Symptoms in the Pharmacy :Gastrointestinal Tract Problems(15)
Diarrhoea:
Management
Oral rehydration therapy
The risk of dehydration from diarrhoea is greatest in babies, and
rehydration therapy is considered to be the standard treatment for
acute diarrhoea in babies and young children.Oral rehydration
sachets may be used with antidiarrhoeals in older children and adults.
Rehydration may still be initiated even if referral to the doctor is
advised. Sachets of powder for reconstitution are available; these
contain sodium as chloride and bicarbonate, glucose and potassium.
The absorption of sodium is facilitated in the presence of glucose.
It is essential that appropriate advice be given by the pharmacist
about how the powder should be reconstituted. Patients should be
reminded that only water should be used to make the solution (never
fruit or fizzy drinks) and that boiled and cooled water should be used
for children younger than 1 year. Boiling water should not be used, as
it would cause the liberation of carbon dioxide. The solution can be
kept for 24 h if stored in a refrigerator.
Quantities
Parents sometimes ask how much rehydration fluid should be given to
children. The following simple rules can be used for guidance; the
amount of solution offered to the patient is based on the number of
watery stools that are passed. Table 6 provides the volumes required
per watery stool.
Other therapy
Loperamide
Loperamide is an effective antidiarrhoeal treatment for use in older
children and adults. When recommending loperamide the pharmacist
should remind patients to drink plenty of extra fluids. Oral rehydration
sachets may be recommended. Loperamide may not be recommended
for use in children under 12 years.
Kaolin
Kaolin has been used as a traditional remedy for diarrhoea for many
years. Its use was justified on the theoretical grounds that it would
absorb water in the GI tract and would absorb toxins and bacteria
onto its surface, thus removing them from the gut. The latter has not
been shown to be true and the usefulness of the former is questionable.
The use of kaolin-based preparations has largely been superseded by
oral rehydration therapy, although patients continue to ask for various
products containing kaolin.
Morphine
Morphine, in various forms, has been included in antidiarrhoeal remedies
for many years. The theoretical basis for its inclusion is thatmorphine, together with other narcotic drugs such as codeine, is
Practical points
1 Patients with diarrhoea should be advised to drink plenty of clear,
non-milky fluids, such as water and diluted squash.
2 Advice to eat no solid food for 24 h may be appropriate. Breast- or
bottle-feeding should be continued in infants. The severity and duration
of diarrhoea are not affected by whether milk feeds are continued.
A well-nourished child should be the aim, particularly where
the infant is poorly nourished to begin with and where the withholding
of milk feeds may be more detrimental than in a well-nourished
infant, where temporary withdrawal is unimportant. Some doctors
continue nevertheless to advise the discontinuation of milk, especially
bottle, during the acute phase of infection.
3 Patients with diarrhoea might be best advised to avoid cow’s milk,
because during diarrhoea the enzyme in the gut that digests milk
(lactase) is inactivated. Temporary lactose intolerance can therefore
be produced, which makes the diarrhoea worse.
Diarrhoea in practice
Case 1
Mrs Robinson asks what you can recommend for diarrhoea. Her son
David, aged 11, has diarrhoea and she is worried that her other two
children, Natalie, aged 4, and Tom, aged just over 1 year, may also get
it. David’s diarrhoea started yesterday; he went to the toilet about five
times and was sick once, but has not been sick since. He has griping
pains, but is generally well and quite lively. Yesterday he had pie and
chips from the local takeaway during his lunch break at school. No
one else in the family ate the same food. Mrs Robinson has not given
him any medicine, but has some kaolin and morphine mixture at home
and wants to know if David could take some, and also if the other
children could take it if necessary.
The pharmacist’s view
It sounds as if David has a bout of acute diarrhoea, possibly caused by
the food he ate yesterday during lunchtime. He has vomited once, but
The doctor’s view
David’s diarrhoea could well be due to food poisoning. Oral rehydration
is the correct treatment. He should also be told not to eat
anything for the next 24 h or so until the diarrhoea has settled. If he
wants to drink other fluids in addition to the electrolyte mixture, he
should be told to avoid milk.
His symptoms should settle down over the next 24 h. If they persist
or he complains of worsening abdominal pain, particularly in
the lower right side of the abdomen, his mother should contact the
doctor. Rarely, an atypical acute appendicitis may present as a bowel
infection.
