Download Pharmaceutical guidelines of patients with pathology of digestive

Pharmaceutical guidelines of patients
with pathology of digestive organs.
SYMPTOMATIC TREATMENT OF
DIARRHEA
DIARRHEA
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becoming more frequent (more than 3 times for
the last 24 hours, for breast-feeding children
more than 5-7 times) or / and dilution of feces
 Diarrhea is an increase in the frequency of
bowel movements or a decrease in the form of
stool (greater looseness of stool). Although
changes in frequency of bowel movements and
looseness of stools can vary independently of
each other, changes often occur in both.
Doctors classify diarrhea as "osmotic,"
"secretory," or "exudative"
Osmotic - something in the bowel is
drawing water from the body into the
bowel ("dietetic candy" or "chewing gum"
diarrhea, in which a sugar substitute,
such as sorbitol, is not absorbed by the
body but draws water from the body into
the bowel, resulting in diarrhea).
 Secretory - occurs when the body is
releasing water into the bowel when it's
not supposed to. Many infections, drugs,
and other conditions cause secretory
diarrhea.
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Classification (cont’d)
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Exudative diarrhea refers to the
presence of blood and pus in the stool.
This occurs with inflammatory bowel
diseases, such as Crohn's disease or
ulcerative colitis, and several infections
Distinguish acute and chronic
diarrhea
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acute (duration less than 2-3 weeks)
 chronic (duration longer than 3 weeks)
It is important to distinguish between acute and
chronic diarrhea because they usually have
different causes, require different diagnostic
tests, and require different treatment
POSSIBLE CAUSES OF
DIARRHEA
In patients with diseases of the gastrointestinal
tract
 Ulcerative colitis
 As part of irritable bowel syndrome or other
chronic diseases of the large intestine
 Crohn's disease (ileitis terminal)
 intestinal infections
 Shortened guts syndrome
 Endocrine dyskinesia
 Chronic gastritis with decreased secretion
POSSIBLE CAUSES OF
DIARRHEA
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In healthy individuals
Drinking milk in patients with lactase
deficiency
Violation of the diet (an abrupt change of diet,
water composition, the use of unripe fruit,
overeating)
Scare ("bear's disease")
The use of drugs (antibiotics, antacids
containing magnesium salts, potassium
preparations, sulphonamides, anticoagulants,
digitalis, cholestyramine, sorbitol, mannitol)
Pathogenesis
During normal digestion, food is kept
liquid by the secretion of large amounts
of water by the stomach, upper small
intestine, pancreas, and gallbladder.
 Food that is not digested reaches the
lower small intestine and colon in liquid
form. The lower small intestine and
particularly the colon absorb the water,
turning the undigested food into a moreor-less solid stool with form.
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Increased amounts of
water in stool can occur if
the stomach and/or small
intestine secretes too much
fluid, the distal small
intestine and colon do not
absorb enough water, or
the undigested, liquid food
passes too quickly through
the small intestine and
colon for enough water to
be removed.
More than one of these
abnormal processes may
occur at the same time.
Pathogenesis (cont’d)
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Some viruses, bacteria and parasites cause increased
secretion of fluid, either by invading and inflaming the
lining of the small intestine (inflammation stimulates
the lining to secrete fluid) or by producing toxins
(chemicals) that also stimulate the lining to secrete
fluid but without causing inflammation.
Inflammation of the small intestine and/or colon from
bacteria or from ileitis/colitis can increase the rapidity
with which food passes through the intestines,
reducing the time that is available for absorbing water.
Conditions of the colon such as collagenous colitis can
block the ability of the colon to absorb water
Clinical symptoms

Sudden onset of bowel frequency associated
with crampy abdominal pains, and a fever will point to an
infective cause;
 bowel frequency with loose blood-stained stools to an
inflammatory basis;
 the passage of pale offensive stools that float, often
accompanied by loss of appetite and weight loss, to
steatorrhoea.
 Nocturnal bowel frequency and urgency usually point
to an organic cause.
