2. DIARRHOEA &
CONSTIPATION
No organ in the body is so misunderstood, so
slandered and maltreated as the colon!
Sir Arthur Hurst, 1935
PRESENTATION BY
ASWATHY.T.D
M PHARM PART- I
PHARMACY PRACTICE
4. INTRODUCTION
Diarrhoea and constipation are common clinical complaints that
negatively affect quality of life, reduce work productivity and lead to
considerable health-care expenditure.
They are non specific symptoms that may be caused by
diet, stress, medication, inadequate fluid intake, a neuromuscular
disorder, an endocrine disorder (e.g.,diabetes, thyroid or parathyroid
disease) or rarely cancer
About 8-9% of people suffer from chronic constipation and about 4-5%
Chronic Diarrhoea .
.
6. What is Diarrhoea ?
An increase in the frequency of bowel movements or a
decrease in the form of stool (greater looseness of stool)
Changes in frequency of bowel
movements and looseness of
stools can vary independently of
each other, changes usually
occur in both
7. Diarrhoea in the 21st
Century Second most common
cause of morbidity and
mortality worldwide
WHO estimation
(2002), diarrhoeal disease
results in:
2.5 million people die
annually, mostly children
1.6 million children
<5yrs old (in developing
countries)
8. Types of diarrhoea
Chronic diarrhoea Acute diarrhoea
Generally lasts > 3 weeks
Most of the causes are
non-infectious
IBS, AIDS, bacterial
outgrowth of small
int., Colon cancer, Chron’s
disease
sudden onset and lasts
less than two weeks
90% are infectious in
etiology
10% are caused by
medications, toxin
ingestions, and ischemia
IMPORTANT !!!
distinguish between acute and chronic diarrhoea
>>>different diagnostic tests, different treatments
9. What are common causes of
diarrhoea?
.
Dietary abuse
Food intolerance
Infection by bacteria, virus &
parasites
Reaction to medicine
Intestinal disease
12. High Risk Groups
1. Travelers
2. Consumers of certain foods
3. Immunodeficient person
4. Daycare participants
5. Institutionalized person
13. Why does diarrhoea develop?
Increased secretion or
impaired absorption of
fluid with in the lumen.
14. What are the pathohysiologic
mechanisms leading to diarrhoea?
a. Change in active ion transport by
either decreased sodium
absorption or increased chloride
absorption.
b. Change in intestinal motility
c. Increase in luminal osmolarity
d. Increase in tissue hydrostatic
pressure
18. Diagnosis
Physical examination
Stool culture
Stool examination, microscopy for
ova, cysts, parasites and fecal WBC
Blood tests
Review of your medications
ELISA test
** For unresolved diarrhoea: sigmoidoscopy, rectal biopsy and
radiological studies to rule out other organic causes
20. Rehydration
* Oral rehydration with fluids containing
glucose, Na+, K+, Cl–, and bicarbonate or
citrate is preferred in most cases to
intravenous fluids
* Fluids should be given at rates of 50–200 mL/kg/24 h
depending on the hydration status.
* Intravenous fluids (lactated Ringer's solution) are
preferred acutely in patients with severe dehydration.
21. ORS
Ingredients Standard WHO-
ORS Mmols/L
Reduced
osmolarity ORS
Mmols/L
Glucose 111 75
Na 90 75
K 20 20
Cl 80 65
Citrate 10 10
Osmolarity 311 245
22. Pharmacologic therapy
Opiates & their derivatives
A. Loperamide: 4 mg initially, then 2 mg
after each loose stool (maximum: 16
mg/d)
B. Diphenoxylate With Atropine: One
tablet three or four times daily
C. Codeine, Paregoric:. 15–60 mg
every 4 hours as needed; the
dosage of paregoric is 4–8 mL after
each liquid bowel movement
23. Adsorbents
Kaolin- pectin mixture: 30-120 mL after each loose
stool
Attapulgite: 1200- 1500 mg after each loose bowel
movements or every 2 hrs; up to 9000 mg/day
Antisecretory agents
Bismuth subsalicylate: 2 tablets or 30 mL every 30 min to 1 hr
as needed up to 8 doses/day
In immunocompromised patients
Octreotide: Initial 50mcg s/c 1-2 times/day & titrate dose
based on indication up to 600mcg/day in 2-4 divided doses
25. ROLE OF PHARMACIST
• Avoid dehydration; drink clear fluids, preferably
those containing electrolytes and an energy source
such as glucose.
• Good hygiene, particularly washing your hands
thoroughly after going to the toilet, is essential in
case the diarrhea is infectious.
• Do not prepare food for other people, especially
babies and old people, while you have acute
diarrhea.
• A carbohydrate diet that includes boiled potatoes or
boiled rice may help.
• If the diarrhea does not resolve after a few days,
seek medical advice.
28. What is constipation?
Constipation is generally defined
as infrequent and/or
unsatisfactory defecation fewer
than 3 times per week.
Patients may define
constipation as passing hard
stools or straining, incomplete
or painful defecation.
Constipation is a symptom,
NOT a disease.
