Anti Diarrhoeal – Management, Drug Therapy

Introduction

Diarrhoea is too frequent, often too precipitate passage of poorly formed stools.

It is defined by WHO as 3 or more loose or watery stools in a 24 hour period.

It occurs due to passage of excess water in faeces. This may be due to:

• Decreased electrolyte and water absorption.
• Increased secretion by intestinal mucosa.
• Increased luminal osmotic load.

Recurrent or protracted diarrhoea is also a major cause of protein-calorie malnutrition in developing countries.

Pathophysiology of Diarrhoea

For many people, Diarrhoea represents an occasional inconvenience or annoyance, yet at least 2 million people in the world, mostly children, die from the consequences of Diarrhoea each year.

Diarrhea can be as;

1. Osmotic Diarrhea :-

Absorption of water in the intestine is dependent on adequate absorption of solutes.

So, if excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhea will result.

Large volumes of water are normally secreted into the small intestinal lumen, but a large majority of this water is efficiently absorbed before reaching the large intestine.

Diarrhea occurs when secretion of water into the intestinal lumen exceeds absorption.

Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species.

Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often , destruction of absorptive epithelium.

In such cases, absorption of water occurs very inefficiently and diarrhea results.

In order for nutrients and water to be efficiently absorbed, the intestinal contents must be adequately exposed to the mucosal epithelium and retained long enough to allow absorption.

Disorders in motility than accelerate transit time could decrease absorption, resulting in diarrhea.

Management

Depends on establishing the underlying cause and instituting specific therapy, since most diarrhoea is self-limiting.

Therapeutic measures:

1. Treatment of fluid depletion, shock and acidosis.
2. Maintenance of nutrition.
3. Anti Diarrhoeal Drug therapy.

REHYDRATION

Rehydration can be done orally or i.v.

Intravenous rehydration It is needed only when fluid loss is severe, i.e. > 10% body weight,or is unable to take enough oral fluids due to weakness, or vomiting.

Volume equivalent to 10% BW should be infused over 2-4 hours; the subsequent rate of infusion is matched with the rate of fluid loss.

Oral rehydration Advent of oral rehydration therapy (ORT) is considered a major advance of recent times.

ORS

Oral Rehydration Salts ; A new formula for oral rehydration salts (ORS), has been released by the World Health Organization. The new formula ORS, a sodium and glucose solution, is widely used to treat children with acute diarrhea.

NOTE– Zinc in pediatric diarrhoea, administration of Zinc along with low osmolarity ORS reduces the duration and severity of acute diarrhoea episodes in children below 5 years of age.

Nutrition

Feeding during diarrhoea has been shown to increase intestinal digestive enzymes and cell proliferation in mucosa.

Simple foods like breast milk or 12 strength buffalo milk, boiled potato, rice, chicken soup, banana, etc. should be given as soon as the patient can eat.

DRUG THERAPY

Drugs used in diarrhea may be categorised into:

1. Specific antimicrobial drugs
2. Probiotics
3. Drugs for inflammatory bowel disease (IBD)
4. Non-specific Anti Diarrhoeal drugs.

Antimicrobials in Diarrhoea

One or more antimicrobial agent is almost routinely prescribed to most patients of diarrhoea.

Diarrhoea patients can be broadly placed in one of the two categories:

(a) Abundant watery diarrhoea lacking mucus or blood, usually dehydrating with frequent vomiting, but little or no fever.

Caused by- Adhesive but noninvasive enterotoxigenic bacteria such as cholera, ETEC, Salmonella enteritidis or by rota virus and viruses which stimulate massive secretion by activating CAMP in intestinal mucosal cell.

ORS and not antimicrobials are the main therapy.

(b) Slightly loose, small volume stools, frequently with mucus and/or blood, mild dehydration, usually attended with fever and abdominal pain, but not vomiting.

These symptoms are indications of mucosal invasion.

Caused by – entero invasive organisms like Shigella, enteropathogenic E. coli (EPEC), Salmonella typhimurium, Yersinia enterocolitica, Campy jejuni, Salmonella typhimurium, Yersinia enterocolitica.

Drugs used

• Diarrhea caused due to ETEC or virus: cotrimoxazole, norfloxcin, doxycycline reduce the duration of diarrhoea and total fluid needed only in severe cases.
• Rifaximin It is active against E. coli and many other gut pathogens.
• EPEC: is less common, but causes Shigella like invasive illness. Cotrimoxazole, fluoroquinolone or colistin may be used in acute cases and in infants.
• Shigella enteritis: only when associated with blood and mucus in stools may be treated with ciprofloxacin or norfloxacin. Cotrimoxazole and ampicillin are alternatives, but many strains are resistant to these.
• Nontyphoid Salmonella enteritis is often invasive; severe cases may be treated with a fluoroquinolone, cotrimoxazole or ampicillin.
• Yersinia enterocolitica: common in colder places, not in tropics. Cotrimoxazole is the most suitable drug in severe cases, ciprofloxacin is an alternative.
• Cholera: tetracyclines reduce stool volume to nearly half. Cotrimoxazole is an alternative, especially in children.
• Campylobacter jejuni: Norfloxacin and other fluoroquinolones drugs used to control diarrhoea.

Probiotics in Diarrhoea

Introduction

These are microbial cell preparations, either live cultures or lyophilised powders, that are intended to restore and maintain healthy gut flora or have other health benefits.

Taking probiotics may help prevent and treat diarrhea by correcting an imbalance in the gut microbiota.

Treats when;

Taking probiotics may help prevent and treat diarrhea associated with infection, traveling, and antibiotic use.

Some probiotics;

• Lactobacillus rhamnosus GG (LGG):

This probiotic is among the most commonly supplemented strains.

LGG is one of the most effective probiotics for treating diarrhea in both adults and children.

• Saccharomyces boulardii:

It has been shown to treat antibiotic-associated and infectious diarrhea

• Bifidobacterium lactis:

This probiotic has immune-boosting and gut protective qualities and reduce the severity and frequency of diarrhea in children.

Side effects

Probiotics are widely considered safe but can cause serious side effects in immunocompromised individuals.

Drugs for inflammatory bowel disease (IBD)

IBD is a chronic relapsing inflammatory disease of the ileum, colon, or both.

Drugs used

• Sulfasalazine (Salicylazosulfapyridine) has a specific therapeutic effect in IRD
• Mesalazine (Mesalamine) = It is not effective orally because of inability to reach the large bowel (it is absorbed in the small intestine)

• Olsalazine It is poorly absorbed in the ileum.
• Balsalazide

Nonspecific Antidiarrheal drugs

• Adsorbants like kaolin, pectin, attapulgite are believed to adsorb bacterial toxins in the gut and coat/protect the mucosa.
• Racecadotril
• Anticholinergics drugs can reduce bowel motility and secretion.
• Loperamide has been clearly shown to reduce secretion.
• Antimotility drugs; These are Anti Diarrhoeal drugs which increase small bowel tone and segmenting activity, reduce propulsive movements and diminish intestinal secretions while enhancing absorption.

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