Magnesium-containing antacids

19. Non-infectious diarrhoea
• Diarrhoea is classified as non-infectious when symptoms worsen or become
chronic in the absence of an identifiable infectious organism – virus, bacterium,
protozoan.
• Infectious aetiologies may be ruled out with a negative stool culture and testing
for ova and parasites
• Non-infectious diarrhoea can occur
1. acutely due to medication and food intolerance or
2. chronically due to primary gastrointestinal (GI) disease, such as inflammatory
bowel disease.

20. Lactose Intolerance
• Lactose intolerance occurs when lactose is not properly absorbed,
travels to the intestine, and is used as an energy source for bacteria
residing in the intestinal tract.
• Undigested lactose creates an osmotic pull in the GI tract that leads to
water retention in the bowel and subsequent diarrhea.
• As with all food intolerances, avoidance of the causative food products
is highly recommended

22. Irritable bowel syndrome (IBS)
• It is a relapsing and remitting disorder of the bowel associated with
abnormal defecation and abdominal discomfort/pain
• To diagnose IBS, patients must be symptomatic for at least six months

23. Non-infectious diarrhoea: Approach to
Management
• Hydration and diet management:
• The main component of treatment for acute non-infectious diarrhoea
is hydration therapy to maintain water and electrolyte balances
despite the loss of important salts in the stool.

24. Non-
infectious
diarrhoea:
Approach
to
Managem
ent cont.
Symptomatic treatment:
Loperamide (Imodium) is an OTC antidiarrheal
that can be used for symptom management in
adult patients with acute non-infectious
diarrhoea in the absence of bloody stools or
fever.
Loperamide is administered as a 4-mg dose,
followed by 2 mg after each unformed stool,
with a maximum total dose of 16 mg/d.

25. Infectious diarrhoea
• Infectious diarrhoea is defined as diarrhoea due to infectious
aetiology, which is commonly associated with symptoms of nausea,
abdominal cramps, and vomiting.
• Causative agents for this infection include viral, bacterial, and
protozoal sources, which may be passed through contaminated food
and drinks or by fecal-oral contamination via sexual intercourse,
community pools, poor water sanitation, gardening, and other
sources.

26. Infectious diarrhoea cont.
• Those at risk for infectious diarrhoea include
• immunocompromised patients,
• extremes of age,
• travellers,
• patients in chronic care facilities,
• those with altered GI physiology (including patients taking proton
pump inhibitors and antibiotics)

27. Infectious diarrhoea cont.
• Infectious diarrhoea can be subclassified as either watery or bloody
diarrhoea (dysentery)
• Watery diarrhoea tends to be less severe than bloody diarrhoea,
• Norovirus, Enterotoxigenic E coli (ETEC) and Vibrio cholera are leading
causes of watery diarrhoea.
• Dysentery is associated with more severe complications and is commonly
caused by Shigella species and Salmonella bacteria.
• Some species such as Escherichia coli may cause either watery or bloody
presentations

28. Infectious diarrhoea: Viral diarrhoea
• Viral sources are the leading cause of diarrhoea worldwide.
• Viral gastroenteritis affects the stomach and small intestine and
commonly presents with diarrhoea and nausea.
• It is commonly associated with fever, nausea, vomiting, watery
diarrhoea, and abdominal pain

29. Initial Evaluation: History
• Duration, pattern, epidemiology
• Severity, dehydration
• Stool volume & frequency
• Stool characteristics (appearance, blood, mucus, oil droplets, undigested food
particles)
• Nocturnal symptoms
• Faecal urgency, incontinence
• Associated symptoms (abdominal pain, cramps, bloating, fever, weight loss, etc)
• Extra-intestinal symptoms

30. Initial Evaluation: History, cont.
• Relationship to meals, specific foods, fasting, & stress
• Medical, surgical, travel, water exposure history
• Recent hospitalizations, antibiotics
• History of radiation
• Current/recent medications
• Diet (including excessive fructose, sugar alcohols, caffeine)
• Sexual orientation
• Possibility of laxative abuse

31. Initial Evaluation: Physical Examination
• Most useful in determining severity of diarrhea
• Orthostatic changes
• Fever
• Bowel sounds (or lack thereof)
• Abdominal distention, tenderness, masses, evidence of prior surgeries
• DRE
• Skin, joints, thyroid, peripheral neuropathy, murmur, edema

32. Initial Evaluation: Physical Examination
Vital signs
Orthostatic signs (feeling
lightheaded or dizzy after
standing up, blurry vision,
weakness, fainting (syncope),
confusion, nausea)
hyperventilation, fever
Volume status
Skin tenting, dry mucous
surphases, tachycardia,
hypotension, mental status
Abdominal and
rectal exam.
Hepatomegaly, Distension,
Bowel sounds, Tenderness,
Masses, evidence of prior
surgeries