29. Epidemiology
2-27% of the population has constipation
Constipation affects twice as many women
as men
Constipation is more prevalent in non-White
persons than in White persons (non-
White:White ratio range 1.13--2.89)
30. Causes of constipation
Diet
Lack of exercise
Age
Irregular bowel habits
Drug induced
Disease States/Conditions
Spasam of sigmoid colon
Dysfunction of myenteric plexus
31. PATHOPHYSIOLOG
YA variety of pathogenetic mechanisms
can cause constipation:
•Abnormal intrinsic motility
•Lack of luminal factors (stretching, chemical and tactile stimuli)
•Medications
•Hormones (very rarely, e.g., in pheochromocytoma)
•Lack of extrinsic innervation (in paraplegia)
•Impaired defecation
32. symptoms of constipation
Infrequent defecation
Nausea
Vomiting
Anorexia
Feeling full quickly
Stools that are small, hard, and/or difficult to
evacuate
Rectal bleeding
Weight loss (in chronic constipation)
33. Diagnosis
Good history is enough for most cases
(Duration, frequency, Consistency, blood in the
stool, weight loss, Diet, Exercise, Toilet
habits, Laxative use (what), other drugs)
Basic laboratory tests:
CBC, BS, BUN, Cr, TSH
Structural:
Barium enema, Sigmoidoscopy, Colonoscopy
34. I’m constipated, now what?
Two approaches to consider:
Non-drug Approach
Drug Approach
35.
36. 1. Exercise - Fibre in the diet - Fluid
Intake
No evidence that increased exercise is beneficial in
severe constipation
Aim for 25-30g fibre/day
Unless dehydrated, increasing fluid does not relieve
chronic constipation and may increase the risk of fluid
overload eg heart or renal failure
37. The kitchen can help!
Add dry, fresh or canned fruit to cereal
Add legumes to soups casseroles
Include grated vegetables in rissoles, soups
Choose fruit desserts
Use high fibre snacks, raisin bread, date
scones, carrot, muffins
EASY FIBRE
SUPPLEMENT
3 TBS unsweetened apple puree
1 TBS unprocessed bran
2-3 TBS prune juice
Use 1 TBS on breakfast cereal
38. Psyllium (Metamucil®), Sterculia (Normacol®), Ispaghula (Fybogel®)
Improve stool consistency and frequency with regular use
Ensure good fluid intake to prevent faecal impaction
Onset of action 2-3 days
Side Effects may include bloating, flatulence, distension
2. Bulk Forming Laxatives
39. Docusate (Coloxyl®), Paraffin oil (Agarol®)
Efficacy of docusate is controversial
May be useful with anal fissures of haemorrhoids or
when straining is a hazard
Liquid paraffin is not recommended for treatment of
constipation
- risk of aspiration and lipid pneumonia
- long term use may result in depletion of
Vitamins A, D, E and K
3. Stool Softeners & Lubricants
40. 4. Stimulant Laxatives
Senna (Senokot®), bisacodyl (Durolax®, Bisalax®)
Increase intestinal motility by stimulating colonic nerves
Useful with opioids
Onset of action 8-12 hours
Development of tolerance is reported to be uncommon
Generally considered 2nd line therapy in elderly due to risk of electrolyte
disturbances
Other adverse effects include cramping, diarrhoea, dehydration
41. 5. Osmotic Laxatives
Lactulose (Duphalac®), Sorbitol (Sorbilax®), PEG products
(Movicol®)
Lactulose/Sorbitol
- equally effective at improving stool frequency
- onset of action – up to 48 hours
- metabolised by bacteria flatulence
Movicol® - improves stool frequency and consistency
- iso-osmotic and therefore water and
electrolyte loss is limited
42. Some precautions with osmotic laxatives
Lactulose contains absorbable sugars and may
adversely affect glycamic control in diabetics
Overuse may result in dehydration
Monitor for any signs of electrolyte disturbances
- oedema
- shortness of breath
- increasing fatigue
- cardiac failure
43. 6. Enemas & Suppositories
Used when rapid relief from faecal loading is required
Induce bowel movements by distension of the rectum
and colon
Frequent use may cause poor rectal tone and may
exacerbate incontinence
Tap water enemas are safest for regular use
Phosphate enemas (Fleet®) increase the risk of
hyperphosphataemia in renal impairment
Glycerine suppositories stimulate rectal secretion by
osmotic action
44. Helping to prevent constipation
Patient education
Diet and Fluid Intake
Exercise
Effective Bowel Habits
Toileting Facilities
Ensure a laxative is
prescribed with opioids
Imaginative ways to increase fibre:-
• Add dry, fresh or canned fruit to cereal
• Add legumes to soups and casseroles
• Include grated vegetables in rissoles & soups
• Choose fruit desserts
• High fibre snacks eg raisin bread, date scones,
carrot muffins
An Effective Fibre Supplement
3 TBS unsweetened apple puree
1 TBS unprocessed bran
2-3 TBS prune juice
Add 1 TBS to breakfast cereal
45. CONCLUSION
Diarrhoea and constipation are common disorders of GIT
that are often self reported by older adults.
Pharmacist is essential in counseling patients on self
management of constipation & diarrhoea.
Good nutrition and hygiene can prevent most diarrhoea.
Patients should be instructed to increase fluid intake and
participate in regular exercise to prevent constipation.
46. REFERENCES
o Davidson’s Principle and Practice of Medicine 20th edition
by Nicholas.N.Boon, Niki. R.colledge, Brain. R. Walker
Page No:677-692
o Harrison’s Principle of Internal Medicine 18th edition, Vol 1
by Longo, Fauci Kasper, Hasper, Jamesoli Page No: 247-
255
o Text book of therapeutics- Drug and Disease
Management, 7th edition by Eric. T. Herfintal, Dick
.R.Gourley; Page No:571-585
o Clinical Pharmacy and Therapeutics, 4th edition by Roger
Walker, Cate Whitelsia Page No: 824- 832
