Community Pharmacy Practice

PCP 311
Dept. of Clinical Pharmacy
Ass. Prof. Mohamed El- Shafie,
PhD
 DIARRHEA
Definition: bowel frequency & looseness (abnormally liquid
or unformed stools) are increased compared to one’s normal
bowel pattern (usually > 3 times/day), when intestine is unable
to absorb water from stool.
Or
Diarrhoea is defined as an increased frequency of bowel
evacuation, with the passage of abnormally
soft or watery faeces.
It may be:
Acute: for < 2 wks
Persistent: for 2-4 wks
Chronic: for > 4 wks

 A majority of acute diarrheal cases are due to infectious etiology.

 Chronic diarrhea is commonly categorized into three groups; watery,
fatty (malabsorption), or infectious.
What are complications of diarrhea?
 Two potentially serious complications of diarrhea are
dehydration (in cases of severe and frequent diarrhea)
and malabsorption (in cases of chronic diarrhea).
 Dehydration, which can be life-threatening if untreated.
Dehydration is particularly dangerous in children, older
adults and those with weakened immune systems.
 Dehydration esp. children & elderly, electrolyte
disturbance, metabolic acidosis & CV collapse
 If your diarrhea fails to improve and resolve completely, you
can be at risk of complications (dehydration, electrolyte
imbalance, kidney failure and organ damage)
 Diarrhea is the result of reduced water absorption by the
bowel or increased water secretion.
 I- INFORMATION TO BE COLLECTED
What You Need to Know?
Age (infant, child, adult, elderly) Recent travel abroad

Duration (acute and self-limiting) Causative factors

Severity Medications

Symptoms / Associated symptom

 Nausea and vomiting
 Fever
 Abdominal cramps
 Flatulence

Other family members affected

Previous history
 AGE:
 Particular care is needed in the very young and the very old.
 Infants (younger than 1 year) and elderly patients are especially at risk of becoming
dehydrated.

 SEVERITY:
 The degree of severity of diarrhoea is related to the nature and frequency of stools.
 Both these aspects are important, since misunderstandings can arise, especially in self
diagnosed complaints.
 Elderly patients who complain of diarrhoea may, in fact, be suffering from faecal impaction.
They may pass liquid stools, but with only one or two bowel movements a day.

 SYMPTOMS
Questions to be asked by pharmacist (adults):
- Food intake and whether other family members or friends are suffering from the
same symptoms, since acute diarrhoea is often infective in origin.
Questions to be asked by pharmacist (infants):
- Vomiting and fever (increase the likelihood that severe dehydration will develop)
- Whether the baby has been taking milk feeds and other drinks as normal.
- Reduced fluid intake predisposes to dehydration
• Often there are localised minor outbreaks of gastroenteritis, and the pharmacist may be
asked several times for advice and treatment by different patients during a short period of
time.
 PREVIOUS HISTORY
 A previous history of diarrhoea or a prolonged change in bowel habit
would warrant referral for further investigation and it is important that the
pharmacist distinguish between acute and chronic conditions.
 Chronic diarrhoea (of more than 3 weeks’ duration) may be caused by
bowel conditions such as Crohn’s disease, IBS or ulcerative colitis and
requires medical advice.
 RECENT TRAVEL ABROAD
 Diarrhoea in a patient who has recently travelled abroad requires referral
since it might be infective in origin.
 Gardiasis should be considered in travellers recently returned from South
America or the Far East.
 When diagnosing the cause of diarrhea, will ask about the person’s
symptoms and any current medications they take, their past medical
history, their family history, their travel history, any other medical
conditions they have.
 They will also ask: when the diarrhea started, how frequent the stools
are, if blood is present in the stool, if the person has been vomiting,
whether the stools are watery or contain mucus or pus, how much stool
 Common causes
of acute diarrhea
I- Infections= gastroentritis
1- Viral as; rotavirus, hepatitis A
2- Bacterial as; Salmonella, Campylobacter & Escherichia coli
A- in small intestine: large volume watery stool (non-inflammatory diarrhea)
B- in large intestine: dysentery-like stool: extreme urge to defecate,
abdominal cramping, fever, chills & small volume stool that contain blood &
pus (inflammatory diarrhea)
3- Protozoal: as Giardia Lamblia, Entamoeba Histolytica
> 2 wks, profuse watery diarrhea, may be accompanied by
flatulence &/or abdominal pain
II- Disease:
1- GIT diseases: Inflammatory bowel disease: IBD (Crohn’s disease,
ulcerative colitis), Irritable bowel syndrome = IBS, colon carcinoma
2- Non- GIT diseases: DM, HIV , hyperthyrodism,
 III- Medications:
- laxatives, antibacterials, antacids containing magnesium,
misoprostol, orlistat, high doses of metformin.
- medications that cause hypermotility (prokinetics) as
metoclopramide, SSRIs, digoxin, colchicine.
IV- Diet induced:
 Food poisoning or allergy
 High fiber diet
 Spicy foods
 Large amounts of caffeine
 Lactose intolerance

