This document discusses the management of diarrhea and constipation. For diarrhea, it focuses on rehydration through oral rehydration solution or intravenous fluids depending on severity. Maintaining nutrition and use of antimicrobial drugs for specific causes of infectious diarrhea are also covered. For constipation, nonpharmacological treatments including diet and lifestyle changes are recommended first. If those fail, various classes of laxatives are discussed including bulk forming, osmotic, and stimulant laxatives.

2. • Diarrhea is too frequent passage of poorly
formed stools.
• Principles of management
(a) Treatment of fluid depletion, shock and acidosis.
(b) Maintenance of nutrition.
(c) Drug therapy.
• Importance of each is governed by severity &
nature of diarrhea.

3. REHYDRATION
• Intravenous rehydration : needed only when
fluid loss is severe, > 10% body weight & unable
to take orally.
• Recommended composition of i.v. fluid is:
– NaCl 85mM = 5g in 1L of water
– KC1 13 mM = 1 g or 5% glucose
– NaHC03 48mM = 4g solution.
• Volume equivalent to 10% BW should be infused
over 2-4 hours; subsequent rate of infusion is
matched with the rate of fluid loss.

4. Rationale of ORS composition
• Oral rehydration is possible if glucose is added
with salt.
• The general principles are:
(a) isotonic or somewhat hypotonic.
(b) molar ratio of glucose should be equal to or
somewhat higher than Na+ .
(c) Enough K+ and bicarbonate / citrate should be
provided to make up the losses in stool

5. • The average electrolyte composition (mM) of 3
important infective diarrhoea stools is:
1. Cholera: Na+ CI- K+ HC03-
infants, children 88 86 30 32
adults 140 104 13 44
2. ETEC 53 24 37 18
3. Rotavirus 37 22 38 6

6. • In 2002 a new formula low Na+ low glucose
ORS has been released by the WHO.

7. MAINTENANCE OF NUTRITION
• Fasting decreases brush border
disaccharidase enzymes and reduces
absorption of salt, water and nutrients.
• Simple foods like breast milk or 1/2
strength buffalo milk, boiled potato, rice,
chicken soup, banana etc.

8. DRUG THERAPY
(i) Specific antimicrobial drugs,
(ii) Nonspecific antidiarrhoeal drugs.
• Have a limited role in overall t/t of diarrhea pts;
• Reasons are:
a) Bacterial pathogen is responsible for only a fraction of
cases,
b) Even in bacterial diarrhea, antimicrobials alter course
of illness only in selected cases,
c) Antimicrobials may prolong the carrier state.

9. • Antimicrobials are of no value in diarrhoea due
to non-infective causes, such as:
I. IBS (irritable bowel syndrome)
II. Coeliac disease
III. Pancreatic enzyme deficiency
IV. Thyrotoxicosis.

10. • Antimicrobials are useful only in severe disease
(but not in mild cases):
1. Travellers' diarrhoea: cotrimoxazole,
norfloxacin, doxycycline and erythromycin
reduce the duration and total fluid needed only
in severe cases.
2. EPEC: Cotrimoxazole, colistin, nalidixic acid or
norfloxacin may be used in acute cases and in
infants.

11. 3. Shigella enteritis: associated with blood and
mucus → treated with ciprofloxacin,
norfloxacin or nalidixic acid; cotrimoxazole and
ampicillin are alternatives, but many strains are
resistant to these.
4. Salmonella typhimurium enteritis is often
invasive; severe cases may be treated with a
fluoroquinolone, cotrimoxazole or ampicillin.
5. Yersinia enterocolitica: Cotrimoxazole is the
most suitable drug in severe cases;
ciprofloxacin is an alternative.

12. C. Antimicrobials are regularly useful in:
(i) Cholera:
(ii) Campylobacter jejuni:
(iii) Clostridium difficile:
(iv) Diarrhoea associated with bacterial growth
(v) Amoebiasis : metronidazole, diloxanide furoate,
(vi) Giardiasis : metronidazole

14. • Absorbants :
– Colloidal bulk forming substances → absorb water
and swell.
– Modify the consistency and frequency of stools and
give an impression of improvement,
– but do not reduce the water and electrolyte loss.

15. Antimotility drugs
• Opioids increase small bowel tone & segmenting
activity, reduce propulsive movements and
diminish intestinal secretions while enhancing
absorption.
• Opioid receptors promote absorption, inhibit
secretion and decrease propulsive movements.
• Drugs are : Diphenoxylate, Loperamide &
Codeine

16. LAXATIVES

17. Constipation :
• Defined as infrequent passage of hard stools.
• Causes:
1.Git disorders:
• Lack of dietary fiber &/or fluid intake
• Motility
• Structural: carcinoma colon, diverticular disease
2. non git disorders:
• Drugs: opioides, anticholinergics, aluminium salts.
• Neurological: Multiple sclerosis, Parkinsonism
• Metabolic/endocrine: DM, Hypothyroidism

18. NONPHARMACOLOGICAL TRETMENT
OF CONSTIPATION
• Diet that contains fiber, water, exercise,
routine bowel habits

19. Laxatives
• Elimination of soft semisolid formed stools
• Uses:
– To treat constipation
– Before or after surgery of any GIT diseases
– In bedridden patients
• Laxatives should be avoided
– intestinal obstruction,
– Severe abdominal pain,
– Appendicitis,
– Ulcerative colitis
– Diverticulitis

20. Drugs for constipation
1. Bulk forming agents :
• wheat bran, methylcellulose
2. Stool softener :
• docusates, liquid parafin
2. Osmotic laxatives:
• magnesium citrate, magnesium sulfate,
lactulose
3. Stimulant laxatives:
• Bisacodyl, senna, castor oil

21. Stool bulking agents
Wheat bran, Ispaghula husk, methylcellulose
• hydrophilic colloids (from indigestible parts of fruits
and vegetables).
• Form gels in the large intestine → water retention
and intestinal distension → increasing peristaltic
activity.
• used cautiously in bed-bound → potential for
intestinal obstruction.

22. Osmotic laxatives
Lactulose, magnesium citrate, magnesium sulfate,
sodium phosphate
• hold water in the intestine by osmosis & distend
bowel → ↑ intestinal activity & produce defecation.
• Electrolyte solutions containing polyethylene glycol
(PEG) are used as colonic lavage solutions to prepare
gut for radiologic or endoscopic procedures.

23. Faecal softeners(emollients)
docusates, liquid parafin
• Surface-active agents that become emulsified
with stool produce softer feces & ease
passage.
• Take days to become effective.

24. Stimulant laxatives
• Senna :
• widely used stimulant laxative.
• also causes water and electrolyte secretion into
bowel.
• Bisacodyl:
• potent stimulant of the colon.
• Acts directly on nerve fibers in mucosa of colon.
• ADR: abdominal cramps & potential for atonic
colon with prolonged use.
• Castor oil:
• is broken down in small intestine to ricinoleic
acid→ irritate the gut → promptly increases
peristalsis.
• avoided by pregnant patients → stimulate uterine
contractions.

25. Nabin Bist
Pharmacy Technician
Patan Academy of Health Sciences
www.pharmainfonepal.com
( Nabin`s Blog )