Symptoms in the Pharmacy :Gastrointestinal Tract Problems(14)

Diarrhoea
Community pharmacists may be asked by patients to treat existing
diarrhoea, or to offer advice on what course of action to take should
diarrhoea occur, for example, to holidaymakers. Diarrhoea is defined
as an increased frequency of bowel evacuation, with the passage of
abnormally soft or watery faeces. The basis of treatment is electrolyte
and fluid replacement; in addition, antidiarrhoeals are useful in adults
and older children.

What you need to know

• Age
• Infant, child, adult, elderly
• Duration
• Severity
• Symptoms, associated symptoms
• Nausea/vomiting
• Fever
• Abdominal cramps
• Flatulence
• Other family members affected?
• Previous history
• Recent travel abroad?
• Causative factors
• Medication
• Medicines already tried
• Other medicines being taken

Significance of questions and answers

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.

Duration
Most cases of diarrhoea will be acute and self-limiting. Because of the
dangers of dehydration it would be wise to refer infants with diarrhoea
of longer than 1 day’s duration to the doctor.

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
Acute diarrhoea is rapid in onset and produces watery stools that are
passed frequently. Abdominal cramps, flatulence and weakness or
malaise may also occur. Nausea and vomiting may be associated
with diarrhoea, as may fever. The pharmacist should always ask
about vomiting and fever in infants; both will increase the likelihood
that severe dehydration will develop. Another important question to
ask about diarrhoea in infants is whether the baby has been taking
milk feeds and other drinks as normal. Reduced fluid intake predisposes
to dehydration.

The pharmacist should question the patient about food intake and
also about whether other family members or friends are suffering from
the same symptoms, since acute diarrhoea is often infective in origin.
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. Types of infective
diarrhoea are discussed later in the chapter.
The presence of blood or mucus in the stools is an indication for
referral. Diarrhoea with severe vomiting or with a high fever would
also require medical advice.

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.

Causes of diarrhoea
Infections
Most cases of diarrhoea are short-lived, the bowel habit being normal
before and after. In these situations the cause is likely to be infective
(viral or bacterial).

Viral. 

Viruses are often responsible for gastroenteritis. In infants
the virus causing such problems often gains entry into the body via
the respiratory tract (rotavirus). Associated symptoms are those of a
cold and perhaps a cough. The infection starts abruptly and vomiting
often precedes diarrhoea. The acute phase is usually over within
2–3 days, although diarrhoea may persist. Sometimes diarrhoea
returns when milk feeds are reintroduced. This is because one of the
milk-digestive enzymes is temporarily inactivated. Milk therefore
passes through the bowel undigested, causing diarrhoea. The health
visitor or doctor would need to give further advice in such situations.
Whilst in the majority the infection is usually not too severe and
is self-limiting, it should be remembered that rotavirus infection
can cause death. This is most likely in those infants already malnourished
and living in poor social circumstances who have not been
breastfed.

Bacterial. 

These are the food-borne infections previously known as
food poisoning. There are several different types of bacteria that can
cause such infections: Staphylococcus, Campylobacter, Salmonella,
Shigella, pathogenic Escherichia coli and Bacillus cereus. The typical
symptoms include severe diarrhoea and/or vomiting, with or without
abdominal pain. Two commonly seen infections are Campylobacter
and Salmonella, which are often associated with contaminated
poultry, although other meats have been implicated. Contaminated
eggs have also been found to be a source of Salmonella. Kitchen
hygiene and thorough cooking are of great importance in preventing
infection.

 The typical features of some of the following
infections:
– Bacillary dysentery is caused by Shigella. It can occur in outbreaks
where there are people living in close proximity and may occur in
travellers to Africa or Asia.

– B. cereus is usually associated with cooked rice, especially if it has
been kept warm or has been reheated. It presents with two different
clinical pictures,

– E. coli infections are less common but can be severe with toxins
being released into the body, which can cause kidney failure.
Antibiotics are generally unnecessary as most food-borne infections
resolve spontaneously. The most important treatment is adequate fluid
replacement. Antibiotics are used for Shigella infections and the more
severe Salmonella or Campylobacter ones. Ciprofloxacin may be used
in such circumstances.

– Protozoan infections are uncommon in Western Europe but may
occur in travellers from further afield. Examples include Entamoeba
histolytica (amoebic dysentery) and Giardia lamblia (giardiasis).
Diagnosis is made by sending stool samples to the laboratory.

Chronic diarrhoea

Recurrent or persistent diarrhoea may be due to an irritable bowel or,
more seriously, a bowel tumour, an inflammation of the bowel (e.g.
ulcerative colitis or Crohn’s disease), an inability to digest or absorb
food (malabsorption, e.g. coeliac disease) or diverticular disease of the
colon.

Irritable bowel syndrome (see p. 122). This non-serious but troublesome
condition is one of the more common causes of recurrent bowel
dysfunction in adolescents and young adults. The patient usually
describes the frequent passage of small volumes of stool rather than
true diarrhoea. The stools are typically variable in nature, often
loose and semi-formed. They may be described as being like rabbit

droppings or pencil-shaped. 

The frequency of bowel action is also
variable as the diarrhoea may alternate with constipation. Often the
bowels are open several times in the morning before the patient leaves
for work. The condition is more likely to occur at times of stress, it
may be associated with anxiety and occasionally it may be triggered
by a bowel infection. Inadequate dietary fibre may also be of significance.
It is possible that certain foods can irritate the bowel, but this is
difficult to prove.

There is no blood present within the motion in an irritable bowel.
Bloody diarrhoea may be a result of an inflammation or tumour of the
bowel. The latter is more likely with increasing age (from middle age
onwards) and is likely to be associated with a prolonged change in
bowel habit; in this case diarrhoea might sometimes alternate with
constipation.

Medication
Medicines already tried

The pharmacist should establish the identity of any medication that
has already been taken to treat the symptoms in order to assess its
appropriateness.

Other medicines being taken
Details of any other medication being taken (both OTC and prescribed)
are also needed, as the diarrhoea may be drug-induced

 OTC medicines should be considered; commonly used
medicines such as magnesium-containing antacids and iron preparations
are examples of medicines that may induce diarrhoea. Laxative
abuse should be considered as a possible cause.