Case 2
Mrs Choudry is collecting her regular repeat prescription for antihypertensive
treatment. You ask how she and the family are, and she tells
you that several members of the family have been suffering with
diarrhoea on and off. You know that the family recently returned
from a trip to India where they had been visiting relatives to attend
a family wedding. In answer to your questions, Mrs Choudry tells you
that the problem with the diarrhoea started after they returned.
The pharmacist’s view
Referral to the GP is needed here as the diarrhoea may be related to
the recent travel.
The doctor’s view
Referral is a sensible course of action. Clearly more information is
required, e.g. date of onset of symptoms, date of return to the UK. It
does not sound as if any of the family are acutely ill but it would be
necessary to ensure that no one is dehydrated. If the diarrhoea is
persisting, it would be helpful to send stool samples to the local public
health laboratory for analysis. It is possible that they may be suffering
from giardiasis, which can be treated with metronidazole. Sometimes
stool samples come back showing no signs of infection, in which case
the diarrhoea is considered as being due to postinfection irritability of
the bowel. This usually resolves spontaneously with no specific treatment.
Case 3
Mrs Jean Berry wants to stock up on some medicines before her family
sets off on their first holiday abroad; they will be going to Spain next
week. Mrs Berry tells you she has heard of people whose holidays have
been ruined by holiday diarrhoea and she wants you to recommend a
good treatment. On questioning, you find out that Mr and Mrs Berry
and their two boys aged 10 and 14 will be going on the holiday.
The pharmacist’s view
Holiday diarrhoea can be troublesome but can easily be dealt with.
Mrs Berry could be advised to buy some loperamide capsules, which
would be suitable treatment for her, Mr Berry and their 14-year-old
son. In addition, she should purchase some oral rehydration sachets
for the younger son. The sachets could also be used by other family
members.
The pharmacist could also give some valuable advice about the
avoidance of potential problems by the Berry family on their first
foreign holiday. Fresh fruit should be peeled before eating and hot
food should not be eaten other than in restaurants. Roadside snack
stalls are best avoided. The question of the quality of drinking water
often crops up.
Finally, patients would be well advised to be wary of buying OTC
medicines abroad. In some countries, a large range of drugs including
oral steroids and antibiotics can be purchased OTC. Each year, patients
return to Britain with serious adverse effects following the use of
oral chloramphenicol, for example, which has been prescribed or
purchased.
The doctor’s view
The pharmacist has covered all the important points. The most likely
cause of diarrhoea would be contaminated food or water. The best
treatment of acute diarrhoea is to stop eating and to drink bottled
mineral water (with or without electrolyte reconstitution powders). It
would be sensible to take an antidiarrhoeal such as loperamide.
Case 4
Mr Radcliffe is an elderly man who lives alone. Today, his home
help asks what you can recommend for diarrhoea, from which
Mr Radcliffe has been suffering for 3 days. He has been passing
watery stools quite frequently and feels rather tired and weak. He
has sent the home help because he dare not leave the house and go out
of reach of the toilet. You check your PMRs, which confirm your
memory that he takes several different medicines: digoxin, furosemide
(frusemide) and paracetamol. Last week you dispensed a prescription
for a course of amoxicillin (amoxycillin). The home help tells you that
he has been eating his usual diet and there does not seem to be a link
between food and his symptoms.
The pharmacist’s view
Mr Radcliffe’s diarrhoea may be due to the amoxicillin, which
he started to take a few days ago. It would be best to call the
patient’s doctor to discuss the appropriate course of action because
Mr Radcliffe’s other drug therapy means that fluid loss and dehydration
may cause electrolyte imbalance and put him at further risk. The
doctor may decide to stop the amoxicillin.
The doctor’s view
It is likely that the amoxicillin has caused the diarrhoea. The most
important consideration in management is to ensure adequate
fluid and electrolyte replacement. This is particularly so as the elderly
(and babies) are not as resilient to the effects of dehydration. In
Mr Radcliffe’s case things are further complicated by his other medication:
furosemide and digoxin. He is not on any potassium supplement
or a potassium-sparing diuretic. Although there may be good
reason for this, diuretics such as furosemide can lower the plasma
potassium level and make digoxin dangerously toxic. Unfortunately,
potassium can also be lost in diarrhoea, further aggravating this
problem. It is therefore reasonable to ask for the doctor to visit and
assess.
There is also a small possibility that the diarrhoea could be due to
pseudomembranous colitis (PMC), which is caused by a bacterium
(Clostridium difficile) in the colon and typically occurs as a complication
of antibiotic treatment. It is thought that antibiotics upset the
normal bowel flora allowing Clostridium difficile to flourish. This is a
The diarrhoea of PMC can range from mild self-limiting symptoms
to severe protracted or recurrent episodes and can sometimes be fatal.
