Diarrhoea management in the community

Diarrhoea & Causes

Diarrhoea is an increase in the passage of liquid stools, relative to a patient’s normal bowel movements. It can be accompanied by other symptoms such as abdominal cramps and flatulence. Diarrhoea is usually a sign of an underlying condition, such as an infection or a GI disorder, and it is classed according to how long the symptoms are present for:

• Acute: Less than 7 days
• Persistent: Up to 14 days
• Chronic: More than 14 days

Diarrhoea can be caused by many conditions such as:

1. Viral infections: Rotavirus is the most common viral cause of diarrhoea
2. Bacterial and parasitic infections: Common bacteria causing diarrhoea are - clostridium difficile, E. coli, Salmonella and Giardia.
3. Drugs: Laxatives, antibiotics, magnesium containing antacids and NSAIDs.
4. Diet: Gluten and lactose intolerance, sweeteners and caffeine
5. Gut disorders: such as ulcerative colitis.

Clinical features

The main symptom is runny or watery stools at least 3 times in a day, which may last for several days. In some instances, patients may also experience:

• Cramps in the abdomen
• Headache, temperature, and aches may also occur (Tidy, 2018).
• Dehydration
• If the cause is viral, the patient may have symptoms of a cough or cold.
• Symptoms usually resolve by 4 days; however, symptoms persist for longer if caused by a virus.

Red flags associated with diarrhoea require referral to a doctor and consist of the following:

• Sudden change in bowel habits for patients over 50
• If it lasts more than 3 days in children and the elderly
• If the patient is unable to drink fluids
• Blood or mucous in stools
• Black stools
• Severe abdominal or rectal pain
• Recent travel to a tropical or subtropical climate
• High fever

Differential Diagnosis (questions to ask the patient):

1. Has there been an increase in the frequency of watery stools?
   • Yes = Likely to be diarrhoea, ask further questions
   • No = Unlikely to be diarrhoea
2. Ask the patient about what they’ve eaten recently and establish if anyone else has had the same foods.
   • Likely diarrhoea caused by bacteria if both parties have symptoms and have had the same food
3. Does the patient experience diarrhoea first thing in the morning or nocturnally?
   • Yes = Refer for further investigation, could be due to IBS or IBD
   • No = Ask further questions
4. Has the patient changed diet recently – eating different foods in different countries?
   • Yes = Ask further questions
   • No = Ask further questions
5. Has the patient recently travelled to a non-Western country?
   • Yes = Refer as it could be due to giardiasis
   • No = Ask further questions
6. Is the diarrhoea medicine induced? Take a medication history for the patient
   • Yes = Speak to their prescriber and suggest an alternative
   • No = Ask further questions
7. Vomiting which prevents oral rehydration therapy?
   • Yes = Refer the patient to prevent dehydration
   • No = Provide advice and treatment for diarrhoea

Some questions depend on if the patient is a young child, infant elderly, or an adult.

Treatments

Priority of treatment is the reversal and/or prevention of fluid and electrolyte loss (NICE, 2021).

Oral Rehydration Solution (1^st line)

• Mechanism: Sodium-glucose co-transport across the intestinal mucosa creates a gradient, allowing water and electrolytes to be drawn from the gut and into the circulation. This reverses/prevents dehydration in diarrhoea (emc, 2021).
• Indication: Oral replacement of fluid and electrolyte loss in watery diarrhoea (emc, 2021).
• Side-effects/counselling: No known side-effects, there may be allergic reactions to an ingredient in the preparation however this is rare. Stop using if you notice any signs of an allergic reaction such as rash, swelling of the lips or swallowing and breathing problems.
  • Not suitable for patients with intestinal obstruction.
  • Use with caution if patient is on a low sodium or potassium diet.
  • Solution should be sipped slowly every 5 to 10 minutes.
• Evidence: A meta-analysis of RCTs comparing the use of enteral vs intravenous rehydration therapy found that using ORS was as effective as IV rehydration. This route was also safer as there were significantly fewer side effects and patients had a shorter hospital stay (Fonseca, 2004).

Loperamide – Imodium; Capsules and tablets

• Mechanism: Slows down gut motility by direct effect on the circular and longitudinal muscles of the intestinal wall. It blocks calcium channels, preventing muscle contractions for peristalsis (DrugBank, 2021).
• Indication: For rapid control of symptoms of diarrhoea.
• Side-effects/counselling:
  • Gastrointestinal issues such as nausea and vomiting, abdominal pain.
  • Headaches, dizziness and dry mouth
  • Only to be taken after a loose motion, not as a regular dose
  • Avoid in pregnancy (NICE, 2021).
• Evidence: Loperamide was compared to diphenoxylate for the treatment of diarrhoea in children and infants. Loperamide was found to be safer and more effective than diphenoxylate. It had fewer side-effects and quicker onset of action (Prakash, 1980).

