Antidiarrheal Therapy by Dr.Hamed Daghzghzadeh
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Transcript of Antidiarrheal Therapy by Dr.Hamed Daghzghzadeh
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Antidiarrheal Therapy
byDr.Hamed Daghzghzadeh
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Diarrhea is loosely defined as passage
of abnormally liquid or unformedStool at an increased frequency.
For adults on a typically westernDiet, stool weight exceeding 200g/dCan generally be considered diarrheal.
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Epidemiology of Acute Diarrhea
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Worldwide >1000,000,000 people/year
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5-8 million deaths / year
in developing countries
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►Secretory diarrhea►Osmotic diarrhea►Inflammatory ( exudative )
diarrhea
►Motility ( dismotile ) diarrhea►Anatomic( absorptive surface)
Pathophysiologic classification of diarrhea
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Major Causes of Acute Diarrhea 8
► INFECTIONS (Including Travelers Diarrhea)Bacterial : Campylobactre Species, C.difficile, E.coli, Salmonella eneritides
, Shigella SpeciesParasitic/protozoal : E. histolytica, Giardia lambilia,Cryptosporidium ,CyclospoaViral : Adenovirus , Norwalk virus , Rotavirus ,AIDS, OthersFungal► FOOD POISONING : B.Cereus , C . Perfringens , Salmonella species ,
S .aureus, Vibrio species, Shigella species , Camppylobacter.jejuni, E.coli► MEDICATIONS► RECENT INGESTION OF LARGE AMOUNT OF
POORLY ABSORBABLE SUGARS► INTESTINAL ISCHEMIA► FECAL IMPACTION► PELVIC INFLAMMATION► GRAFT VS HOST DISEASE
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Most acute diarrheas are due to
infectious diseases that have limited
courses from a few days to a few
weeks.
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MAJOR CAUSES OF CHRONIC DIARRHEA► IBS► IBD► Ischemic bowel disease► Chronic bacterial / mycobacterial infection► Parasitic & fungal infections► Radiation enteritis► Malabsorption Syndromes► Medications, Alcohol► Colon cancer , Villous Adenoma ,intestinal
Lymphoma► Diverticulitis► Previous Surgery ( gastrectomy, vagatomy, intestinal
resection )► Endocrine causes► Fecal impaction► Heavy metal poisoning► Epidemic idiopathic chronic diarrhea
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NONSPECIFIC Rx OF
DIARRHEA
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The most important Rx for diarrhea is to
ensure that fluid and
electrolyte deficits are replenished with IV or oral rehydration
solution.
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ORS
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►The rate of replacement should match the clinical presentation.
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Empiric Therapy
of Acute Diarrhea
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Aminoacid & Glucose absorption accelerates sodium and fluid absorption
in the jejunum.
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Saline solutions containing glucose or amino acids will be absorbed readily
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Oral rehydration solutions increase
fluid and electrolyte absorption; they are
not designed to reduce stool output,
so stool weight actually may increase
with their use.
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Infection is a frequent cause of acute
diarrhea.
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If the prevalence of bacterial or protozoal infection is high in a
community or in a specific situation, empiric use of antibiotics is logical.
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as in the treatment of travelers' diarrhea
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Even without bacteriologic
proof of infection.
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Empiric antibiotic therapy is often also logically
used for more severely ill
patients while awaiting bacterial culture results.
Adachi JA, Zeichner LO, DuPont HL, Ericsson CD: Empirical antimicrobial therapy for traveler's diarrhea. Clin Infect Dis 31:1079, 2000.
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Ciprofluxacine 500 mg Q12h ( 3 days)
OrAzythromycin 1000 mg single
dose
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Experts also advise against empiric
treatment of salmonellosis unless
enteric fever is present. Sirinavin S, Garner P: Antibiotics for treating salmonella gut infections.
Cochrane Database Syst Rev 30:CD001167, 2000.
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Nonspecific antidiarrheal agents
can reduce stool frequency and stool weight and can reduce coexisting symptoms, such as abdominal cramps
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Opiates, such as loperamide, or diphenoxylate with atropine frequently are
employed.
Schiller LR: Review article: Anti-diarrhoeal pharmacology and therapeutics. Aliment Pharmacol Ther 9:87, 1995.
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Intraluminal agents, such as bismuth subsalicylate
and adsorbents (e.g., kaolin) also may help reduce the fluidity of bowel movements.
Schiller LR: Review article: Anti-diarrhoeal pharmacology and therapeutics. Aliment Pharmacol Ther 9:87, 1995.
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Empiric Therapy of Chronic Diarrhea
is used in three situations: (1) Initial treatment before diagnostic
testing; (2) After diagnostic testing has failed
to confirm a diagnosis(3) When a diagnosis has been made
but no specific treatment is available or specific treatment has failed to produce a cure.
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Generally, empiric antibiotic therapy is
less useful in chronic diarrhea
than in acute diarrhea.
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In chronic diarrhea an empiric course of metronidazole or a
fluoroquinolone before extensive diagnostic
testing, is not recommended.
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►Remember that diarrhea can be a prominent symptom of malaria.
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Other drugs
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►VERAPAMIL►NIFEDIPENEREDUCE MOTILITYINCREASE ABSORBTION
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Travelers' diarrhea
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Travelers' diarrhea affects
30% to 50% of travelers to developing
countries.
