DIARRHOEA &CONSTIPATIONNo organ in the body is so misunderstood, soslandered and maltreated as the colon!Sir Arthur Hurst, 1935PRESENTATION BYASWATHY.T.DM PHARM PART- IPHARMACY PRACTICE
IntroductionEpidemiologyEtiologyPathophysiologyClinical manifestationsDiagnosisTreatmentRole of pharmacistConclusionReferencesCONTENTS
INTRODUCTION Diarrhoea and constipation are common clinical complaints thatnegatively affect quality of life, reduce work productivity and lead toconsiderable health-care expenditure.They are non specific symptoms that may be caused bydiet, stress, medication, inadequate fluid intake, a neuromusculardisorder, an endocrine disorder (e.g.,diabetes, thyroid or parathyroiddisease) or rarely cancer About 8-9% of people suffer from chronic constipation and about 4-5%Chronic Diarrhoea ..
What is Diarrhoea ?An increase in the frequency of bowel movements or adecrease in the form of stool (greater looseness of stool)Changes in frequency of bowelmovements and looseness ofstools can vary independently ofeach other, changes usuallyoccur in both
Diarrhoea in the 21stCentury Second most commoncause of morbidity andmortality worldwideWHO estimation(2002), diarrhoeal diseaseresults in:2.5 million people dieannually, mostly children1.6 million children<5yrs old (in developingcountries)
Types of diarrhoeaChronic diarrhoea Acute diarrhoeaGenerally lasts > 3 weeksMost of the causes arenon-infectiousIBS, AIDS, bacterialoutgrowth of smallint., Colon cancer, Chron’sdiseasesudden onset and lastsless than two weeks90% are infectious inetiology10% are caused bymedications, toxiningestions, and ischemiaIMPORTANT !!!distinguish between acute and chronic diarrhoea>>>different diagnostic tests, different treatments
What are common causes ofdiarrhoea?.Dietary abuseFood intoleranceInfection by bacteria, virus ¶sitesReaction to medicineIntestinal disease
High Risk Groups1. Travelers2. Consumers of certain foods3. Immunodeficient person4. Daycare participants5. Institutionalized person
Why does diarrhoea develop?Increased secretion orimpaired absorption offluid with in the lumen.
What are the pathohysiologicmechanisms leading to diarrhoea?a. Change in active ion transport byeither decreased sodiumabsorption or increased chlorideabsorption.b. Change in intestinal motilityc. Increase in luminal osmolarityd. Increase in tissue hydrostaticpressure
ClinicalFeaturesStoolsLooseBlood stainedOffensive smellSteatorrhea (floating, oily, difficult to flush)Sudden onset of bowel frequencyCrampy abdominal painUrgencyFever, Nausea, +/- VomitingLoss of appetiteLoss 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 forova, cysts, parasites and fecal WBC Blood testsReview of your medicationsELISA test** For unresolved diarrhoea: sigmoidoscopy, rectal biopsy andradiological studies to rule out other organic causes
TREATMENTNonpharmacologicmanagementDiet Discontinuing consumption of solid foods and diary products for24 hrs Frequent feedings of fruit drinks, tea, "flat" carbonatedbeverages, and soft, easily digested foods (eg, soups, crackers)are encouraged
Rehydration* Oral rehydration with fluids containingglucose, Na+, K+, Cl–, and bicarbonate orcitrate is preferred in most cases tointravenous fluids* Fluids should be given at rates of 50–200 mL/kg/24 hdepending on the hydration status.* Intravenous fluids (lactated Ringers solution) arepreferred acutely in patients with severe dehydration.
Pharmacologic therapyOpiates & their derivativesA. Loperamide: 4 mg initially, then 2 mgafter each loose stool (maximum: 16mg/d)B. Diphenoxylate With Atropine: Onetablet three or four times dailyC. Codeine, Paregoric:. 15–60 mgevery 4 hours as needed; thedosage of paregoric is 4–8 mL aftereach liquid bowel movement
AdsorbentsKaolin- pectin mixture: 30-120 mL after each loosestoolAttapulgite: 1200- 1500 mg after each loose bowelmovements or every 2 hrs; up to 9000 mg/dayAntisecretory agentsBismuth subsalicylate: 2 tablets or 30 mL every 30 min to 1 hras needed up to 8 doses/dayIn immunocompromised patientsOctreotide: Initial 50mcg s/c 1-2 times/day & titrate dosebased on indication up to 600mcg/day in 2-4 divided doses
ROLE OF PHARMACIST• Avoid dehydration; drink clear fluids, preferablythose containing electrolytes and an energy sourcesuch as glucose.• Good hygiene, particularly washing your handsthoroughly after going to the toilet, is essential incase the diarrhea is infectious.• Do not prepare food for other people, especiallybabies and old people, while you have acutediarrhea.• A carbohydrate diet that includes boiled potatoes orboiled rice may help.• If the diarrhea does not resolve after a few days,seek medical advice.
