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Antidiarrheal
Therapy
by
Dr.Hamed Daghzghzadeh
Diarrhea
is loosely defined as passage
of abnormally liquid or unformed
Stool at an increased frequency.
For adults on a typically western
Diet, stool weight exceeding 200g/d
Can generally be considered diarrheal.
Epidemiology of Acute
Diarrhea
Worldwide >1000,000,000
people/year
5-8 million deaths / year
in developing countries
Pathophysiologic classification of diarrhea
►Secretory diarrhea
►Osmotic
diarrhea
►Inflammatory ( exudative )
diarrhea
►Motility ( dismotile ) diarrhea
►Anatomic( absorptive surface)
Major Causes of Acute Diarrhea
8
► INFECTIONS (Including Travelers Diarrhea)
Bacterial : Campylobactre Species, C.difficile, E.coli, Salmonella eneritides
,
Shigella Species
Parasitic/protozoal : E. histolytica, Giardia lambilia,Cryptosporidium ,Cyclospoa
Viral : Adenovirus , Norwalk virus , Rotavirus ,AIDS, Others
Fungal
► FOOD
POISONING :
B.Cereus , C . Perfringens , Salmonella species ,
S .aureus, Vibrio species, Shigella species , Camppylobacter.jejuni, E.coli
MEDICATIONS
► RECENT INGESTION OF LARGE AMOUNT OF
POORLY ABSORBABLE SUGARS
► INTESTINAL ISCHEMIA
► FECAL IMPACTION
► PELVIC INFLAMMATION
► GRAFT VS HOST DISEASE
►
Most acute diarrheas
are due to infectious
diseases that have
limited courses from a
few days to a few
weeks.
MAJOR CAUSES OF CHRONIC DIARRHEA
IBS
► IBD
► Ischemic bowel disease
► Chronic bacterial / mycobacterial infection
► Parasitic & fungal infections
► Radiation enteritis
► Malabsorption Syndromes
► Medications, Alcohol
► Colon cancer , Villous Adenoma ,intestinal Lymphoma
► Diverticulitis
► Previous Surgery ( gastrectomy, vagatomy, intestinal resection )
► Endocrine causes
► Fecal impaction
► Heavy metal poisoning
► Epidemic idiopathic chronic diarrhea
►
NONSPECIFIC
Rx OF
DIARRHEA
The most important Rx
for diarrhea is to ensure
that
fluid and electrolyte
deficits are replenished
with IV or oral
rehydration solution.
The rate of replacement should ►
match the clinical presentation.
Empiric Therapy
of
Acute Diarrhea
Aminoacid &
Glucose absorption
accelerates sodium
and fluid absorption
in the jejunum.
Saline solutions
containing glucose
or amino acids will
be absorbed readily
Oral rehydration
solutions increase fluid
and electrolyte
absorption; they are not
designed to reduce stool
output, so stool weight
actually may increase
with their use.
Infection
is a frequent
cause of acute
diarrhea.
If the prevalence of bacterial or
protozoal infection is high in a
community or in a specific
situation, empiric use of
antibiotics is logical.
as in the treatment of
travelers'
diarrhea
Even without
bacteriologic
proof of
infection.
Empiric antibiotic therapy is
often also logically used
for more
severely ill patients
while awaiting bacterial
culture results.
Adachi JA, Zeichner LO, DuPont HL, Ericsson CD: Empirical antimicrobial therapy for traveler's diarrhea. Clin
Infect Dis 31:1079, 2000.
Ciprofluxacine 500 mg Q12h ( 3 days)
Or
Azythromycin 1000 mg
single dose
Experts also advise
against empiric
treatment of
salmonellosis unless
enteric fever is present.
Sirinavin S, Garner P: Antibiotics for treating salmonella gut infections. Cochrane
Database Syst Rev 30:CD001167, 2000.
Nonspecific antidiarrheal agents
can reduce stool
frequency and stool
weight and can
reduce coexisting
symptoms, such as
abdominal cramps
Opiates, such as
loperamide, or
diphenoxylate with
atropine frequently
are employed.
Schiller LR: Review article: Anti-diarrhoeal pharmacology and
therapeutics. Aliment Pharmacol Ther 9:87, 1995.
Intraluminal agents, such as
bismuth subsalicylate and
adsorbents (e.g., kaolin) also
may help reduce the fluidity
of bowel movements.
Schiller LR: Review article: Anti-diarrhoeal pharmacology and therapeutics. Aliment
Pharmacol Ther 9:87, 1995.
Empiric Therapy of Chronic Diarrhea
is used in three situations:
Initial treatment before diagnostic
testing;
(2) After diagnostic testing has failed to
confirm a diagnosis
(3) When a diagnosis has been made but no
specific treatment is available or specific
treatment has failed to produce a cure.
(1)
Generally, empiric
antibiotic therapy is
less useful in
chronic diarrhea
than in acute diarrhea.
In chronic diarrhea
an empiric course of
metronidazole or a
fluoroquinolone
before extensive diagnostic
testing,
is not recommended.
►Remember
that
diarrhea can be a
prominent symptom
of malaria.
Other drugs
►VERAPAMIL
►NIFEDIPENE
REDUCE MOTILITY
INCREASE ABSORBTION
Travelers'
diarrhea
Travelers'
diarrhea
affects
30% to 50% of
travelers to
developing
countries.