 Passage of frequent small-volume stools (often
formed) points to a functional cause
Threatening symptoms of diarrhea
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1. The presence of blood in the stool
2. Feces in the form of "rice broth"
 3. Increased body temperature
 4. Nausea and vomiting
 5. Diarrhea accompanied by severe abdominal pain
 6. Diarrhea occurs in several family members
 7. Diarrhea lasts for a few weeks
 8. Diarrhea is accompanied by loss of consciousness
 9. Diarrhea accompanied by severe thirst, dry mouth,
dry skin
 10. Diarrhea is accompanied by a small amount of
urine
 11. Diarrhea in pregnancy
Signs of dehydration:
Dark urine
 Small amount of urine
 Rapid heart rate
 Headaches
 Dry skin
 Irritability
 Confusion
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Signs of dehydration in young
children :
Dry mouth and tongue
 Sunken eyes or cheeks
 No or decreased tear production
 Decreased number of wet diapers
 Irritability or listlessness
 Skin that stays pinched instead of
flattening out after being pinched
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Acute diarrhea
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Diarrhea of sudden onset is very common, often short-lived and
requires no investigation or treatment. This type of diarrhea is seen
after dietary indiscretions, but diarrhea due to viral agents also lasts
24–48 hours
Travellers’ diarrhea, which affects people travelling outside their own
countries, particularly to developing countries, usually lasts 2–5 days;
Clinical features associated with the acute diarrheas include fever,
abdominal pain and vomiting. If the diarrhea is particularly severe,
dehydration can be a problem;
The very young and very old are at special risk from this.
Investigations are necessary if the diarrhea has lasted more than 1
week. Stools (up to three) should be sent immediately to the laboratory
for culture and examination for ova, cysts and parasites.
If the diagnosis has still not been made, a sigmoidoscopy and rectal
biopsy should be performed and imaging should be considered.
Acute diarrhea (cont’d)
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Oral fluid and electrolyte replacement is often
necessary. Special oral rehydration solutions
(e.g. sodium chloride and glucose powder) are
available for use in severe episodes of
diarrhea, particularly in infants.
 Antidiarrheal drugs are thought to impair the
clearance of any pathogen from the bowel but
may be necessary for short-term relief (e.g.
Codeine phosphate 30 mg four times daily, or
loperamide 2 mg three times daily). Antibiotics
are sometimes given depending on the
organism.
Antibiotics in adult acute
bacterial gastroenteritis
Chronic diarrhea
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Always needs investigation. All patients should
have a sigmoidoscopy and rectal biopsy.
 whether the large or the small bowel is
investigated first will depend on the clinical
story of, for example, bloody diarrhoea or
steatorrhoea.
 When difficulties exist in distinguishing
between functional and organic causes of
diarrhoea, hospital admission for a formal 72hour assessment of stool weights is helpful
and will also assist in the diagnosis of
factitious causes of diarrhoea.
Antibiotic-associated diarrhea
(pseudomembranous colitis)
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Pseudomembranous colitis may develop
following the use of any antibiotic.
 Diarrhoea occurs in the first few days after
taking the antibiotic or even up to 6 weeks
after stopping the drug.
 The causative agent is Clostridium difficile. It is
a Gram-positive, anaerobic, spore-forming
bacillus and is found as part of the normal
bowel flora in 3–5% of the population and
even more commonly (up to 20%) in
hospitalized people.
Antibiotic-associated diarrhea
(pseudomembranous colitis) (cont’d)
Pathogenesis
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C. difficile produces two toxins: toxin A is an
enterotoxin while toxin B is cytotoxic and causes
bloody diarrhoea.
 It causes illness either after other bowel commensals
have been eliminated by antibiotic therapy or in
debilitated patients who have not been on antibiotics.
 Almost all antibiotics have been implicated but the
present increase has been attributed to the overuse of
quinolones (e.g. ciprofloxacin).
 Hospital-acquired infections remain high, partly due to
increased person-to-person spread and from fomites.
In recent years new strains of C. difficile with greater
capacity for toxin production have been reported.
There have been a number of hospital outbreaks with
a high mortality.
Clinical features
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C. difficile diarrhoea can begin anything from 2 days to
a month after taking antibiotics.
 Elderly hospitalized patients are most frequently
affected. It is unclear as to why some carriers remain
asymptomatic.
 Symptoms can range from mild diarrhoea to profuse,
watery, haemorrhagic colitis, along with lower
abdominal pain.
 The colonic mucosa is inflamed and ulcerated and can
be covered by an adherent membrane-like material
(pseudomembranous colitis). The disease is usually
more severe in the elderly and can cause intractable
diarrhoea, leading to death.
Treatment
metronidazole 400 mg three times daily
or
 oral vancomycin 125 mg four times daily
 Causative antibiotics should be
discontinued if possible.
