The National Minor Illness Centre

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1 The National Minor Illness Centre Diarrhoea and Vomiting Update September 2007 Diarrhoea and vomiting is one of the commonest minor illnesses brought to health professionals. In the primary care setting it is rarely serious. The most common cause is a viral infection, but bacterial infection may also occur: this is known as food poisoning to reflect the usual source of the infection. 1

2 Diarrhoea and vomiting - history Duration Severity, episodes in 24hrs Preceding constipation Urine output and colour It is important to establish the degree of fluid lost in diarrhoea and vomiting, though patients often find it surprisingly hard to give this information. Urine output and colour are also a useful guide to the level of hydration. The question about preceding constipation is important, in order not to miss the problem of faecal impaction and overflow. 2

3 D&V - history Blood Fever Foreign travel Contacts Blood in the stool is a significant symptom which is likely to prompt referral. Remember that blood from the stomach will be altered by the digestive process, and will appear brown in the vomit ( coffee-grounds ) or black in the stool (melaena). Recent travel to a country outside Europe or the USA increases the likelihood of bacterial infection: Egypt and India seem to be the commonest sources. The question about whether any contacts have similar symptoms is useful in distinguishing viral and bacterial infections: in viral infections there is usually an interval of two days before contacts become ill, whereas if all the family have eaten infected food their symptoms will start almost simultaneously. 3

4 D&V - history Suspect foods Sorbitol Previous bowel disease Occupation Barbecues, and undercooked chicken, are notorious sources of food poisoning bacteria. Sorbitol is an artificial sweetener used in some diet and diabetic foods, for example sugar-free Polo mints. Some people are very sensitive to its laxative action. Patients with ulcerative colitis, Crohn s disease or diverticular disease who present with diarrhoea +/- vomiting need assessment by a doctor in case this is an exacerbation of their underlying condition. Asking about the patient s occupation is important in order to assess the need for time off work and the risk to the public. This will be discussed later. 4

5 D&V medication check? CAUSING symptoms? AFFECTED by condition? STOP ACE inhibitor or diuretic STOP methotrexate Medications which commonly cause diarrhoea include antibiotics, especially erythromycin; metformin and orlistat. The absorption of most medications will be affected by diarrhoea and vomiting; this is particularly relevant to medicines for diabetes and the combined oral contraceptive pill. Recent evidence has emerged that ACE inhibitors and diuretics may have dangerous effects in the presence of dehydration, and may precipitate renal failure. These drugs should be stopped until the symptoms have settled. The blood levels of methotrexate may become dangerously high in a dehydrated patient. 5

6 D&V - examination Check for dehydration BP if on cardiovascular drugs Examine abdomen, if pain prominent Consider rectal examination, if preceding constipation The most important part of the examination is to check for dehydration. Look for dryness of the mouth, dullness of the eyes, and reduced skin turgor. In young babies the fontanelle may also be sunken. If the patient is taking ACE inhibitors or other anti-hypertensive drugs, ensure that the blood pressure is not too low. Most patients with diarrhoea will experience intermittent griping abdominal pain which signals the need to empty their bowel. Rarely appendicitis or other abdominal pathology may present with diarrhoea and vomiting, so it is wise to examine the abdomen if pain is a prominent symptom. If you suspect faecal obstruction and overflow you will need to perform or arrange a rectal examination. 6

7 D&V without looking at your handouts. Please list ten indications for requesting a stool culture. Just going through the motions See if you can think of ten reasons why you would send a stool to the laboratory for culture in a patient with diarrhoea and vomiting. 7

8 D&V - stool culture if.. 1. Suspected food poisoning 2. Blood in stool 3. Severe malaise 4. Recent travel outside Europe / USA 5. Symptoms for 4 days or more CKS/Prodigy has recently changed its guidance for the duration of the illness before stool testing is needed, to four days instead of five. 8

9 Stool culture if.. 6. Food handler 7. Working with vulnerable people 8. Pregnant 9. Immunocompromised 10. Recent broad spectrum antibiotics (request clostridium difficile)..and has also added the following categories. So the cleaner on the chemotherapy ward, or an admin worker in a nursing home, would fall into this category as, indeed, would you. Pregnant women who contract salmonella are at increased risk of septicaemia. Immunocompromised patients are more likely to need antibiotic therapy for bacterial food poisoning. We are now becoming more aware of c. diff as an opportunist organism which moves into the bowel when the normal flora has been disrupted by antibiotic therapy. It is called difficile because it is difficult to culture in the laboratory, so the microbiology team will only look for it if you specifically request it: ensure that you write your suspicion on the request form 9