33. Investigations
• FBC with differential
• Serum electrolytes,
• Liver function tests,
• Calcium, Magnesium, Phosphorus,
• TSH, total T4,
• INR/Prothrombin time.
• HIV
• Nutritional Studies: Iron, Serum
Folate Vitamin B12,
• Vitamin D
• ESR, CRP,
• Others Amoeba Ab, anti-
transglutaminase IgA Ab, anti-
endomyseal IgA Ab,

34. Investigations
• Anaemia - in malabsorption syndrome. (vitamin B12, folate, iron) and
inflammatory conditions.
• Hypoalbuminemia - in malabsorption, protein-losing enteropathies, and
inflammatory diseases.
• Hyponatremia and metabolic acidosis – profound secretory diarrhoea.
• Malabsorption of fat-soluble vitamins may result in an abnormal prothrombin
time, low serum calcium, or abnormal serum alkaline phosphatase.
• Hormone levels - gastrin, VIP, somatostatin, cortisol, neurokinins, calcitonin

35. Investigations: Stool studies
• Culture (more useful only for acute),
• Ova &Parasite
• Giardia Antigen,
• Clostridium difficile
• Coccidia,
• Microsporidia,
• Cryptosporidiosis
• Fecal occult blood

36. Investigations: Stool studies, cont.
• Faecal leukocytes (or marker for neutrophils: lactoferrin or calprotectin)
• Stool electrolytes for osmolar gap = 290 – 2[Na + K]
• Stool pH (<6 suggests CHO malabsorption due to colonic bacterial
fermentation to CO2, H2, and short chain FA)
• Fat content (48h or 72h quantitative or Sudan stain)
• Laxative screen (if positive, repeat before approaching

37. Imaging
• Imaging
• Abdominal X-ray series
• Abdominal CT/MRI or CT/MR enterography
• Upper gastrointestinal lseries
• Endoscopy vs Push Enteroscopy with small bowel biopsy and aspirate
for quantitative culture
• Colonoscopy vs Flexible Sigmoidoscopy, including random biopsies

38. Treatment Considerations
• Correct dehydration and electrolyte deficits
• Oral rehydration therapy (cereal-based best)
• Sports drinks + crackers/pretzels
• Metronidazole is used for the management of a number of parasitic and
anaerobic conditions.
• Metronidazole is associated with GI side effects such as nausea, diarrhoea,
metallic taste, and abdominal discomfort.
• Generally, empiric course of antibiotics is not useful for chronic diarrhea

39. Treatment Considerations
Empiric trials of (in appropriate clinical setting):
• Dietary restrictions
• Loperamide
• Diphenoxylamin
• Opiates (codeine, morphine, tincture
of opium)
• Bile acid binding resins
• Clonidine (diabetic diarrhea)
• Octreotide (for endocrinopathies,
dumping syndrome, chemotherapy-
induced diarrhea, AIDS-related
diarrhea)
• Fiber supplements (psyllium) and pectin
• Pancreatic enzyme supplementation

40. CONSTIPATION

41. Introduction
• Constipation is a symptom, NOT a disease.
• It has many causes
• It may be a sign of undiagnosed disease

42. Introduction, cont.
• Patients definition & concept about constipation can be different
• Patients definition:
• Straining 52%,
• hard stools 44%,
• Infrequent stool 32%
• Misconception:
• 62% believe that daily defecation is necessary to good digestive health

43. Definition
• Any of two of following symptoms for at least 3 month (not necessarily
consecutive) in a year
• Straining
• Hard or lumpy stool
• Use of digital rectal manoeuvres
• Sensation of anorectal blockage
• Sensation of incomplete evacuation
• Fewer than 3 defecation per week

44. Causes of
constipation
↓ fiber diet: most common
↓ liquid intake: 8 glasses/d is needed
↓ Exercise: bedridden, coma
Ignoring urge to defecate
Systemic: Hypothyroidism, DM, Uremia,
pregnancy, hypercalcemia, Hypokalemia
Neurological: Stroke, Parkinsonism, Multiple
sclerosis, Senility

45. Causes of
constipation,
cont.
GI-related:
IBS, Haemorrhoid, Anal fissure, Anorectal &
Colorectal carcinoma, obstruction
Medication: Opiate, Anticholinergics, Al(OH)3,
Iron, cholestyramine, Antihypertensive drugs
(CCBs, diuretics), relaxants, chronic use of
laxatives, Antiepileptics, progesterone
Uncertain: idiopathic chronic constipation

47. 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

48. Diagnosis
•CBC,
•Electrolytes,
•Urea & Creatinine
•TSH
Basic
laboratory
tests:
•Barium enema,
•Sigmoidoscopy,
•Colonoscopy
Imaging:

49. PREVENTION
• High fibre diet - beans, whole grains, cereals, fresh fruits (contain the
natural laxative sorbitol), vegetables
• Limit foods with no fibre (cheese, meat, sweets, processed foods)
• Minimum fluid consumption of 1500mL daily
• Regular, private toilet routine
• Use of a laxative if using constipating medication or in presence of
diseases associated with constipation

