Diarrhea & Constipation are two common symptoms that occur everyday in any country. They may indicate simple to chronic cases in the beginning. However, right treatment that carried out may help patient solve it, detect any abnormalities and prevent serious further problems later.

1. DIARRHOEA
&
CONSTIPATION
NURHANANI BINTI ABD HALIM
PHARMACY ASSISTANT
(PHARMACY SERVICES)

2. DIARRHOEA

3. Sub topics
• Definition
• Signs & Symptoms
• Severe symptoms
• Causes
• Treatment
• Drugs available at KPJ Perlis

4. DEFINITION
• Loose and watery stools or bowel movement
• Occur frequently 3 times or more in a day
• Acute diarrhea: Lasts for 1-3 days
*then will go by its own
• Chronic diarrhea: at least 4 weeks persistently
* usually indicated for serious disease

5. SIGNS & SYMPTOMS
• Cramps / pain in the abdomen
• Bloating of the belly
• Loose, thin, watery stools
• Need an urgent use of bathroom
• Loss of bowel control
• Fever exceed 39⁰C & fatigue
(usually caused by bacteria infection)
• Cough & flu
(extra symptoms caused by viral infection)

6. SEVERE SYMPTOMS
Dehydrated
Loss of weight
Fever
Bloody/black in the stool (5%-10% only, diarrhea
>2weeks: start antibiotic and find the causes eg
tumor etc)
Severe abdominal/rectal pain
Lasts more than 2 weeks

7. CAUSES
Generally diarrhea is a normal body mechanism that act
to remove toxins, but must monitor the symptoms to
avoid fluid loss due to other cases.
• Virus. Eg Rotavirus in children (40-50%)
• Bacteria & parasites, including Travelers’ Diarrhea in
contaminated water and food. Most common cause of
food poisoning & contamination Eg E. Coli, Salmonella.
• Medication. Usually antibiotics (mostly in children),
cancer drugs and antacids (with Magnesium).
• Food allergy/compatibility & dysbacteriosis (Travelers’
diarrhea)

8. TREATMENT
• Pharmacological:
o Loramide (Loperamide)
o Lomotil (Diphenoxylate HCl 2.5
+ Atropine 25mcg)
o Prebiotic eg: Bioflor, Hexbio
o Smecta (Dioctahedral Smectite)
o Hidrasec (Racecadotril)
o Ultracarbon (medicinal
charcoal)
o Antibiotics (not the first choice
as can develop diarrhea)
Focus on replacing loss of fluids and electrolytes
to prevent dehydrated
• Non pharmacological:
o Drink more water, fruit
juices.
o Oral rehydration salt
o Petroleum jelly /
lignocaine gel /
haemorrhoid cream
o Prebiotic drink : Yakult

9. Drugs Available In KPJ PERLIS
Loramide (Loperamide) Prebiotic eg: Bioflor
(Saccharomyces
Boulardil)
Smecta (Dioctahedral
Smectite)
Hidrasec (Racecadotril)
Upha Lyte Ultracarbon (medicinal
charcoal)
Hexbio

10. Loramide
Sudden diarrhea including Travelers’ diarrhea, IBD. Act by slow down bowel
movement and makes stools less watery. Treat only the sx, not the causes.
• Active ingredient: Loperamide 2mg
• Doses:
– Acute diarrhoea
Adult: Initially, 4 mg followed by 2 mg after each loose stool. Max: 16 mg
daily. Discontinue if clinical improvement is not observed w/in 48 hr.
Child: 4-8 yr 1 mg 3-4 times daily for up to 3 days; 9-12 yr 2 mg 4 times daily
for up to 5 days.
– Chronic diarrhoea
Adult: Initially, 4-8 mg daily in divided doses, adjusted if necessary. Max: 16
mg daily; discontinue if no improvement at this dose after 10 days.
• Instruction: take with a glass of water before/after meal
• Side effect: diarrhea can swing to constipation if not solved within 2 days
• Combination treatment:

