This document provides information on the definition, causes, pathology, treatment and management of diarrhoea. It discusses oral rehydration therapy and intravenous fluid replacement. It covers specific infectious causes of diarrhoea and appropriate antibiotic use. The document also outlines management of inflammatory bowel diseases and use of antimotility drugs and symptomatic treatments.

2.  WHO definition:
3 or more loose or watery stools in a 24hr
period
 Diarrhoea constitute a major cause of
morbidity and mortality
 In India around 1000 children die every day
 Recurrent diarrhoea is also a major cause of
protein calorie malnutrition

3. Pathology:
 It occurs due to passage of excess water in
faeces
 Decreased electrolyte and water absorption
 Increased secretion by intestinal mucosa
 Increased luminal osmotic load
 Inflammation of mucosa and exudation into
lumen

4.  Most of the diarrhoeas are self limiting
 Therapeutic measures are
A. Treatment of fluid depletion, shock, acidosis
B. Maintenance of nutrition
C. Drug therapy

5. Intravenous rehydration:
 Needed only when
1. Fluid loss is severe i.e >10% of body weight
2. If the patient is losing >10 ml/kg/hr
3. Unable to take enough oral fluids

6.  The recommended composition of i.v fluid is
NaCl - 85 mM - 5 g
KCl - 13 mM - 1 g
NaHCO3 - 48mM - 4 g
in 1 l of water or 5% glucose solution
 Volume equivalent to 10% of BW should be
infused over 2-4 hrs

7.  Oral rehydration is possible if glucose is
added with salt
 It capitalizes on the intactness of glucose
coupled Na+ absorption
 It should be isotonic or hypotonic to plasma
 The molar ratio of glucose should be equal to
or heigher than sodium
 Enough K+ and bicarbonate/ citrate should be
added to make up the losses in stool

8. Formula WHO – ORS:
 Standard ORS osmolarity is 310mOsm/l
 New formula ORS osmolarity is 245 mOsm/l
 Low sodium low glucose
 Faster water absorption
 Precludes risk of hypernatremia
 cheaper

9. CONTENT
 NaCl - 2.6 g
 KCl – 1.5 g
 Trisodium citrate –
2.9 g
 Glucose – 13.5 g
 Water – 1l
CONCENTRATION
 Na+ - 75mM
 K+ - 20mM
 Cl- - 65 mM
 Citrate - 10mM
 Glucose - 75 mM

10. Administration of ORT
 Patients are encouraged to drink ORS ½ - 1
hr interval
 Initially 5 – 7.5% BW volume equivalent is
given in 2 – 4 h0urs (5 ml/kg/hr in children).
 Restore and maintain hydration, electrolyte
and pH balance

11. Non-diarrhoeal uses of ORT
 (a) Postsurgical, postburn and post-trauma
maintenance of hydration and nutrition (in
place of i.v. infusion).
 (b) Heat stroke.
 (c) During changeover from intravenous to
enteral alimentation

12.  Reduces the duration and severity of acute
diarrhoea episodes in children <5 years of
age.
 Continued Zinc supplementation 20 mg/day
for 6–60 mths age; 10 mg/day for 0–6 mth
age) for 10–14 days following the episode
also reduces recurrences of diarrhoea for the
next 2–3 months.
 Strengthen the immune response and help
regeneration of intestinal epithelium.

13.  Patients of diarrhoea should not be starved
 Feeding during diarrhoea has been shown to
increase intestinal digestive enzymes and cell
proliferation in mucosa.
 Simple foods like breast milk or ½ strength
buffalo milk, boiled potato, rice, chicken
soup, banana, sago, etc. should be given

14.  Drugs used in diarrhoeas may be categorised
into:
1. Specific antimicrobial drugs
2. Probiotics
3. Drugs for inflammatory bowel disease
(IBD)
4. Nonspecific antidiarrhoeal drugs.

15.  Have a limited role in the overall treatment of
diarrhoeal diseases;
 The reasons are:
• Bacterial pathogen is responsible for only a
fraction of cases.
• Even in bacterial diarrhoea, antimicrobials
alter the course of illness only in selected
cases.
• Antimicrobials may prolong the carrier
state.