50. Treatment

51. Treatment options
• Two approaches to consider:
• Non-drug Approach
• Drug Approach

52. Non-drug Approach
• Initial treatment: Lifestyle modification
• ↑fluid intake
• >25 g of fibre/day
• Fiber-bulk/distension-stool propulsion/ Effect may take weeks/ Adverse
effects: bloating, flatulence
• Exercise
• Regular bowel regimen pattern

53. Therapeutic options: Drug Measures
• Bulk-forming Agents
• Emollients/Stool Softeners: Provide moisture to stool
• Osmotics: Draw water into colon
• Hyper-osmotics
• Stimulants: Cause muscle contractions in intestines

54. Drug classes
• Those causing water evacuation in 1-6 hr
• Caster oil, Saline cathartics, PEG lavage solutions
• Those causing soft or semi fluid stool in 6-8 hr
• C-lax, Bisacodyl
• Those causing softening of stool in 1-3 days
• Psyllium, Lactulose, Mineral oil, Decussate

55. Bulk-Forming Agents
• the safest agents
• suitable for long-term use
• administered with a full glass of water or juice
• Do not use if patient is dehydrated or fluid restricted
• drug of choice for prevention; not for immediate relief
• Increase volume of stool
• Stimulate natural intestine peristalsis
• Lasts 12-24 h (even 3 days)
• Examples Psyllium, Methylcellulose, Dextran

56. Emollients/Stool Softeners
• Used for prevention not for immediate relief
• Anionic surfactants
• Decrease stool surface tension,
• Increase fluid secretion into intestine
• Lasts 1-3 days
• Example: Docusate
• SE: GI cramp

57. Lubricants
• Liquid Paraffin
• Inhibition of fluid reabsorption from colon
• Stimulation of peristaltic activity
• Softening of stool
• lasts 6-8 h
• 15-45 ml PO, or rectal
• SE: Aspiration (neonate, Geriatrics, before sleep), malabsorbtion (lipid soluble
Vit.), Anal pruritis, staining

58. Stimulant laxatives
• Bisacodyl (Dulcolax)
• Stimulates myenteric mucosal nerve plexus of the colon – rhythmic muscle
contractions
• Intermittent use - if osmotic laxatives fail or are not tolerated.
• usually given at bedtime (Oral: 6-8hr, Supp: 15-60min) – provide overnight relief
• Interactions: Milk, Antacids (EC)
• SE: Cramp, fluid and electrolyte imbalance
• Contraindication: pregnancy, lactation

59. Osmotics
• Milk of Magnesia (MOM), Mgso4 (Mg: Osmotic, Release cholecystokin)
• Indications: Antacid (5-15 ml PRN), inLaxatives (30-60 ml)
• Onset: 3-6 hr
• Administer with sufficient water to prevent dehydration.
• Limitations: frequent diarrheal, electrolyte abnormalities.
• Interactions: Quinolones, Tetracycline, Fe, EC drugs (bisacodyl, sulfasalazine)
• Breast-feeding: can be used

60. Hyperosmotics
• Glycerin, Lactulose, mannitol, Sorbitol
• Lactulose:
• Very safe to use long term;
• Takes 1-2 days to work.
• SE – bloating, flatulence, abdominal cramp, diarrhea, electrolyte
imbalance

61. Hyperosmotics cont.
• Glycerine
• Is very safe and acceptable for intermittent basis particularly in infants
• Quick onset of action (30-60 minutes).
• Less effective if the stool is dry and hard.
• Suppository: 1g, 3g

62. Tap-water enema
• 200 ml results in a bowel movement within 0.5hr
• Soapsuds are no longer recommended (proctitis, colitis)

63. Acute constipation
Glycerin suppository Sorbitol powder
Bisacodyl
(Dulcolax)
Anthraquinones ( C-
lax)
Saline laxative
(MOM)
Tap-water enema
If laxative treatment
is required for > 1
week, refer to a
physician

64. Chronic
constipation
Most common in
bedridden or
geriatrics
Choice: Psyllium (with
enough liquids)
Low doses of other
laxatives: C-lax,
MOM, Sorbitol,
Lactulose

65. Constipation
in
hospitalized
patients
May be related to general
anesthesia or opiates
Glycerin suppository
Milk of magnesium
Tap water enema

66. Constipation
in infants &
children
If constipation is a
persistent problem:
Consider neurological,
metabolic or
anatomical
abnormalities
If No:
Approach as adults

67. chronic
idiopathic
constipation
Cisapride (also
for Parkinson's
disease)
Erythromycin

68. Summary
• Underlying causes of constipation should be considered
• Foundation of treatment is diet and psyllium
• Acute constipation may be treated with tap-water enema or glycerin
suppository, if needed, oral sorbitol, low dose bisacodyl or C-Lax
• Approach for chronic constipation is use of psyllium and if needed,
intermittent low-doses of other drugs

69. Thank You For Listening