11. Bioflor
• Active ingredient: Saccharomyces Boulardii
• Doses:
– Adult 1 or 2 cap/sachet once or bd.
– Childn >6 yr 1-2 cap daily. Infant & childn >2 yr 1-2 sachet daily
for approx 1 wk.
• Instruction: May be taken with or without food: Powd for
oral susp: Pour & mix contents w/ water/sweetened
beverage/food/baby feeding bottle.
• Side effect: uncommonly found
• Combination treatment:
– Bioflor + ORS = decrease diarrhea duration (WHO 1995)
– Bioflor + Hidrasec = decrease hypersecretion of water &
electrolytes

12. Smecta
• Active ingredient: Dioctahedral Smectite
• Doses:
– Adult Ave: 3 sachets daily. Daily dosage can be doubled at
the beginning of the treatment.
– Childn ≥1 yr 4 sachets daily for 3 days then 2 sachets daily.
– Infant up to 1 yr 2 sachets daily for 3 days then 1 sachet
daily.
• Instruction: can be taken with/without food
• Side effect: constipation, flatulence & vomiting are
uncommon
• Combination treatment:
– Smecta + mesalazine = induced mucosal healing in UC

13. Hidrasec
• Active ingredient: Racecadotril
• Doses: adult 1 capsule tds, Sachet of 30mg for 13kg and
above, infant sachet of 10mg for infants below 13kg.
• Instruction:should be taken preferably before the main
meals. It should be continued until two normal stools are
produced, not exceeding 7 days.
• Side effect: angioedema, such as:
• swollen face, tongue or pharynx
• difficulty to swallow
• hives and difficulties to breath.
The most common side effects are headache
• Combination treatment:
– Hidrasec + ORS = replace loss of fluid

14. Upha Lyte
• Active ingredient: Salts & other electrolytes as
Oral Rehydration Salt (ORS)
• Doses: adult 1 sachet each, children below 2 y/o
¼ to ½ sachet after each watery stool bd to tds
• Instruction: Add water only. Do not add ORS to
milk, soup, fruit juice or soft drinks. Do not add
sugar.
• Side effect: don’t often have any side-effects.
• Combination treatment:
– Hidrasec + ORS

15. Ultracarbon
• Active ingredient: Medicinal Charcoal
• Doses:
– Diarrhoea Adult 2-4 tab tds-qds. Childn ½ adult dose.
– Intoxication Adult 2-4 tab/kg. Childn 3-4 tab/kg. Followed
by 1 tbsp (adult) or ½-1 tbsp (childn) of Na sulfate in 1 glass
of water 30-60 min later.
• Instruction: To take with an empty stomach
• Side effect: GI upset, dark to black stool
• Combination treatment:

16. Ultracarbon..
• Charcoal is used to treat stomach pain caused
by excess gas, diarrhea, or indigestion.
• Charcoal also is used to relieve itching related
to kidney dialysis treatment and to
treat poisoning or drug overdose.

17. Hexbio
• Active ingredient: Lactobacillus acidophilus BCMC® 12130, Lactobacillus
casei BCMC® 12313, Lactobacillus lactisBCMC® 12451, Bifidobacterium
bifidum BCMC® 02290, Bifidobacterium infantis BCMC® 02129, Bifidobacterium
longum BCMC® 02120
• Doses: Adult: 1 sachet bd, Paeds: 1 sachet od
• Instruction: May be mixed with water, juice, milk, cold beverages except
hot water
• Side effect: some individual will experience loose stools
initially but will resolve by time.
• Combination treatment:
– Hexbio (as prebiotic) + ORS = decrease diarrhea duration
(WHO 1995)
– gap for 4 hours if taking antibiotic at the same time.