There is often a low-grade fever, and abdominal pain/cramps may
occur. The symptoms usually begin within 1 week of starting antibiotic
treatment but may start up to 6 weeks after a course of antibiotics.
Where possible, antibiotics should be discontinued in cases of PMC. It
is sometimes necessary to treat severe cases with metronidazole or
vancomycin.
Treatment timescale
One day in children, otherwise 2 days.
One day in children, otherwise 2 days.
Management
Oral rehydration therapy
The risk of dehydration from diarrhoea is greatest in babies, and
rehydration therapy is considered to be the standard treatment for
acute diarrhoea in babies and young children.
sachets may be used with antidiarrhoeals in older children and adults.
Rehydration may still be initiated even if referral to the doctor is
advised. Sachets of powder for reconstitution are available; these
contain sodium as chloride and bicarbonate, glucose and potassium.
The absorption of sodium is facilitated in the presence of glucose.
A variety of flavours are available.
It is essential that appropriate advice be given by the pharmacist
about how the powder should be reconstituted. Patients should be
reminded that only water should be used to make the solution (never
fruit or fizzy drinks) and that boiled and cooled water should be used
for children younger than 1 year. Boiling water should not be used, as
it would cause the liberation of carbon dioxide. The solution can be
kept for 24 h if stored in a refrigerator.
Fizzy, sugary drinks should
never be used to make rehydration fluids, as they will produce a
hyperosmolar solution that may exacerbate the problem. The sodium
content of such drinks, as well as the glucose content, may be high.
Home-made salt and sugar solutions should not be recommended,
since the accuracy of electrolyte content cannot be guaranteed, and
this accuracy is essential, especially in infants, young children and
never be used to make rehydration fluids, as they will produce a
hyperosmolar solution that may exacerbate the problem. The sodium
content of such drinks, as well as the glucose content, may be high.
Home-made salt and sugar solutions should not be recommended,
since the accuracy of electrolyte content cannot be guaranteed, and
this accuracy is essential, especially in infants, young children and
elderly patients. Special measuring spoons are available; their correct
use would produce a more acceptable solution, but their use should be
reserved for the treatment of adults, where electrolyte concentration is
less crucial.
use would produce a more acceptable solution, but their use should be
reserved for the treatment of adults, where electrolyte concentration is
less crucial.
Quantities
Parents sometimes ask how much rehydration fluid should be given to
children. The following simple rules can be used for guidance; the
amount of solution offered to the patient is based on the number of
watery stools that are passed. Table 6 provides the volumes required
per watery stool.
Other therapy
Loperamide
Loperamide is an effective antidiarrhoeal treatment for use in older
children and adults. When recommending loperamide the pharmacist
should remind patients to drink plenty of extra fluids. Oral rehydration
sachets may be recommended. Loperamide may not be recommended
for use in children under 12 years.
Kaolin
Kaolin has been used as a traditional remedy for diarrhoea for many
years. Its use was justified on the theoretical grounds that it would
absorb water in the GI tract and would absorb toxins and bacteria
onto its surface, thus removing them from the gut. The latter has not
been shown to be true and the usefulness of the former is questionable.
The use of kaolin-based preparations has largely been superseded by
oral rehydration therapy, although patients continue to ask for various
products containing kaolin.
Morphine
Morphine, in various forms, has been included in antidiarrhoeal remedies
for many years. The theoretical basis for its inclusion is that
known to slow the action of the GI tract; indeed, constipation is a
well-recognised side-effect of such drugs. However, at the doses included
in most OTC preparations, it is unlikely that such an effect
would be produced. Kaolin and morphine mixture remains a popular
choice for some patients, despite the lack of evidence of its effectiveness.
well-recognised side-effect of such drugs. However, at the doses included
in most OTC preparations, it is unlikely that such an effect
would be produced. Kaolin and morphine mixture remains a popular
choice for some patients, despite the lack of evidence of its effectiveness.
Practical points
1 Patients with diarrhoea should be advised to drink plenty of clear,
non-milky fluids, such as water and diluted squash.
2 Advice to eat no solid food for 24 h may be appropriate. Breast- or
bottle-feeding should be continued in infants. The severity and duration
of diarrhoea are not affected by whether milk feeds are continued.