16.  Irritable bowel syndrome (IBS)
 Coeliac disease
 Pancreatic enzyme deficiency
 Tropical sprue
 Thyrotoxicosis.
 Rotavirus induced diarrhoea
 Salmonella food poisoning is generally a
selflimiting disease.Antibiotics have been
widely used, but may be harmful rather than
beneficial

17. Disease Drug used
Travellers’ diarrhoea cotrimoxazole, norfloxacin,
Doxycycline , Rifaximin
EPEC Cotrimoxazole,
fluoroquinolone , colistin
Shigella enteritis Ciprofloxacin, norfloxacin.
Cotrimoxazole and
ampicillin
Nontyphoid Salmonella
enteritis
fluoroquinolone,
cotrimoxazole or ampicillin
Yersinia enterocolitica Cotrimoxazole, ciprofloxacin

18. Disease Drug used
Cholera: Tetracyclines, Cotrimoxazole
norfloxacin/ciprofloxacin.
Ampicillin and erythromycin
Campylobacter jejuni Norfloxacin, erythromycin,
Clostridium difficile metronidazole, vancomycin
bacterial growth
in blind loops/diverticulitis
tetracycline or metronidazole
Amoebiasis, Giardiasis Metronidazole, diloxanide
furoate

19.  Microbial cell preparations, either live
cultures or lyophillised powders
 Restore and maintain healthy gut flora
 Organisms used are Lactobacillus,
Bifidobacterium, Streptococcus faecallis,
Enterococcus sps and Saccharomyces
boulardii
 Reduce antibiotic associated diarrhoea, acute
infective diarrhoea, travellers diarrhoea

20.  Chronic relapsing inflammatory disease of
the ileum, colon or both, may be associated
with systemic manifestations
 Two types
- Ulcerative colitis
- Crohn’s disease – any part of the GIT

21. Drugs used in IBD can be grouped into:
 5 amino salicylic acid
 Corticosteroids
 Immunosuppressants
 TNF alpha inhibitors
 Antibiotics like metronidazole/ ciprofloxacin
 Anti integrin monoclonal antibody -
Natalizumab

22. Sulfasalazine:
 5 aminosalicylic acid with sufapyridine linked
through azo bond
 Low solubility, poorly absorbed from ileum
 Azo bond split by colonic bacteria to 5 ASA
and sulfapyridine.
 5 ASA exerts local anti-inflammatory effect
 Reduces number of stools, abdominal cramps
and fever

23.  A dose of 3-4 g/day gives remission
 Maintenance dose therapy with 1.5- 2 g/day
 Most useful in ulcerative colitis
 Sulfapyridine acts as carrier for 5 ASA to the
colon. Has therapeutic effect in RA
 Side effects - rashes, fever, joint pains,
haemolysis and blood dyscrasias, nausea,
vomiting, headache, malaise and anaemia

24. Mesalazine:
 5 ASA compond,
 Primary use in preventing relapse of UC
 Better tolerated
 Side effects: nausea, diarrhoea, abdominal pain.
 Nephrotoxic
 Enhance the gastric toxicity of corticosteroids
and hypoglycemic action of sulfonylureas
 4g enema once or twice daily is effective in distal

25. Olsalazine:
 Consist of 2 molecules of 5 ASA together by
azo bond
Balsalazine:
 5 ASA linked to 4 aminobenzoyl β alanine
 Dose: 1.5g bd to 2.25g tds

26.  Prednisolone 40 – 60 mg/day effective in
controlling remission in both UC and CD
 Symptomatice relief starts within 3-7 days
and remission is induced in 2-3 wks
 In severe cases with systemic manifestations
i.v. Methylprednisolone 40 – 60 mg 12 to 24
hrly for few days
 Hydrocortisone enema or foam can be used
for topical treatment of proctitis

27.  Generally used for short term
 Neither effective nor suitable for maintaining
remission

28.  Long term management of IBD especially
CrD
Azathioprine: purine antimetabolite
 indicated in steroid resistant, steroid
dependent and severe cases of IBD
 Side effects bone marrow hyper sensitivity
 Dose 1.5 -2 mg/kg/day