18. Hexbio…
• Health supplement used to restore and maintain
gut health, provides relief to constipation,
diarrhea, gastric problems, bloating, indigestion
and other stomach problems.
• Helps in nutrients absorption and faster recovery
• Other indication:
– Common cold (URTI caused by rhinovirus/coronavirus)
– Flu (caused by influenza virus)

20. CONSTIPATION

21. Sub topics
• Definition
• Signs & Symptoms
• Severe symptoms
• Causes & Pathophysiology
• Complication
• Treatment
• Drugs available at KPJ Perlis
• Conclusion
• References

22. DEFINITION
• Infrequent bowel movement or difficult
passage of stools. Generally patient having
fewer than 3 bowel movements a week.
• Stool conditions was hard, dry, small and
cause painful when passing off.

23. SIGNS & SYMPTOMS
• Trouble when having bowel movement
• Straining
• Feeling cannot complete empty stool from
rectum
• Swollen/pain belly
• Lumpy /hard stool

24. SEVERE SYMPTOMS
• Blood in stools
• Losing weight
• Severe pain of abdomen and bowel
movement
• Persists for more than 2 weeks

26. CAUSES
• Food & lifestyle habits
 Drink less water
 Low fiber diet
 Taking too much dairy products
 Stress
 Resisting an urge to poop
• Blockage
 Anal fissure
 Colon/abdominal cancer
 IBD
• Medication
 Antacids (with Ca & Al)
 Antidepressant
• Nerve associated problems
 Autonomic neuropathy
 Parkinson
 Stroke
• Hormones related problems
 Diabetes
 Hypothyroidism &
hyperparathyroidism
 Pregnancy

27. COMPLICATIONS
• Haemorrhoid
• Anal fissure
• Fecal impaction
• Rectal prolapse/incontinence/bleeding/hernia
• Uterine hernia/prolapse

28. TREATMENT
• Pharmacological
 Laxatives : Lactulose
 Enema : Glycerin
 Bisacodyl
 Fleet Enema
 Prime Enema
 Forlax
• Non-pharmacological
 Add more fibers in the diet
 Drink more water
 Duphalac
 Co-Motion Fibre
 Surbex Nutri Fibre
 Fortrans

29. Drugs
available
in KPJ
PERLIS
Fleet
Enema
Prime
Enema
Fortrans
Forlax
Co-
Motion
Fibre
Duphalac
Pico
Salax
Surbex
Nutri
Fibre
Dulcolax

30. Prime enema
• Active ingredient: Glycerine 25%, NaCl 15%
• Doses: Adult: 1 unit 20ml, Paeds: 1 unit 10ml
• Instruction: Lie on your left side with your lower leg straight and your
upper leg bent. If giving this medicine to a child, have the child kneel
on the floor and then lower the chest forward until the side of the
child's face is resting on the floor. Gently insert the tip of the
applicator or bulb syringe into the rectum, pointing it toward your
navel (belly button). Do not force the applicator into the rectum or
injury could result. Slowly squeeze the bottle or bulb until it is nearly
empty. Do not reuse the remaining liquid.
• Side effect: usually it does not cause any side effect, but some of this
may occur: loose stools, nausea or stomach discomfort; or rectal pain
or burning.

31. Fortrans
• Active ingredient: Per sachet Macrogol 4000 64 g,
KCl 0.75 g, saccharin Na 0.1 g, Na bicarbonate 1.68
g, NaCl 1.46 g, anhydrous Na sulphate 5.7 g
• Doses: one sachet must be added to 1 liter of
water, before or after meal. Must be taken each 3-
4 hours the day before the procedure (rectal
surgery/endoscopy), usu 6pm, 9pm, 6am
• Instruction: Clearing of bowels in prep for
endoscopic & radiological exam & colonic surgery.
• Side effect: nausea & vomiting at the beginning of
the treatment which will stop with continuous use

32. Fleet Enema
• Active ingredient: Na biphosphate 16%, Na
phosphate 6%
• Doses: 60ml bottle for paeds and 120ml
bottle for adult.
• Instruction: patient must be in knee-chest position.
Sodium phosphate is a saline laxative that is
thought to work by increasing fluid in the small
intestine. It usually causes a bowel movement after
1 to 5 minutes.
• Side effect: nausea & vomiting at the beginning of
the treatment which will stop with continuous use