Good nutrition andhygiene can preventmost diarrhoea.SEE YOU………
What is constipation?Constipation is generally definedas infrequent and/orunsatisfactory defecation fewerthan 3 times per week.Patients may defineconstipation as passing hardstools or straining, incompleteor painful defecation.Constipation is a symptom,NOT a disease.
Epidemiology2-27% of the population has constipationConstipation affects twice as many womenas menConstipation is more prevalent in non-Whitepersons 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/ConditionsSpasam of sigmoid colonDysfunction of myenteric plexus
PATHOPHYSIOLOGYA variety of pathogenetic mechanismscan 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 defecationNauseaVomitingAnorexiaFeeling full quicklyStools that are small, hard, and/or difficult toevacuateRectal bleedingWeight loss (in chronic constipation)
DiagnosisGood history is enough for most cases(Duration, frequency, Consistency, blood in thestool, weight loss, Diet, Exercise, Toilethabits, Laxative use (what), other drugs)Basic laboratory tests:CBC, BS, BUN, Cr, TSHStructural:Barium enema, Sigmoidoscopy, Colonoscopy
I’m constipated, now what?Two approaches to consider: Non-drug Approach Drug Approach
1. Exercise - Fibre in the diet - FluidIntakeNo evidence that increased exercise is beneficial insevere constipationAim for 25-30g fibre/dayUnless dehydrated, increasing fluid does not relievechronic constipation and may increase the risk of fluidoverload eg heart or renal failure
The kitchen can help!Add dry, fresh or canned fruit to cerealAdd legumes to soups casserolesInclude grated vegetables in rissoles, soupsChoose fruit dessertsUse high fibre snacks, raisin bread, datescones, carrot, muffinsEASY FIBRESUPPLEMENT3 TBS unsweetened apple puree1 TBS unprocessed bran2-3 TBS prune juiceUse 1 TBS on breakfast cereal
Psyllium (Metamucil®), Sterculia (Normacol®), Ispaghula (Fybogel®)Improve stool consistency and frequency with regular useEnsure good fluid intake to prevent faecal impactionOnset of action 2-3 daysSide Effects may include bloating, flatulence, distension2. Bulk Forming Laxatives
Docusate (Coloxyl®), Paraffin oil (Agarol®)Efficacy of docusate is controversialMay be useful with anal fissures of haemorrhoids orwhen straining is a hazardLiquid paraffin is not recommended for treatment ofconstipation- risk of aspiration and lipid pneumonia- long term use may result in depletion ofVitamins A, D, E and K3. Stool Softeners & Lubricants
4. Stimulant LaxativesSenna (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 electrolytedisturbances 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 andelectrolyte loss is limited
Some precautions with osmotic laxativesLactulose contains absorbable sugars and mayadversely affect glycamic control in diabeticsOveruse may result in dehydrationMonitor for any signs of electrolyte disturbances- oedema- shortness of breath- increasing fatigue- cardiac failure
6. Enemas & SuppositoriesUsed when rapid relief from faecal loading is requiredInduce bowel movements by distension of the rectumand colonFrequent use may cause poor rectal tone and mayexacerbate incontinenceTap water enemas are safest for regular usePhosphate enemas (Fleet®) increase the risk ofhyperphosphataemia in renal impairmentGlycerine suppositories stimulate rectal secretion byosmotic action
Helping to prevent constipation Patient education Diet and Fluid Intake Exercise Effective Bowel Habits Toileting Facilities Ensure a laxative isprescribed with opioidsImaginative 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 muffinsAn Effective Fibre Supplement3 TBS unsweetened apple puree1 TBS unprocessed bran2-3 TBS prune juiceAdd 1 TBS to breakfast cereal
CONCLUSION Diarrhoea and constipation are common disorders of GITthat are often self reported by older adults. Pharmacist is essential in counseling patients on selfmanagement of constipation & diarrhoea. Good nutrition and hygiene can prevent most diarrhoea.Patients should be instructed to increase fluid intake andparticipate in regular exercise to prevent constipation.
REFERENCESo Davidson’s Principle and Practice of Medicine 20th editionby Nicholas.N.Boon, Niki. R.colledge, Brain. R. WalkerPage No:677-692o Harrison’s Principle of Internal Medicine 18th edition, Vol 1by Longo, Fauci Kasper, Hasper, Jamesoli Page No: 247-255o Text book of therapeutics- Drug and DiseaseManagement, 7th edition by Eric. T. Herfintal, Dick.R.Gourley; Page No:571-585o Clinical Pharmacy and Therapeutics, 4th edition by RogerWalker, Cate Whitelsia Page No: 824- 832