Diarrhoea management

Armon K, Stephenson T, MacFaul R, et al. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001 85 132-142... 

There are some descriptions of water-borne outbreaks, or even small epidemics of acute gastroenteritis (diarrhoea), cholera and hepatitis E associated with catastrophic floods that occurred in developing countries, such as Sudan [34, 35], Nicaragua [36], Mozambique [37] and West Bengal [37]. On the contrary, no changes in the base-line outbreak incidence have been reported in developed countries after major floods [37, 38]. When infrastructures and water management are adequate, outbreaks of faecal-oral water-borne infectious diseases do not follow flood events, even in the case where water flooding has compromised the security of water facilities [37]. 

Codeine, one of the principal alkaloids of opium, has an analgesic efficacy much lower than other opioids, due to an extremely low affinity for opioid receptors. It is approximately one-sixth as potent as morphine. It has a low abuse potential. In contrast to other opioids, with the exception of oxycodone, codeine is relatively more effective when administered orally than parenterally. This is due to methylation at the C3 site on the phenyl ring (Figure 7.3), which may protect it from conjugating enzymes. It is used in the management of mild-to-moderate pain, often in combination with non-opioid analgesics, such as aspirin or paracetamol. It is valuable as an antitussive and for the treatment of diarrhoea. Side effects are uncommon and respiratory depression, even with large doses, is seldom a problem. 

The treatment of constipation and questions of use and abuse of laxatives are not normally of major interest to the anaesthetist. However, constipation is a particular problem in terminal care patients, especially where they are receiving opioid drugs for pain relief, and its prevention and management must be an integral part of their treatment. Both constipation and diarrhoea are problems in the intensive care patient. 

Diarrhoea is often of infective origin, but management is generaiiy non-specific. Diarrhoea is aiso common foiiowing antibiotic therapy which disturbs normai bowei flora. Repiacement therapy using eiectroiyte soiutions may be needed, and can be iife-saving in severe diarrhoea, especiaiiy in chiidren. Orai rehydration is preferred, aithough parenterai fluids may be required. 

A number of other ciasses of drug have shown potentiai in the management of diarrhoea. These inciude gut-specific o2-adrenergic agonists, intestinai Ci- channei biockers, somatostatin anaiogues, and caimoduiin inhibitors. 

Medical treatments of IBS are limited. Laxatives (particularly dietary fibre and bulking laxatives such as ispaghula) and antidiarrhoeals (loperamide and sometimes codeine) are prescribed to manage the symptoms of altered bowel habit. Colestyramine is of use in those with diarrhoea caused by bile salt... 

This can be controlled with the co-administration of standard antidiarrhoeal agents such as loperamide. All patients on FOLFOX chemotherapy (or any 5-fluorouracil-containing regimen) should be co-prescribed an antidiarrhoeal medication to use on an as required basis. The onset of diarrhoea should also indicate to the patient that they must increase their fluid intake to prevent dehydration. Patients must be warned that if the diarrhoea is not controlled (for example, within 48 hours of onset) then dehydration is a danger and they should be advised to contact their treating hospital or GP for advice. Severe manifestations may have to be managed by delay and/or dose modification of the patient s next cycle of chemotherapy. 

Adverse effects. Most patients tolerate oral iron therapy but 10-20% have symptoms that may be attributed to iron, generally gastrointestinal upset. These effects of oral iron include nausea, abdominal pain, and either constipation or diarrhoea. Upper GI effects appear to be dose-related and are best managed by ingestion of the tablet with or after food and/or reduction in the amount of iron content in each dose. This will prolong the necessary period of treatment. Diarrhoea or constipation can usually be treated symptomatically without a change in regimen. 

Problems of conscipation, diarrhoea and irritable bowel syndrome are common. Infective diarrhoeal diseases are a significant cause of morbidity and mortality worldwide, especially in infants and children.The management of these conditions is reviewed. 

In the normal adult, 7-8 litres of of water and electrolytes are secreted daily into the gastrointestinal tract. This, together with dietary fluid, is absorbed by epithehal cells in the small and large bowel. Water follows the osmotic gradients which result from shifts of electrolytes across the intestinal epithelium, and sodium and chloride transport mechanisms are central to the causation and management of diarrhoea, especially that caused by bacteria and viruses. The energy for the process is provided by the activity of Na /K ATPase. 

Almroth S, Latham M C 1995 Rational home management of diarrhoea. Lancet 345 709-711 Eastwood M 1995 The dilemma of laxative abuse. Lancet 346 1115... 

Goodburn, E. Mattosinho, S. Mongi, P. Waterston, A. Management of childhood diarrhoea by pharmacists and parents Is Britain lagging behind the Third World Br. Med. J. 1991, 302, 440-443. 

Gattuso JM, Kamm MA. Adverse effects of drugs used in the management of constipation and diarrhoea. Drug Saf 1994 10 47-65. 

Since the late 1990s, therapy radiographers have been trained to administer medicines for the management of radiotherapy side effects, such as pain rectal symptoms, constipation, diarrhoea skin reactions, wound care oral care nausea and vomiting. They are also beginning to use PGDs for X-ray contrast agents. 

Community case management for acute respiratory infection (ARI) and diarrhoea were clearly successful in reducing mortality their overall effects on the appropriateness of drugs choices, especially in the case of ARI, have however not been well studied. Other approaches that may yield moderate to large improvements were audit and feedback (or group processes), and audit combined with supervision. As in the industrialised world, the simple dissemination of printed educational material (clinical guidelines, prescribing information) had no impact. Experience in Zimbabwe underlines the relevance of... 

Irritable bowel syndrome. Functional disorder characterized most commonly by cramping, abdominal pain, bloating, constipation and diarrhoea. Its symptoms can be controlled with diet, stress management and medications. 

A randomised, controlled trial of misoprostol (n = 100) compared to oxytocin (n = 100) in the active management of fhird-stage laboxir foxmd that misoprostol was as effective as oxytocin but resulted in greater incidence of shivering, fever and diarrhoea [60 3-... 

Several new reports on the use of human, porcine or salmon calcitonin in the management of Paget s disease of bone have appeared. Biochemical and clinical improvement (especially reduction of pain) is obvious although not always complete 4 5, 6 ). Addition of diphosphonate to the treatment with calcitonin improved the biochemical results (8 ). Side effects (nausea, vomiting, transient facial flushing or diarrhoea) usually subside after a few days of treatment (4 ). The possibility of acute renal failure due to salmon calcitonin is raised by the report of a single case (7 ). 

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