A well-nourished child should be the aim, particularly where
the infant is poorly nourished to begin with and where the withholding
of milk feeds may be more detrimental than in a well-nourished
infant, where temporary withdrawal is unimportant. Some doctors
continue nevertheless to advise the discontinuation of milk, especially
bottle, during the acute phase of infection.
3 Patients with diarrhoea might be best advised to avoid cow’s milk,
because during diarrhoea the enzyme in the gut that digests milk
(lactase) is inactivated. Temporary lactose intolerance can therefore
be produced, which makes the diarrhoea worse.
Diarrhoea in practice
Case 1
Mrs Robinson asks what you can recommend for diarrhoea. Her son
David, aged 11, has diarrhoea and she is worried that her other two
children, Natalie, aged 4, and Tom, aged just over 1 year, may also get
it. David’s diarrhoea started yesterday; he went to the toilet about five
times and was sick once, but has not been sick since. He has griping
pains, but is generally well and quite lively. Yesterday he had pie and
chips from the local takeaway during his lunch break at school. No
one else in the family ate the same food. Mrs Robinson has not given
him any medicine, but has some kaolin and morphine mixture at home
and wants to know if David could take some, and also if the other
children could take it if necessary.
The pharmacist’s view
It sounds as if David has a bout of acute diarrhoea, possibly caused by
the food he ate yesterday during lunchtime. He has vomited once, but
now the diarrhoea is the problem. The child is otherwise well. He is 11
years old, so the best plan would be to start oral rehydration with
some proprietary sachets, with advice to his mother about how they
should be reconstituted. Kaolin and morphine mixture should not be
given to children under 12, and in any case is not considered first-line
treatment for diarrhoea. If either or both the other children get diarrhoea,
they can also be given some rehydration solution. David should
see the doctor the day after tomorrow if his condition has not improved.
years old, so the best plan would be to start oral rehydration with
some proprietary sachets, with advice to his mother about how they
should be reconstituted. Kaolin and morphine mixture should not be
given to children under 12, and in any case is not considered first-line
treatment for diarrhoea. If either or both the other children get diarrhoea,
they can also be given some rehydration solution. David should
see the doctor the day after tomorrow if his condition has not improved.
The doctor’s view
David’s diarrhoea could well be due to food poisoning. Oral rehydration
is the correct treatment. He should also be told not to eat
anything for the next 24 h or so until the diarrhoea has settled. If he
wants to drink other fluids in addition to the electrolyte mixture, he
should be told to avoid milk.
His symptoms should settle down over the next 24 h. If they persist
or he complains of worsening abdominal pain, particularly in
the lower right side of the abdomen, his mother should contact the
doctor. Rarely, an atypical acute appendicitis may present as a bowel
infection.
Case 2
Mrs Choudry is collecting her regular repeat prescription for antihypertensive
treatment. You ask how she and the family are, and she tells
you that several members of the family have been suffering with
diarrhoea on and off. You know that the family recently returned
from a trip to India where they had been visiting relatives to attend
a family wedding. In answer to your questions, Mrs Choudry tells you
that the problem with the diarrhoea started after they returned.
The pharmacist’s view
Referral to the GP is needed here as the diarrhoea may be related to
the recent travel.
The doctor’s view
Referral is a sensible course of action. Clearly more information is
required, e.g. date of onset of symptoms, date of return to the UK. It
does not sound as if any of the family are acutely ill but it would be
necessary to ensure that no one is dehydrated. If the diarrhoea is
persisting, it would be helpful to send stool samples to the local public
health laboratory for analysis. It is possible that they may be suffering
from giardiasis, which can be treated with metronidazole. Sometimes
stool samples come back showing no signs of infection, in which case
the diarrhoea is considered as being due to postinfection irritability of
the bowel. This usually resolves spontaneously with no specific treatment.
Case 3
Mrs Jean Berry wants to stock up on some medicines before her family
sets off on their first holiday abroad; they will be going to Spain next
week. Mrs Berry tells you she has heard of people whose holidays have
been ruined by holiday diarrhoea and she wants you to recommend a
good treatment. On questioning, you find out that Mr and Mrs Berry
and their two boys aged 10 and 14 will be going on the holiday.
The pharmacist’s view
Holiday diarrhoea can be troublesome but can easily be dealt with.
Mrs Berry could be advised to buy some loperamide capsules, which
would be suitable treatment for her, Mr Berry and their 14-year-old
son. In addition, she should purchase some oral rehydration sachets
for the younger son. The sachets could also be used by other family
members.