Bismuth – Pepto-Bismol

• Mechanism: Bismuth forms salts in the gastrointestinal tract. These salts have antimicrobial and bactericidal activity, killing bacteria and preventing them from binding to mucosal cells. This reduces intestinal secretion and fluid loss, decreases gastrointestinal inflammation and promotes the healing of existing ulcers (DrugBank, 2021).
• Indication: For the relief of diarrhoea
• Side-effects/counselling:
  • Nausea and vomiting
  • Darkening of the tongue and faeces
  • Avoid in breastfeeding if possible
• Evidence: In randomized double-blind and placebo-controlled studies investigating bismuth subsalicylate, it was found to significantly reduce symptoms of travelers’ diarrhoea. More patients were symptom free and there was a decrease in the number of unformed stools (Steffen, 1990).

Rotavirus vaccine (Preventative)

• Mechanism: Stimulates the immune system to produce antibodies against the rotavirus before exposure to the actual virus. This allows the immune system to be better prepared when it encounters the virus, killing it before it can cause any issues (NHS, 2020).
• Indication: Prevention of diarrhoea caused by the rotavirus.
• Side-effects/counselling:
  • In rare cases, the vaccine could cause an allergic reaction or intussusception.
  • Sore arm for 2-3 days after the injection.
  • Some babies may develop mild diarrhoea in the days after the vaccination
  • Babies may be restless and irritable (NHS, 2020)
• Evidence: A systematic review looked at RCTs in children comparing rotavirus vaccines verses placebo or no intervention. It was concluded that Rotarix, RotaTeq and Rotavac were all effective in preventing episodes of rotavirus diarrhoea. There was no increased risk of serious adverse events (Soares-Weiser, 2019). The addition of the vaccine to UK vaccine schedule has decreased rotavirus diarrhoea by more than 70% (Rutter, 2017). 

Non-Pharmacological advice:

• Drink plenty of fluids – avoid caffeine and alcohol
• Avoid certain foods such as dairy foods, fatty foods or high-fiber foods for a few days – They can aggravate diarrhoea
• Eat if you can – Starchy foods such as rice, bread and pasta are recommended (Mayo Clinic, 2021).

References

DrugBank. (2021). Bismuth subsalicylate. Retrieved from DrugBank Online: https://go.drugbank.com/drugs/DB01294

DrugBank. (2021). Loperamide. Retrieved from DrugBank Online: https://go.drugbank.com/drugs/DB00836

emc. (2011). Kaolin and Morphine Mixture BP. Retrieved from emc: https://www.medicines.org.uk/emc/product/37/smpc

emc. (2021, 07). Dioralyte Blackcurrant Sachets. Retrieved from emc: https://www.medicines.org.uk/emc/product/2773/smpc

Fonseca, B. K. (2004). Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Archives of Pediatrics and Adolescent Medicine, 483-490.

Johnson, P. C. (1986). Comparison of loperamide with bismuth subsalicylate for the treatment of acute travelers' diarrhea. JAMA, 757-760.

Mayo Clinic. (2021). Diarrhoea; Diagnosis & Treatment. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/diarrhea/diagnosis-treatment/drc-20352246

NHS. (2020, 04 16). Rotavirus vaccine overview. Retrieved from NHS: https://www.nhs.uk/conditions/vaccinations/rotavirus-vaccine/

NICE. (2021). Diarrhoea (Acute) BNF. Retrieved from BNF.NICE: https://bnf.nice.org.uk/treatment-summary/diarrhoea-acute.html

NICE. (2021). LOPERAMIDE HYDROCHLORIDE. Retrieved from BNF.NICE: https://bnf.nice.org.uk/drug/loperamide-hydrochloride.html

Prakash, P. S. (1980). Loperamide versus diphenoxylate in diarrhea of infants and children. Indian Journal of Paediatrics, 303-306.

Rutter, P. (2017). Diarrhoea. In P. Rutter, Community Pharmacy; Symptoms, Diagnosis and Treatment (pp. 172-179). Elsevier.

Soares-Weiser, K. B. (2019). Vaccines for preventing rotavirus diarrhoea: vaccines in use. The Cochrane database of systematic reviews.

Steffen, R. (1990). Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea. Reviews of Infectious Diseases, 80-86.

Tidy, D. C. (2018, 03). Diarrhoea. Retrieved from Patient.info: https://patient.info/digestive-health/diarrhoea