Diarrhea and Intestinal Gas

Diarrhea definition

GI disturbance characterized by an abnormal increase in stool frequency, liquidity, weight, or volume

Duration of acute diarrhea

Fewer than 14 days

Duration of chronic diarrhea

More than 4 weeks

Duration of persistent diarrhea

Between 14 days and 4 weeks

Common medication classes associated with diarrhea

Antihistamines, leukotriene antagonists, SSRIs, antibiotics, antivirals, bisphosphonates, beta blockers, K-sparing diuretics, ACE inhibitors, ARBs, HMG CoA reductase inhibitors, biguanides, PPIs, sedatives

Most common cause (virus) of viral diarrhea

Noroviruses

Where do viral diarrhea outbreaks usually occur?

Health care institutions, long-term care facilities, cruise ships, college campuses, military personnel, immunocompromised patients

Most common cause (virus) of severe diarrhea in infants and young children

Rotavirus

Diarrhea caused by toxin-producing pathogens in the small intestine usually present with _________ diarrhea

watery

Diarrhea caused by toxin-producing pathogens in the large intestine usually present with __________ diarrhea

dysentery-like (bloody)

Treatment for protozoal diarrhea

Refer to HCP

Which classes of pathogens have quicker onset in Traveler's diarrhea?

Bacterial and viral

Which classes of pathogens have slower onset in Traveler's diarrhea?

Protozoal

Treatment of Traveler's Diarrhea

Antidiarrheals and antibiotics

Food-borne diarrhea definition

- Viral or bacterial contamination due to poor hygiene and sanitation practices related to manufacturing, preparation, and distribution of foods

Food-induced diarrhea definition

Diarrhea caused by food intolerances and foods that are excessively fatty or spicy

Symptoms of mild-moderate dehydration

- Fatigue, restlessness, irritable, thirsty, normal to increased HR, slightly sunken eyes, decreased tears, dry mouth, prolonged capillary refill, cool extremities, decreased urine output

Symptoms of severe dehydration

Apathetic, lethargic, unconscious, drinks poorly, tachycardia, bradycardia (severe cases), weak pulse, deep breathing, deeply sunken eyes, no tears, parched mouth, cold and cyanotic extremities, low BP

When is oral rehydration optional?

Healthy adults with mild diarrhea who can maintain an adequate fluid intake

Advantages of using household fluids for rehydration

Can manage mild, self-limiting diarrhea in some patients

Disadvantages of household fluids for rehydration

- Should be avoided if dehydration is a feature or in cases of moderate-severe diarrhea

- Not formulated for acute diarrhea so carbohydrate and sodium content may be inappropriate

Adjustments to dietary intake when acute diarrhea occurs

- Avoid fatty foods, foods rich in simple sugars, spicy foods, and caffeine-containing beverages

- BRAT diet is not recommended due to insufficient calories, protein, and fat

When is diarrhea contagious?

Usually occurs in congregate living conditions (daycare centers and nursing homes) through person-to-person transmission

How to prevent transmission of diarrhea

Isolating affected individuals, strict attention to handwashing, and use of sterile techniques

Risks of using loperamide in children 2-6 years old with acute diarrhea

High risk for adverse effects such as life-threatening ileus and toxic megacolon

Probiotics that can be used to manage or prevent acute uncomplicated diarrhea

- Several lactobacillus species

- Bifidobacterium lactis

- Saccharomyces boulardii

Food categories that are associated with major gas production

- Vegetables

- Fruits

- Carbohydrates

- Dairy

- Carbonated beverages

Four symptoms of lactase deficiency

- Gas pains

- Bloating

- Nausea

- Diarrhea

Patients with celiac disease have an intolerance to what?

Gluten

Treatment of celiac disease

Adherence to a strict gluten-free diet

Common symptoms of intestinal gas

- Belching

- Burping

- Bloating

- Flatulence

Less common symptoms of intestinal gas

- Nausea

- Borborygmi (audible bowel sounds)

- Dyspepsia/indigestion

How long to follow up for a patient experiencing intestinal gas?

1 week

Diarrhea exclusion criteria: Age and weight

- Less than 6 months old

- Weight less than 17.5 lbs or 8 kg

Diarrhea exclusion criteria: Signs of severe dehydration such as

- Children showing behavioral/mental changes (irritability, apathy, lethargy, unconscious)

- Children who have not urinated in 8 hours

- Children who have no tears when crying

- Orthostatic hypotension

Diarrhea exclusion criteria: Risk for significant complications including chronic medical conditions or concurrent illness including_________

- Diabetes, severe CVD, renal disease

- Immunosuppressed patients (chemo, organ transplantation, AIDS)

- Frail patients older than 65

Diarrhea exclusion criteria: Length of time

Chronic or persistent diarrhea (more than 14 days)

Other exclusion criteria for diarrhea

- Persistent fever

- Visible blood, pus, or mucus in stool

- High output, including frequent and substantial volumes of diarrhea

- Persistent vomiting

- Severe abdominal pain/distress: tenderness, distension

- Suboptimal response to ORS already administered

- Pregnancy

Loperamide indications

- Acute, nonspecific diarrhea

- Traveler's diarrhea (with antibiotics)