V- Habits: alcoholism
Some other major causes of chronic diarrhea include:
 Microscopic colitis: This is a persistent type of diarrhea that
usually affects older adults. It develops due to inflammation and occurs
often during the night.
 Malabsorptive and maldigestive diarrhea: The first is due
to impaired nutrient absorption, and the second is due to impaired
digestive function.
 Chronic infections: A history of travel or antibiotic use can be
clues in chronic diarrhea. Various bacteria and parasites can also be
the cause.
 Drug-induced diarrhea: Laxatives and other drugs, including
antibiotics, can trigger diarrhea.
 Endocrine-related causes: Sometimes, hormonal factors cause
diarrhea. This is the case in Addison’s disease and carcinoid tumors.
 Cancer-related causes: Neoplastic diarrhea is associated
with a number of gut cancers.
 When to refer????????
1- Adult persistent diarrhea: > 2-3 days with no sign of
slight improvement despite adequate ttt.
2- Vey high frequency (10-20 bowel movements/daily):
3- Accompanying symptoms:
 Blood/mucus in stool: inflammatory (IBD), infectious
(dysentery), fissures, or neoplasma (colorectal cancer).
 High fever: > 38.5 C: dysentery
 Severe abdominal tenderness or mild tenderness lasting
for > 48 hrs.
Alternating with constipation, with colicky abdominal pain
upon rising in the morning or immediately following a meal
in adolescents and young adults: IBS.
 Vomiting over a period > 48 hrs
 Dehydration (dry mouth, sunken eyes, dry non elastic
skin) or wt loss (>5% )
 Diarrhea in infants
Most commonly occurs as a result of :
1. Viral infection
2. Teething
3. Poor sterilization of feeding bottles
4. Excessive sugar intake
• Complications:
 Dehydration: babies and very old patients are particularly
susceptible to dehydration caused by diarrhea
 Malnutrition,
• If not improving after 24 hrs in a baby < 6 months & 48
hrs in older babies: consider referral.
Refer for diarrhea include:
 Blood or pus in bowel movements
 A fever
 Signs of dehydration, such as extreme thirst and dry mouth
 Chronic diarrhea
 Diarrhea during sleep
 Significant weight loss
 Severe abdominal pain
 People at risk of complications, such as young children and
older adults, should also see a doctor for treatment if diarrhea
does not improve with time and home remedies.
 Management-
1- Non-drug treatment
 Good personal hygiene
 Proper handling, cooking & storage of foods
 Avoid fatty or spicy foods & food rich in simple sugars
 Inc. bulk diet e.g. rice, bananas, whole wheat & bran
The BRAT diet.
This consists of: Bananas Rice Apple Toast
 Adopting this diet for the first 24 hours may prevent the bowels from
working too hard.
 Avoid carbonated or caffeinated beverages & hypertonic fruit juices
 Regular intake of flat soft fluids (ginger, tea, soup), esp. in young children
& elderly
 Counsel patient: drink plenty of water non milky fluids
 Best avoid: fatty food, high sugar content ( hyper osmolar solution,
exacerbate the problem)
Diet: The following diet tips may help with diarrhea:
 Sipping on clear liquids, such as electrolyte drinks, water, or fruit juice without added
sugar
 After each loose stool, replacing lost fluids with at least 1 cup of liquid
 Doing most of the drinking between, not during, meals
 Consuming high potassium foods and liquids, such as diluted fruit juices, potatoes
and bananas
 Consuming high sodium foods and liquids, such as broths, soups, sports drinks, and
salted crackers
 Eating foods high in soluble fiber, such as banana, oatmeal, and rice, as these help
thicken the stool
 Limiting foods that may make diarrhea worse, such as creamy, fried, high dairy, and
sugary foods
Foods and beverages that might make diarrhea worse include:
 Sugar-free gum, mints, sweet cherries, and prunes
