DIARRHEA

Non Infection
Anisyah Achmad
Major of Pharmacy, Medical Faculty
University of Brawijaya
diarrhoea implies that an excess volume of
stool is passed, and this is usually
accompanied by increased frequency of
Defecation (> 3x) and increased liquidity of
the stool.

Normal stool volume

varies between individuals and is about
200–300·mL/day.
 Diarrhoeal stool is usually more liquid.
It may also contain more fat
when caused by malabsorption
(steatorrhoea) and it may contain pus
and blood when caused by intestinal
inflammation (such as IBD)
 Diarrhoea is usually acute
(before 3 weeks ) that is, sudden
in onset and short-lived,
although it can be chronic (> 2
month)
 When increased secretion into the
intestine exceeds the capacity of the
small and large intestine to reabsorb
fluid, so stool volume increases.
Other bacterial toxins, hormones elaborated by
hormone-producing tumours, particularly
carcinoids and vasoactive intestinal peptide
(VIP)-omas, and tubulovillous colonic adenomas
that secrete fluid and mucus from the abnormal
epithelium can also cause secretory diarrhoea.

Excess bile salts that are not reabsorbed in the

terminal ileum, as a result of terminal ileal disease
or resection, can induce colonic hypersecretion.
 A non-absorbable osmotic load in
the intestine can overload the
intestine’scapacity for reabsorbing
water against the osmotic gradient.
lactase deficiency.
Lactase is the enzyme that normally splits lactose,
the predominant disaccharide in milk, into the
absorbable monosaccharides glucose and
galactose. Without lactase, ingested lactose
remains in the intestine, creating an osmotic
load.
Other causes of osmotic diarrhoea include
the use of non-absorbable food
sweeteners, such as sorbitol, and
laxatives, such as lactulose and
magnesium sulphate.
 Damage to the intestinal lining, caused by bacterial
or viral infection, or immune-mediated processes,
causes infiltration of fluid and inflammatory
cells into the intestinal wall and extrusion of this
inflammatory exudate into the intestinal lumen.

a. Excess mucus may also be secreted by the

damaged epithelium.
b. Inflammation also increases fluid secretion and
inhibits reabsorption
Pain and urgency often accompany
inflammatory diarrhoea and leucocytes
and blood are found mixed in with the
stool.

Common causes include bacterial and

amoebic.
 Whenever a person travels from one country to
another—particularly if the change involves a
marked difference in climate, social conditions,
or sanitation standards and facilities—diarrhea
is likely to develop within 2–10 days
There may be up to ten or even more
 loose stools per day

 abdominal cramps

 nausea

 vomiting

 Fever

The stools do not usually contain mucus or

blood, dehydration, and occasionally acidosis,
there are no systemic manifestations of
infection.
The illness usually subsides spontaneously
within 1–5 days
Avoidance of fresh foods and water
sources that are likely to be
contaminated is recommended for
travelers.

Where infectious diarrheal illnesses

are endemic. Prophylaxis is
recommended for those with
significant underlying disease
(inflammatory bowel disease, AIDS,
diabetes, heart disease in the elderly)
 Prophylaxis is started upon entry into the
destination country and is continued for 1 or 2
days after leaving.

 For stays of more than 3 weeks, prophylaxis is

not recommended.

 For prophylaxis, bismuth subsalicylate

norfloxacin 400 mg, ciprofloxacin 500 mg,
ofloxacin 300 mg, or trimethoprim-
sulfamethoxazole 160/800 mg. daily for 5 days
 The aims of antidiarrheal therapy
are to prevent:
(1) dehydration and electrolyte
depletion; and
(2) excessive-ly high stool frequency.
Education
Patients will find it more comfortable to
rest the bowel by avoiding high-fiber
foods, fats, milk products, caffeine, and
alcohol.
 Oral rehydration with fluids containing
glucose, Na+, K+, Cl–, and bicarbonate or
citrate is preferred in most cases to
intravenous fluids because it is inexpensive,
safe, and highly effective in almost all awake
patients
 The WHO rehydration formulation is
3.5 g NaCl, 1.5 g KCl, 2.9 g Na citrate and 20 g
glucose per litre. This provides 90mMNa+,
20mM K+, 80mMCl-, 10mM citrate and 111mM
glucose.
Antiperistalic agents act by altering intestinal motility.
Have proabsorptive or antisecretory activity.
Loperamide
Diphenoxylate
Codeine
Tincture opium

Antimotility agents are contraindicated in diarrhea

caused by invasive pathogens because the induced
intestinal stasis may enhance tissue invasion by the
organisms or delay their clearance from the bowel
 Loperamide
a dosage of 4 mg initially, followed by 2 mg
after each loose stool (maximum:16 mg/24 h)
 With overdosage,
there is a hazard of ileus. It is contrain-dicated
in child below age 12 y.
 They include atropine, hyoscine, hyoscyamine
and dicyclomine.
They are not effective in reducing the
frequency and volume of stools, but may have
some value in selected cases in reducing pain
from abdominal cramps.

It is contraindication for acute diare

 Charcoal, kaolin, pectin, dioctahedral smectite,
Attapulgite (anhydrous aluminum silicate),
aluminum hydroxide and tannic acid
 Prolonged use may interfere with some
medications, for example theophylline
and digoxin.

 Psyllium and other hydrophilic agents are

bulk forming agents.

 Commonly, they are used in chronic diarrhea

and irritable bowel syndrome, not in acute
diarrhea.
Adsorbent powders are nonab-sorbable
materials with a large surface area. These bind
diverse substances,in-cluding toxins, permitting
them to be inactivated and eliminated.
Charcoal dose is in the range of 4–8 g.
Kaolin (hy-drated aluminum silicate)
Chalk
Demulcents, e.g., pectin
(home remedy: grated apples) are carbohy-
drates that expand on absorbing water.
They improve the consistency of bowel
contents; beyond that they are devoid
of any favorable effect.
Lactobacillus acidophilus and Saccharomyces boulardii,
which increase acidity of stool, prohibit
the growth of enteropathogens and produce short
chain fatty acids that are beneficial for intestine
recovery, and increase the rate of fluid and electrolyte
absorption.

In children, could reduce the clinical course of acute

diarrhea.
In adults, used mainly in chronic diarrhea and relapse of
antibiotic associated enterocolitis
Bismuth salts preparations, according
to their mode of action, are also an
antisecretory agents.
They are found t be as effective as loperamide,
and reduce the number of stools passed by
about 50%
Bismuth subsalicylate
Two tablets or 30 mL four times daily,
reduces symptoms in patients with
traveler's diarrhea by virtue of its anti-
inflammatory and antibacterial
properties

Astringents such as tannic acid

Although astringents induce constipation (cf.
Al 3+ salts, ) a therapeutic effect in diarrhea is
doubtful.
THANK YOU