The pharmacist could also give some valuable advice about the
avoidance of potential problems by the Berry family on their first
foreign holiday. Fresh fruit should be peeled before eating and hot
food should not be eaten other than in restaurants. Roadside snack
stalls are best avoided. The question of the quality of drinking water
often crops up.
Good advice to travellers would be to check with the
tour company representative as to the advisability of drinking local
water. If in doubt, bottled mineral water can be drunk; such water (the
still variety) could also be used to reconstitute rehydration sachets. Ice
in drinks may be best avoided, depending on the water supply.
Holiday diarrhoea is usually self-limiting, but if it is still present
after several days, medical advice should be sought. If the diarrhoea
persists or is recurrent after returning home, the doctor should be seen.
tour company representative as to the advisability of drinking local
water. If in doubt, bottled mineral water can be drunk; such water (the
still variety) could also be used to reconstitute rehydration sachets. Ice
in drinks may be best avoided, depending on the water supply.
Holiday diarrhoea is usually self-limiting, but if it is still present
after several days, medical advice should be sought. If the diarrhoea
persists or is recurrent after returning home, the doctor should be seen.
Finally, patients would be well advised to be wary of buying OTC
medicines abroad. In some countries, a large range of drugs including
oral steroids and antibiotics can be purchased OTC. Each year, patients
return to Britain with serious adverse effects following the use of
oral chloramphenicol, for example, which has been prescribed or
purchased.
The doctor’s view
The pharmacist has covered all the important points. The most likely
cause of diarrhoea would be contaminated food or water. The best
treatment of acute diarrhoea is to stop eating and to drink bottled
mineral water (with or without electrolyte reconstitution powders). It
would be sensible to take an antidiarrhoeal such as loperamide.
Case 4
Mr Radcliffe is an elderly man who lives alone. Today, his home
help asks what you can recommend for diarrhoea, from which
Mr Radcliffe has been suffering for 3 days. He has been passing
watery stools quite frequently and feels rather tired and weak. He
has sent the home help because he dare not leave the house and go out
of reach of the toilet. You check your PMRs, which confirm your
memory that he takes several different medicines: digoxin, furosemide
(frusemide) and paracetamol. Last week you dispensed a prescription
for a course of amoxicillin (amoxycillin). The home help tells you that
he has been eating his usual diet and there does not seem to be a link
between food and his symptoms.
The pharmacist’s view
Mr Radcliffe’s diarrhoea may be due to the amoxicillin, which
he started to take a few days ago. It would be best to call the
patient’s doctor to discuss the appropriate course of action because
Mr Radcliffe’s other drug therapy means that fluid loss and dehydration
may cause electrolyte imbalance and put him at further risk. The
doctor may decide to stop the amoxicillin.
The doctor’s view
It is likely that the amoxicillin has caused the diarrhoea. The most
important consideration in management is to ensure adequate
fluid and electrolyte replacement. This is particularly so as the elderly
(and babies) are not as resilient to the effects of dehydration. In
Mr Radcliffe’s case things are further complicated by his other medication:
furosemide and digoxin. He is not on any potassium supplement
or a potassium-sparing diuretic. Although there may be good
reason for this, diuretics such as furosemide can lower the plasma
potassium level and make digoxin dangerously toxic. Unfortunately,
potassium can also be lost in diarrhoea, further aggravating this
problem. It is therefore reasonable to ask for the doctor to visit and
assess.
There is also a small possibility that the diarrhoea could be due to
pseudomembranous colitis (PMC), which is caused by a bacterium
(Clostridium difficile) in the colon and typically occurs as a complication
of antibiotic treatment. It is thought that antibiotics upset the
normal bowel flora allowing Clostridium difficile to flourish. This is a
relatively uncommon condition, which can be caused by most antibiotics,
but has been reported most often with clindamycin, ampicillin,
amoxicillin, and the cephalosporins. The condition is more likely to
occur in the elderly.
but has been reported most often with clindamycin, ampicillin,
amoxicillin, and the cephalosporins. The condition is more likely to
occur in the elderly.
The diarrhoea of PMC can range from mild self-limiting symptoms
to severe protracted or recurrent episodes and can sometimes be fatal.
There is often a low-grade fever, and abdominal pain/cramps may
occur. The symptoms usually begin within 1 week of starting antibiotic
treatment but may start up to 6 weeks after a course of antibiotics.
Where possible, antibiotics should be discontinued in cases of PMC. It
is sometimes necessary to treat severe cases with metronidazole or
vancomycin.
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