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Enterotoxigenic Escherichia coli (ETEC)
is the most common cause of travelers'
diarrhea worldwide
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Other causes of travelers' diarrhea
►Shigella ►Campylobacter►Aeromonas,► Plesiomonas,►Vibrio►Rotaviruses►Norwalk virus►Giardia
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Most cases of travelers' diarrhea
occur between 5 and 15 days after
arrival.
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►Persons with gastric hypoacidity and immunosuppressed patients are probably at greater risk of developing travelers' diarrhea.
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►Most bouts of travelers' diarrhea are self-limited, with resolution after 4 to 6 days
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The illness is heralded by
malaise, anorexia, and abdominal
cramps, followed by watery, usually
nonbloody, diarrhea
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►In some cases, nausea and vomiting may be a prominent component
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How to prevent Travelers' diarrhea?
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Bcause travelers' diarrhea is contracted by the ingestion of
fecally contaminated food or water.
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The first line of defense for the traveler is care in selecting food and beverages.
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►The first approach is chemoprophylaxis using either antibiotics or bismuth to prevent diarrhea.
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The most widely used approach to travelers' diarrhea is probably the provision of antibiotics to be used by the traveler, if and when diarrhea strikes.
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Antibiotic prophylaxis is indicated for travelers (to high risk countries), with
1.Gastric achlorhydria2.IBD3.Immunocompromise
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A reasonable current recommendation is to provide a three-day course of a quinolone for travelers to most developing countries.
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The patient is told to begin the antibiotic when diarrhea starts and to continue treatment for
3 days.
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A quinolone represents the drug of choice for travelers if antibiotic prophylaxis is used or for the treatment of travelers' diarrhea.
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A single daily dose of ciprofloxacin (500 mg) had a
protective efficacy of 94%.
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Norfloxacin in a daily dose of 400 mg had a protective efficacy of 93% .
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►Chemoprophylaxis with bismuth is moderately effective (approximately 65%) in preventing diarrhea.
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►Two bismuth tablets(240mgx2) taken four times daily.
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It needs to be emphasized before travel that self-treatment regimens are not appropriate for the traveler with
bloody diarrhea, severe abdominal pain, high fever
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The disadvantagesrelate to the possibility of 1-side effects 2-selection of antibiotic-resistant organisms.
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The advantage of prophylactic antibiotics
is their high efficacy in preventing disease.
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Finally, the most important
component of self-treatment is the replacement of the fluid and electrolytes lost during diarrhea.
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Watery diarrhea that occurs later after return or that persists longer than 10 days despite antibiotic therapy is most commonly
Giardia lamblia infection.
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If the diarrhea fails to respond to metronidazole,
a gastrointestinal evaluation should be
performed.
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The diagnostic & therapeutic
considerations differ somewhat for
bloody diarrhea, and the pace of the
workup should be accelerated.
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Indications of antibiotic coverage wether or not a causative organism is
discovered in acute diarrhea 3
1. Immunecompromised patient.2. Mechanical heart valves or
recent vascular graft.3. Elderly.
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Thank you
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Constipation
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Constipation
►Constipation, or associated symptoms, afflicts many people in the Western world.
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The prevalence is greatest among children and the elderly.
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►Many people ignore the symptoms or treat themselves by dietary modification or over-the-counter remedies.
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PRESENTING SYMPTOMS
►Aperson who says "I am constipated" is either conscious of an unpleasant sensation related to bowel movements or believes that bowel function is abnormal.
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►6% - 23% of subjects said in response to interview that they had experienced constipation during the past 12 months.
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►At least 10% of the subjects experienced difficulty in defecation at least once a month.
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►More women than men regard themselves as constipated.
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CLINICAL DEFINITION AND CLASSIFICATIONA
►Clinical definition of constipation needs to take account of both difficult defecation and infrequent stools.
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General Factors►Sex►Age ►Nationality ►Diet ►Exercise and Daily Activity
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Defecatory Function
►Failure of Relaxation of the Anal Sphincter Complex
►Ineffective Straining ►Diminished Rectal Sensation
►Size and Consistency of Stool
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Psychological and Behavioral Factors
►Personality affects stool size and consistency.
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CONSTIPATION AS A MANIFESTATION OF
SYSTEMIC DISORDERS
►Hypothyroidism
►Diabetes Mellitus
►Hypercalcemia
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CONSTIPATION AS A MANIFESTATION OF CENTRAL
NERVOUS SYSTEM DISEASE OR EXTRINSIC NERVE SUPPLY TO THE
GUT ►Loss of Conscious Control ►Parkinson's Disease►Multiple Sclerosis ►Spinal Cord Lesions
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CONSTIPATION SECONDARY TO STRUCTURAL DISORDERS OF THE COLON, RECTUM, ANUS,
AND PELVIC FLOOR
►Disorders of Smooth Muscle
►Enteric Nerves
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Disorders of the Anorectum and Pelvic Floor
►Rectocele►Weakness of the Pelvic Floor—
"Descending Perineum Syndrome" ►Full-Thickness Rectal Prolapse,
Intrarectal Mucosal Prolapse, and Solitary Rectal Ulcer Syndrome
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PSYCHOLOGICAL DISORDERS AS CAUSES OF OR
AGGRAVATING FACTORS IN CONSTIPATION
►Depression► Eating Disorders ►Denied Bowel Movements
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CLINICAL ASSESSMENT
►History►Social History ►Physical Examination ►Prospective Use of a Diary Card
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