Gastrointestinal problems

Dr. Rabie Gabriel

Diarrhea
Background
• Diarrhea can be defined as an increase in
frequency of the passage of soft or watery
stools relative to the usual bowel habit for that
individual.
• Diarrhea is also objectively defined as passing a
stool weight or volume greater than 200 g or 200
mL per 24 hours.
• It is not a disease but a sign of an underlying
problem such as an infection or
gastrointestinal disorder.
Background
• It can be classed as
– acute (less than 7 days),
– persistent (more than 14 days), or
– chronic (lasting longer than a month).

• Most cases of acute diarrhea are due to

infections with viruses and bacteria and are self-
limited. Non-infectious etiologies become more
common as the course of the diarrhea persists
and becomes chronic.
Acute diarrhea
• Acute diarrhea is most commonly caused by an
infection, including virus, bacteria, parasite, and
toxin from food poisoning, as well as extraintestinal
infections such as otitis media, pneumonia, and
urinary tract infections.
• Of the viral diarrheas, rotavirus and norovirus are
the first and second most common causes of viral
gastroenteritis, respectively. These types seldom
require more than electrolyte replacement, as they
are most often self-limiting and resolve without
serious sequelae
Norovirus
Acute diarrhea
• Most cases of bacterial diarrhea are contracted
through ingesting contaminated food or drink,
although direct fecal-oral contact and sexual spread
can also occur. Examples include: campylobacter,
Pathogenic Escherichia coli, Shigella, and
Salmonella Spp.
• Patients may contract infections from parasites
such as Giardia lamblia or Entamoeba histolytica
through ingesting food or water contaminated with
animal or human feces that contain their cysts.
Campylobacter
E. Coli
Salmonella
Shigella
Giardia lamblia
Entameba Hystolotica
Chronic diarrhea
• Recurrent or persistent: there are several
causes and chronic diarrhoea requires medical
investigation.
• Causes include:
– Irritable-bowel syndrome (IBS)
– inflammatory bowel disease (for example, Crohn’s
disease, ulcerative colitis)
– malabsorption syndromes (such as celiac disease)
– Bowel tumor
– Metabolic disease (diabetes, hyperthyroidism)
– Side-effects of drugs
– Laxative abuse.
When to refer
• Duration:
– More than 72 hours in older children and
adults
– More than 48 hours in children under 3 years
and elderly patients
– More than 24 hours in people with diabetes
– More than 24 hours in babies under 1 year
– Babies under 3 months: refer immediately.
• Signs of dehydration in babies: dry skin, sunken
eyes and fontanelle, dry tongue, drowsiness,
less urine than normal.
When to refer

• Diarrhea associated with severe vomiting and

fever
• History of change in bowel habit
• Recurrent diarrhea
• Presence of blood or mucus in stools
• Suspected adverse drug reaction
• Alternating constipation and diarrhea in elderly
patients may indicate fecal impaction
Treatment
Oral rehydration therapy
• The first line of treatment for acute diarrhea is fluid
and electrolyte replacement by oral rehydration
therapy (ORT).
• Normally, the body loses between 70 and 200 ml of
water per day through defecation.
• In diarrhea, water loss of up to four times this volume
per loose stool occurs, and sodium and potassium
alkaline salts are excreted along with it, leading to a
fall in plasma pH (acidosis). This can have serious
metabolic consequences, particularly in the very
young and the elderly.
Treatment
Oral rehydration therapy
• Fluid and electrolyte losses are increased if
vomiting also occurs.
• Oral rehydration salts are not intended to relieve
symptoms but are designed to replace water
and electrolytes lost through diarrhea and
vomiting.
• They contain sodium and potassium to replace
these essential ions and citrate and/or
bicarbonate to correct acidosis.
Treatment
Oral rehydration therapy

• Glucose is also an important ingredient as it acts as a

carrier for the transport of sodium ions, and hence
water, across the mucosa of the small intestine, as
well as providing the energy necessary for that
process.
• ORT can be recommended for patients of any age,
even when referral to a doctor is considered
necessary.
Composition of the new ORS adopted by
WHO
Treatment
Loperamide

• Loperamide is a synthetic opioid analogue and

is thought to exert its action via opiate receptors
slowing intestinal tract time and increasing the
capacity of the gut.
• The dose is two capsules immediately, followed
by one capsule after each further bout of
diarrhea.
Treatment
Bismuth subsalicylate
• Bismuth-containing products have been used for
many decades. Its use has declined over time as other
products have become more popular.
• However, bismuth subsalicylate has been shown to be
effective in treating traveler’s diarrhea.
• The dose is 30 mL or two tablets taken every 30 min to
1 hour when needed, with a maximum of eight doses
in 24 hours.
• However, some studies showed bismuth subsalicylate
to be significantly slower in symptom resolution than
its comparator drug loperamide.
Treatment
Kaolin and morphine

• The constipating side effect of opioid analgesics

can be used to treat diarrhea.
• However, kaolin and morphine products have no
evidence of efficacy and should not be
recommended.
• It remains a popular home remedy, especially with
the elderly.
Treatment
Alternative to ORS

• Patients can be advised to increase their intake

of fluids, particularly fruit juices with their
glucose and potassium content, and soups
because of their sodium chloride content