 Caffeinated drinks and medications
 Fructose in high amounts, from fruit juices, grapes, honey, dates, nuts, figs, soft
drinks, and prunes
 Lactose in dairy products
 Magnesium
 Olestra (Olean), which is a fat substitute
 Anything that contains artificial sweeteners
Fluid & electrolyte replacement:
 The World Health Organization (WHO) say that ORS can safely and effectively
treat over 90%Trusted Source of nonsevere diarrhea cases.
 Oral rehydration solutions (ORS): contains water, salts & sugar:
recommended for babies & elderly
• M.O.A: glucose acts as a carrier for transporting salt & water from intestines into
blood.
 Recipe for home made ORS:
• 1/2 teaspoon of table salt (NaCl) + 1/4 teaspoon of potassium salt (KCl) + 1/2
teaspoon of backing soda (Na bicarb) + 2 teaspoons of sugar (glucose) + 1 L
water
 Or more simply
1 teaspoon of table salt + 8 teaspoons of sugar + 1 L water
Antidiarrheal medications:
Over-the-counter antidiarrheal medications are also available.
These include loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol).
 Diphenoxylate atropine, with rehydration therapy > 16 years
 Kaolin: traditional remedy
 Probiotics (Rifaximine): reduce stool frequency, shorten duration of infective
diarhea, used with rehydration therapy
 2- Pharmacological treatment
I- Symptomatic relief
1: Antiprestaltic (antimotility); oral loperamide (Imodium)
M.O.A:
1- Stimulate microopioid Rs in small & large intestines’ muscles leading
to antiperistaltic action thereby reducing amount of fluid lost in stool
2- Antisecretory: prevent secretion of intestinal fluids into bowel
Contraindications:
1- Symptoms of acute bacterial diarrhea (e.g. fever, chills, bloody
diarrhea) as expulsion of the toxin is necessary
2- Pts with sever colitis, or children < 6 yrs, as it can cause toxic
megacolon
2- Adsorbents: kaolin & pectin (Kapect)
Disadv: can adsorb nutrients & other medications (separated
by 2-3 hrs)
3- Bismuth subsalicylate (BSS): oral
Bismuth subsalicylate is used to treat diarrhea, heartburn, and
upset stomach in adults and children 12 years of age and older.
M.O.A: adsorbent (adsorb intestinal toxins), antisecretory,
antibacterial, coating & protective for intestinal mucosa
Disadv:
1- Moderate effectiveness, reduce number of stools by 50%, with
need for frequent dosing (up to 8 doses /day),
2- Cause darkening of tongue & stool
Contraindications:
– Damaged intestinal mucosa (higher salicylate absorption)
– Hematological diseases e.g. hypoprothrombinemia & hemophilia
– Documented allergy to salicylates
– Children < 12 yrs
– Within 6 wks following varicella vaccination
– Renal impairment because of the risk of bismuth
encephalopathy.
3- Probiotics; as lactobacillus
M.O.A:
– An exogenous species of bacteria or yeast they are
introduced into gut to reestablish normal gut flora &
resist colonization by bacterial pathogens .
– It produces lactic acid, thus creating an acidic
environment unfavorable to pathogenic
microorganisms
– Not FDA approved

Contraindications:
– immunosuppression due to risk of
bacteremia
– milk allergy
– < 3 yrs
II- Antimicrobials:
Indications:
 inflammatory infectious diarrhea: profuse bloody or mucoid
diarrhea with fever (> 38.5 C)
Persistent profuse diarrhea (> 2 wks): possible Giardia
Esp. in immunocompromised, mechanical heart valves or recent
vascular grafts & elderly.
Agents:
– empirical; depend on: suspected pathogen, age & allergy history
 Febrile dysentery:
– macrolides (as azithromycin 500 mg once daily X 3 days) is preferred over
fluoroquinolones (as ciprofloxacin 500 mg bid for 3–5 d) due to higher rates of
resistance to the latter
– Nifuroxazide (Antinal):
 Giardia or Entamoeba histolytica:
– tinidazole (Protozole; 2gm PO x 1 dose) is superior to metronidazole
(Flagyl, Amrizole; 250 mg qid for 7 d).