WHO defines diarrhoea as 3 or more loose and watery stools in 24 hours of period.
May be due to
- Decreased water & electrolyte balance
- Increased secretion by intestinal mucosa
- Increased luminal osmotic load
- Inflammation of the mucosa & exudation in lumen.
Principles of management –
Most diarrhoeas are self limiting.
Management of diarrhoea depends on establishing the underlying cause & instituting specific therapy.
- Treatment of fluid depletion
- Maintenance of nutrition
- Drug therapy
Hydration must be maintained in all cases of diarrhoea to prevent fluid depletion and shock.
Intravenous rehydration –
- Needed when fluid loss is severe, >10% body weight.
- Or when person is not able to take oral fluids.
- Composition of i.v. fluid –
NaCl – 85 mM = 5 g
KCl – 13 mM = 1 g
NaHCO3 – 48 mM = 4 g
The above in 1 L water or 5% glucose solution .
Oral rehydration –
- It contains sodium & potassium chloride, trisodium citrate &
- Glucose helps in absorption of sodium because glucose facilitated sodium reabsorption remains intact even in severe diarrhoea.
- Trisodium citrate is to prevent acidosis.
The Who has formulated a new formula WHO-ORS, in which the concentration of glucose & NaCl as well as total osmolarity is decreased because –
WHO std. formula was used for cholera stools in which loss of Na was more. Now there is a decrease in cholera cases & major cause of diarrhoea now is rotavirus.
It had lead to edema because of high Na content.
II. MAINTENANCE OF NUTRITION
Fasting decreases the brush border disaccharide enzymes & reduces absorption of salt, water & nutrients. This may lead to malnutrition is diarrhoea is prolonged or recurrent.
III. DRUG THERAPY
1] Antimicrobials in Diarrhoea :-
- These drugs have a limited role because bacterial pathogen is responsible for only a fraction of cases.
- Antimicrobials are useful in slightly loose, smaller volume stools, frequently with mucous or blood, and associated with fever, abdominal pain or vomiting .
- These are generally caused by organisms like –
Shigella, enteropathogenic E.coli, Campylobacter jejuni, salmonella typhimurim, E.histolytica, etc.
2] Probiotics in diarrhoea.
- These are microbial cell preparations, either live cultures or lyophilised powders.
- They restore & maintain healthy gut flora
- Recolonization of gut by non pathogenic, mostly lactic acid forming bacteria & yeast is believed to help restore the balance of gut flora.
- Natural curd / yoghurt is an abundant source of lactic acid producing organisms, which serve as probiotics.
- Probiotics reduce antibiotic associated diarrhoea, acute infective diarrhoea & risk of traveller’s diarrhoea.
Non – specific antidiarrhoeal drugs
b. Antisecretory drugs
c. Antimotility drugs
a] Absorbents –
– These are colloid bulk forming agents like ispaghula, methyl cellulose, etc which absorb water & swell.
– They modify the consistency & frequency & give an impression of improvement, but do not reduce water & electrolyte balance.
b] Antisecretory drugs –
- It is an encephalinase inhibitor
- Prevents degradation of endogenous enkephalins which are mainly opioid receptor agonists.
- Decreases intestinal hypersecretion by lowering mucosal cAMP due to enhanced enkephalin action.
- Long acting somatostatin analogue
- Used to decrease secretory diarrhoea & other symptoms of carcionoid syndrome & vasoactive intestinal peptide tumors (VIPoma)
- In high doses, it is useful for treatment of diarrhoea due to vagotomy & AIDS.
Others like bismuth subsalicylate, anticholinergics, opioids are used.
c] Antimotility drugs –
– These are opioid drugs which increase small bowel tone & segmenting activity, reduce propulsive movements & diminish intestinal secretions.
– They afford only symptomatic relief in diarrhoea.
- It is a non-addictive over the counter drug for diarrhoea
Codeine, Diphenoxylate may also be used.
Note :- Antimotility drugs are limited to non-infective diarrhoea, because they delay the clearance of pathogen from intestine.
Also, drugs for inflammatory bowel disease are used in the treatment of diarrhoeas.
Contributed by – Soumya Khot, Jay Shah.