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Travellers’ diarrhea
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Travellers’ diarrhea is defined as the passage of three or more
unformed stools per day in a resident of an industrialized country
travelling in a developing nation.
Infection is usually food- or water-borne, and younger travellers
are most often affected (probably reflecting behaviour patterns).
Reported attack rates vary from country to country, but approach
50% for a 2-week stay in many tropical countries.
The disease is usually benign and self-limiting: treatment with
quinolone antibiotics may hasten recovery but is not normally
necessary.
Prophylactic antibiotic therapy may also be effective for short
stays, but should not be used routinely.
Purgative abuse
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This is most commonly seen in females who surreptitiously take highdose purgatives and are often extensively investigated for chronic
diarrhea.
The diarrhea is usually of high volume (> 1 L daily) and patients may
have a low serum potassium.
Sigmoidoscopy may show pigmented mucosa, a condition known as
melanosis coli. Histologically the rectal biopsy shows pigment-laden
macrophages in patients taking an anthraquinone purgative (e.g. senna).
Melanosis coli is also seen in people regularly taking purgatives in
normal doses.
In advanced cases a barium enema may show a dilated colon and loss
of haustral pattern.
Phenolphthalein laxatives can be detected by pouring an alkali (e.g.
sodium hydroxide) on the stools, which then turn pink; a magnesiumcontaining purgative will give a high faecal magnesium content.
Anthraquinones can also be measured in the urine. If the diagnosis is
suspected, a locker or bed search (while the patient is out of the ward) is
occasionally necessary. Management is difficult as most patients deny
purgative ingestion.
Purgative abuse often occurs in association with eating disorders and all
patients needs psychiatric help. It is sometimes safer not to confront the
patient with their diagnosis.
Diarrhoea in patients with
HIV infection
Chronic diarrhoea is a common symptom
in HIV infection, but HIV’s role in the
pathogenesis of diarrhoea is unclear.
 Cryptosporidium is the pathogen most
commonly isolated. Isospora belli and
microsporidia have also been found.
 The cause of the diarrhoea is often not
found and treatment is symptomatic.
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Functional diarrhea
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In this form of functional bowel disease, symptoms
occur in the absence of abdominal pain and commonly
are:
■ The passage of several stools in rapid succession
usually first thing in the morning. No further bowel
action may occur that day or defecation only after
meals.
■ The first stool of the day is usually formed, the later
ones mushy, looser or watery.
■ Urgency of defecation.
■ Anxiety, uncertainty about bowel function with
restriction of movement (e.g. travelling).
■ Exhaustion after the ‘morning rush’.
Treatment of functional diarrhea
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loperamide often combined with a
tricyclic antidepressant prescribed at
night (e.g. clomipramine 10–30 mg).
Drugs for treatment of diarrhea
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Anastaltic (loperamide)
enzyme agents (creon, festal, enzymtal,
enzystal, pancreatin)
drugs for oral rehydration (gastrolit, rehydron)
Antidiarrheal microbial products, probiotics
(bifidumbacterin, bificol, bifiform, colibacterin,
lactobacterin, hilak)
drugs of other pharmacological groups
(smecta, antispasmodics)
Pharmaceutical guardianship for
diarrhea
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When diarrhea is a loss of fluid and
electrolytes, so you need prescriptions for oral
rehydration
 Loperamide administered with caution to
patients with impaired liver function
 If you experience constipation reception
anastaltic drugs must be stopped immediately
 In the appointment of loperamide may appear
a pain in the lower abdomen, fatigue, lethargy,
headache
Pharmaceutical guardianship for
diarrhea (cont’d)
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On the background of antimicrobial therapy
may use probiotics or drugs linex or bifiform
because they contain antibiotic-resistant
strains of the intestinal flora
 Unacceptably to add sugar in oral rehydration
solutions (increased osmolarity of the solution
and as a result - increased diarrhea)
 Since Smecta has adsorbent properties, and
may slow or reduce absorption of
simultaneously taken drugs. It is
recommended to comply with the interval
between smecta doses and other drugs
Pharmaceutical guardianship for
diarrhea (cont’d)
Simethicone, which is part of enzimtal,
pangrol, reduces flatulence
 Drugs hilak & hilak forte should not take
with milk and other dairy products
 Concomitant use of hilak and hilak forte
with antacids is unacceptable
 Laktobacterin is recommended to drink
milk
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