29. Methotrexate:
 Dihydrofolate reductase inhibitor
 Acts faster than azathioprine
 Doses effective in IBD are higher than those
for RA
 Weekly parenteral therapy is needed
 Toxicity is more

30. Cyclosporine:
 Potent immunosuppresant used in UC
 I.V. Cyclosporine usually controls symptoms
in 7-10 days, bridge therapy for 2-3 mnths till
azathioprine takes effects
 Renal toxicity
 Poor efficacy in IBD

31. TNF alpha inhibitors:
INFLIXIMAB, ADALIMUMAB,
CERTOLIZUMAB:
 Indicated in severe activeCrD, fistulating Crd
and severe UC
 Infused every 2-8 wks, it decreases acute
flareups and helps in fistula closure

32.  Absorbants and adsorbants
 Antisecretary drugs
 Antimotility drugs

33.  Colloidal bulk forming substances like
isphagula, methyl cellulose, carboxy methyl
cellulose which absorbs water and swell
 Modify consistency and frequency of stools
 Useful in diarrhoeal phase of IBS
 Adsorbants like kaolin, pectin adsorb
bacterial toxins in the gut and protects
mucosa

34. Racecadotril:
 Prodrug that rapidly converted to thiorphan
 Prevents degradation of endogenous
enkephalins
 Decreases intestinal hypersecretion
 Indicated in short term treatment of acute
secretary diarrhoea
 T1/2 is 3 hrs
 Side effects: nausea, vomiting, drowsiness,
flatulance
 Dose: 100mg tds

35. Bismuth subsalicylate:
 Taken as suspension 60ml 6hrly
 Decreases PG synthesis
 Reduces Cl secretion
 Prophylactic value in travellers diarrhoea

36. Anticholinergic:
 Atropinic drugs reduce bowel motility and
secretion
 Benefit in nervous /drug induced diarrhoea
 Provide symptamatic relief in dysenteries,
diverticulitis

37. Octreotide
 Somatostatin analogue
 Have long halflife. t1/2 is 90 mins
 Has antisecretory and antimotility action
 Used to control diarrhoea in carcinoid and
vasoactive intestinal peptide secreting
tumours and for refractory diarrhoea in AIDS
patients given by S.C injection

38.  Opioid drugs which increase small bowel tone
and segmental activity, reduce propulsive
movements and diminish intestinal
secretions
 Symptomatic relief in diarrhoea
 They increase the resistance to luminal
transit and allow more time for the
absorptive process

39. Codeine:
 Alkaloid
 Prominent constipating activity
 60mg tds
 Dependence potential

40. Diphenoxylate:2.5mg + atropine 0.025mg
 Synthetic opioid, chemically related to
pethidine
 Crosses blood brain barrier – CNS effects
 Abuse liability is low
 Causes respiratory depression, paralytic ileus
and toxic megacolon in children
 Contraindicated in children below 6 yrs

41. Loperamide:
 Opiate analogue with weak antichollinergic
property
 Poor water solubility
 Longer duration of action
 Also inhibits secretion
 Side effects are abdominal cramps and rashes
and paralytic ileus and toxic megacolon in
children
 contraindicated in children < 4yrs

42.  Use in noninfective diarrhoea, mild travellers
diarrhoea
 Contraindicated in infective diarrhoea – delay
the clearance of pathogen
 Careful use in mild IBD
 Can be used to induce short term
constipation eg; after anal surgery, reduce
the volume, fluidity and bag cleaning
frequency in ileostomy/ colostomy patients

43.  A 35yr old man has come with complaint of
acute onset diarrhoea.The stools are
relatively small volume, liquid but not watery,
frothy and are preceded by gripping pain in
abdomen. Foul smelling wind, eructation and
mild fever are the other complaints. He has
passed 4 loose motions in the past 8 hrs and
there is no appetite. He admits to have eaten
spicy snacks last evening at a road side stall.

44.  Physical examination reveals body
temperature 101f, no signs of dehydration
but diffuse abdominal tenderness.A tentative
diagnosis of enteroinvasive diarrhoea is
made.
 Does this patient require rehydration
therapy?
 Should an antibiotic be prescribed? If so
which antibiotic is preferred?

45.  Should an antimotility drug to coprescribed
to reduce number of stools?
 Should any other symptomatic drug be given
to him?