- Chronic diarrhea associated with IBS and IBD

- Reducing volume of high-output ileostomies

Loperamide therapeutic effect

- Decreased fecal volume

- Increased viscosity

- Increased bulk volume

- Decreased fluid and electrolyte loss

Loperamide MOA

- Stimulates micro-opioid receptors on intestinal muscles to slow motility and allowing for absorption of water and electrolytes

- Decrease GI secretions and disruption of mechanisms involved in peristalsis

- Inhibition of voltage-dependent Ca channels contributing to the antisecretory effect

Loperamide side effects

- Occasional: dizziness, constipation

- Infrequent: Abdominal pain, abdominal distension, N/V, dry mouth, fatigue, hypersensitivity reactions

Loperamide contraindications

Invasive bacterial diarrhea or antibiotic-associated diarrhea

Age limitations for loperamide

OTC for children 6 and older

Loperamide counseling points

- Encourage safe use due to potential for abuse at higher than recommended doses

- Do not use for more than 48 hours without approval from a healthcare professional

- Discontinue use if abdominal distension, constipation, or ileus occurs

BSS indications

- Acute diarrhea including traveler's diarrhea in adults and children older than 12 years old

- Indigestion

- Adjuvant to antibiotics for treating H. pylori-associated PUD

BSS therapeutic effect

- Decreased frequency of uniformed stools

- Increased consistency and viscosity

- Decreased abdominal cramps

- Decreased N/V

- Antibacterial and antisecretory actions

BSS MOA

- Forms bismuth oxychloride and salicylic acid in presence of gastric acid

- Bismuth: antibacterial

- Salicylate: antisecretory actions due to inhibition of prostaglandins, intestinal secretions

- Binds enterotoxins

BSS side effects

- Dose-related mild tinnitus (discontinue if this occurs)

- Rare: bismiuth-related neurotoxicity (slow onset tremors, postural instability, ataxia, etc.)

BSS contraindications

- AIDS, acute diarrhea, pregnancy

BSS age limitations

OTC for children 12 years and older

BSS counseling points

- Can cause harmless black staining of stool and darkening of the tongue

- May interfere with radiographic intestinal studies

- Do not use for more than 48 hours without approval from a HCP

Exclusion criteria for intestinal gas

- Symptoms that persist for more than several days concurrently or occur more often than several times a month

- Severe debilitating symptoms (severe pain)

- Sudden change in location of abdominal pain

- Symptoms accompanied by significant abdominal discomfort or sudden change in bowel function

- Concurrent symptoms of severe or persistent diarrhea or constipation, GI bleeding, fatigue, weight loss, or nocturnal symptoms

Eating habits to help with intestinal gas

- Eat slowly and chew food thoroughly and avoid overeating

- Drink slowly, avoid washing down solids with a beverage

- Avoid chewing gum and sucking hard candy, especially those with artificial sweeteners

Diet recommendations for intestinal gas

- Keep a food journal while tracking symptoms

- Avoid gas-producing foods

- Avoid foods with air whipped in them, carbonated, or caffeinated beverages

Other lifestyle considerations for intestinal gas

- Avoid pipe, cigar smoking

- Check dentures for proper fit

- Avoid tight-fitting garments and belts

- Do not lie down or sit in a slumped position immediately after eating

- Develop regular exercise and sleep routine

Meds that can contribute to intestinal gas

- Anticholinergic meds

- Meds that affect GI motility (opioids, Ca channel blockers), glucose metabolism, intestinal flora

- Psyllium fiber

- Nonabsorbable polymers

- Meds that release gas

Treatment strategy to prevent gas

- Alpha-galactosidase

- Lactase

Treatment strategy to relieve gas symptoms

- Simethicone

- Activated charcoal

Simethicone MOA

Defoaming agent that breaks up gas bubbles and allows for easier elimination of gas

Simethicone counseling points

- Use on a trial basis due to questionable efficacy

- Often in combo products with antacids

- No minimum age

Activated charcoal MOA

Adsorbent properties facilitate elimination of intestinal gas from GI tract

Activated charcoal counseling points

- Not FDA approved

- May cause abdominal distention, constipation, intestinal obstruction, and vomiting

Alpha-galactosidase MOA

Hydrolyzes oligosaccharides into their monomeric components before metabolism by colonic bacteria

Alpha-galactosidase counseling points

- Derived from mold so allergic reactions are possible in patients with mold allergy

- Do not use if diagnosed with galactosemia

Lactase MOA

- Breaks down lactose into glucose and galactose to decrease gas and diarrhea associated with lactose intolerance

Lactose counseling points

- Tae at first bite of lactose containing food

- Dosing varies depending on product and degree of lactose intolerance

- Do not exceed recommended dose

- Low lactose or soy milk may be used to minimize lactose intolerance

- Ca and Vitamin D supplements may be used

- Recommended for children 4 years and older