34. Forlax
• Active ingredient: Macrogol 4000
• Doses: Adult 1-2 sachets daily. Child up to 8yo
Max duration: 3 month
• Instruction: may be taken with or without food,
it work by increasing volume of the intestinal
liquids and the effect become apparent within
24-48hours
• Side effect: abdominal pain, nausea, diarrhea

35. Surbex Nutri Fiber
• Active ingredient: Nutriose wheat dextrin
powder
• Doses: 1-2 sachets (5-10g) daily
• Instruction: Prevent incident of constipation.
Can be mixed in favourite beverages, cooking or
baking.
• Side effect: suitable for long term usage but not
for those having celiac disease or gluten
intolerance

36. Pico Salax
• Active ingredient: Na picosulfate 10 mg,
Mg oxide 3.5 g, anhydrous citric acid 12 g
• Doses: Adult 1-2 sachets daily. Child Max
duration: 3 month
• Instruction: may be taken with or without food.
• Side effect: usually it does not cause any side
effect, but some of this may occur: loose stools,
nausea or stomach discomfort; or rectal pain or
burning.

37. Dulcolax
• Active ingredient: Bisacodyl
• Doses: Adult & childn >10 yr 1-2 tab, childn 4-10 yr 1
tab. To be taken at night for effect on the following
morning
• Instruction: Should be taken on an empty stomach: Take
1 hr before or after antacids, milk or other dairy
products. It works by stimulating the bowel muscles and
also accumulates water in the intestines.
• Side effect: Anaphylactic reaction, angioedema,
dehydration, hypersensitivity, dizziness, syncope, colitis,
abdominal cramps, abdominal pain, diarrhoea, vomiting,
nausea, abdominal discomfort, blood in stool, anorectal
discomfort.

38. Duphalac
• Active ingredient: Lactulose
• Doses:
– Adult 15-45ml (chronic constipation, maintenance dose
5-10ml, preferably to be taken at breakfast)
– Child 5-10ml
• Instruction: may be taken with or without food.
Onset clinical action may be seen at a couple of
days.
• Side effect : Flatulence, nausea, vomiting,
abdominal pain & diarrhea occasionally w/
electrolyte imbalance (high doses only).

39. Hexbio
• Active ingredient: Lactobacillus
acidophilus BCMC® 12130, Lactobacillus casei BCMC® 12313, Lactobacillus
lactisBCMC® 12451, Bifidobacterium bifidum BCMC® 02290, Bifidobacterium
infantis BCMC® 02129, Bifidobacterium longum BCMC® 02120
• Doses: Adult: 1 sachet bd, Paeds: 1 sachet od
• Instruction:
– May be mixed with water, juice, milk, cold beverages except hot
water
• Side effect: some individual will experience loose
stools initially but will resolve by time.
• Combination treatment:
– gap for 4 hours if taking antibiotic at the same time.

41. Conclusion
• Physician usually investigate the diarrhea and
constipation based on the structures and
frequencies, as it may bring to other indicator.
• Diarrhea :
– Normal body mechanism to flush off toxins from body
but should be monitored to prevent dehydration esp
in paeds.
– Antibiotic wasn’t the first choice to treat it as it may
cause another diarrhea esp in paeds.
• Constipation :
– When

42. REFERENCES
• https://medlineplus.gov/diarrhea.html
• https://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea#2
• https://www.mayoclinic.org/diseases-conditions/diarrhea/symptoms-causes/syc-
20352241
• https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-
causes/syc-20354253
• https://www.webmd.com/digestive-disorders/qa/how-is-constipation-defined
• https://www.everydayhealth.com/constipation/guide/
• https://www.webmd.com/digestive-disorders/understanding-constipation-
treatment
• https://www.webmd.com/digestive-disorders/digestive-diseases-constipation#2
• https://studylib.net/doc/5751252/hexbio-clinical-presentation
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4301466/