Enterotoxigenic Escherichia coli
(ETEC)
is the most common cause
of travelers' diarrhea
worldwide
Other causes of travelers' diarrhea
►Shigella
►Campylobacter
►Aeromonas,
►
Plesiomonas,
►Vibrio
►Rotaviruses
►Norwalk virus
►Giardia
Most cases of
travelers' diarrhea
occur between
5 and 15 days after
arrival.
►Persons
with
gastric hypoacidity and
immunosuppressed patients are
probably at greater risk of
developing travelers' diarrhea.
►Most
bouts of
travelers' diarrhea are
self-limited, with
resolution after 4 to 6
days
The illness is heralded
by malaise, anorexia,
and abdominal
cramps, followed by
watery, usually
nonbloody, diarrhea
►In
some cases, nausea
and vomiting may be a
prominent component
How to prevent Travelers' diarrhea?
Bcause travelers' diarrhea is
contracted by the
ingestion of
fecally contaminated
food or water.
The first line of
defense for the
traveler is care in
selecting food and
beverages.
►The
first approach is
chemoprophylaxis
using either antibiotics
or bismuth to prevent
diarrhea.
The most widely used
approach to travelers' diarrhea
is probably the provision
of antibiotics to be used
by the traveler, if and
when diarrhea strikes.
Antibiotic prophylaxis is indicated for
travelers (to high risk countries), with
1. Gastric
achlorhydria
2. IBD
3. Immunocompromise
A reasonable current
recommendation is to
provide a three-day
course of a quinolone
most
developing countries.
for travelers to
 The patient is told to
begin the antibiotic
when diarrhea starts and
to continue treatment for
3 days.
A quinolone represents the
drug of choice for
travelers if antibiotic
prophylaxis is used or for
the treatment of travelers'
diarrhea.
A
single daily dose
of ciprofloxacin
(500 mg) had a
protective efficacy
of 94%.
Norfloxacin in a
daily dose of 400
mg had a protective
efficacy of 93% .
►Chemoprophylaxis
with
bismuth is moderately
effective (approximately
65%) in preventing
diarrhea.
►Two
bismuth
tablets(240mgx2)
taken four times daily.
It needs to be emphasized before
travel that self-treatment regimens
are not appropriate for the
traveler with
bloody diarrhea,
 severe abdominal pain,
 high fever

The disadvantages
relate to the possibility of
1-side effects
2-selection of
antibiotic-resistant organisms.
The advantage of
prophylactic antibiotics
is
their high efficacy in
preventing disease.
Finally,
the most important
component of self-treatment
is the replacement of the
fluid and electrolytes lost
during diarrhea.
Watery diarrhea that occurs later
after return or that persists longer
than 10 days despite antibiotic
therapy is most commonly
Giardia lamblia
infection.
If the diarrhea fails to
respond to metronidazole,
a gastrointestinal
evaluation should be
performed.
The diagnostic &
therapeutic
considerations differ
somewhat for
bloody diarrhea,
and the pace of the workup
should be accelerated.
Indications of antibiotic coverage
wether or not a causative organism is
discovered in acute diarrhea
3
1.
2.
3.
Immunecompromised patient.
Mechanical heart valves or
recent vascular graft.
Elderly.
Thank you
Constipation
Constipation
►Constipation,
or
associated symptoms,
afflicts many people
in the Western world.
The prevalence is greatest among children and the elderly.
►Many
people ignore the
symptoms or treat
themselves by dietary
modification or over-thecounter remedies.
PRESENTING SYMPTOMS
►Aperson
who says "I am
constipated" is either
conscious of an unpleasant
sensation related to bowel
movements or believes that
bowel function is abnormal.
►6%
- 23% of subjects
said in response to
interview that they had
experienced constipation
during the past 12
months.
►At
least 10% of the
subjects experienced
difficulty in defecation
at least once a month.
►More
women than
men regard
themselves as
constipated.
CLINICAL DEFINITION AND
CLASSIFICATIONA
►Clinical
definition of
constipation needs
to take account of
both difficult
defecation and
infrequent stools.
General Factors
►Sex
►Age
►Nationality
►Diet
►Exercise
and Daily Activity
Defecatory Function
►Failure
of Relaxation of the
Anal Sphincter Complex
►Ineffective Straining
►Diminished Rectal Sensation
►Size and Consistency of Stool
Psychological and Behavioral
Factors
►Personality
affects stool size
and consistency.
CONSTIPATION AS A
MANIFESTATION OF SYSTEMIC
DISORDERS
►Hypothyroidism
►Diabetes
Mellitus
►Hypercalcemia
CONSTIPATION AS A MANIFESTATION
OF CENTRAL NERVOUS SYSTEM
DISEASE OR EXTRINSIC NERVE
SUPPLY TO THE GUT
►Loss
of Conscious Control
►Parkinson's Disease
►Multiple Sclerosis
►Spinal Cord Lesions
CONSTIPATION SECONDARY TO
STRUCTURAL DISORDERS OF THE
COLON, RECTUM, ANUS, AND
PELVIC FLOOR
►Disorders
of Smooth Muscle
►Enteric Nerves
Disorders of the Anorectum and
Pelvic Floor
► Rectocele
► Weakness
of the Pelvic Floor—
"Descending Perineum Syndrome"
► Full-Thickness Rectal Prolapse,
Intrarectal Mucosal Prolapse, and
Solitary Rectal Ulcer Syndrome
PSYCHOLOGICAL DISORDERS AS
CAUSES OF OR AGGRAVATING
FACTORS IN CONSTIPATION
►Depression
Eating Disorders
►Denied Bowel Movements
►
CLINICAL ASSESSMENT
►History
►Social
History
►Physical Examination
►Prospective Use of a
Diary Card