10 D&V - advice Reassure - rarely serious Dehydration is rare over 6 months of age Discuss hygiene Exclude patients from work / school until 24 hours after symptoms settle (48 hours for high-risk groups) In primary care, serious illness is rare amongst patients with D&V and dehydration is very unusual except in small babies. It is important to discuss hand-washing and bleaching the toilet and the door handle, to avoid cross-infection. Those who work with food or with vulnerable people should not return to work until they have been clear of symptoms for 48 hours. They may require a certificate for this, although health professionals have no objective method of confirming the patient s statement. 10

11 D&V - advice Oral rehydration solution for: babies under 6 months clinically dehydrated Extra fluids should be taken, especially fruit juice and soup Oral rehydration solution (ORS) is available in a range of flavours, none of which is very palatable. It should only be recommended in babies and dehydrated patients, and even then as an adjunct to normal fluids and not a substitute. Previous advice to recommend ORS exclusively has been shown to be harmful, particularly in patients who refuse it because of the taste. Extra fluids should be encouraged; the type does not matter. Citrus juices may be best avoided because they have an irritant effect. Isotonis sports drinks have the advantage of containing the correct amount of salt; homemade rehydration mixtures may be dangerous if the formula is inaccurately remembered. Dehydration guideline: 1&ss=6&xl=999 11

12 D&V - advice Sips, not gulps Ice Pops may help if fluids are not tolerated If the patient is vomiting or nauseous they should be advised to take fluids in very small amounts frequently. Sucking ice cubes or Ice Pops may also be helpful. 12

13 D&V - advice Fasting is no longer recommended Normal diet should be resumed as soon as possible Babies should continue normal feeds Traditionally, patients were advised to fast for at least 24 hours if they had diarrhoea and vomiting. This advice has been shown to delay recovery, presumably because the body becomes depleted of nutrients and the immune system cannot function efficiently. Continuing to feed, although messier, results in speedier resolution of symptoms. Patients often resist this advice, sying that the food goes straight through me. It helps to explain that the digestive tract is extremely long and it usually takes 48 hours for food to pass from one end to the other. The effect they have observed is the gastro-colic reflex, where food entering the stomach triggers emptying of the bowel. They are still able to absorb most of their food. Various recommendations of special foods in this situation have not been found to be consistently helpful, so a normal diet is recommended. A major change in guidance in 2006 was that all babies, including those on formula milk, should continue with normal feeds as well as extra fluids. 13

14 D&V - advice Recommend probiotics Babies may develop temporary lactose intolerance; send stool for reducing substances Consider lactose-free milk in babies with persistent diarrhoea There is increasing evidence that probiotics such as lactobacillus acidophillus are effective in reducing the duration of diarrhoea, especially when it has been caused by antibiotics. Unfortunately there is no standardised product available on prescription in the UK, but for adults capsules are preferable to yoghourts because there is less chance that the bacteria will be destroyed by the stomach acid. These capsules (e.g. Vega Acidophillus) are sold in most community pharmacies for 5-6. In 2007 Infacol launched probiotic drops for babies, which are licensed from birth. Unfortunately they are expensive (around 10). After an episode of D&V, children may develop a reduced ability to digest lactose, a sugar found in cow s milk. They will have persistent diarrhoea; the condition can be diagnosed by asking the laboratory to test the stool for reducing substances, In this situation lactosefree milk (e.g. SMA LF) can be bought or prescribed for a week or two until the problem resolves. In a few children this intolerance may persist, in which case referral to a dietitian is advised. References Brown, K.H., Peerson, J.M. and Fontaine, O. (1994) Use of nonhuman milks in the dietary management of young children with acute diarrhoea: a meta-analysis of clinical trials. Pediatrics 93(1), Allen, S., Okoko, B., Martinez, E. et al. (2003) Probiotics for treating infectious diarrhoea (Cochrane Review). The Cochrane Library. Issue 4. Chichester, UK: John Wiley & Sons, Ltd. 14

15 D&V prescription / OTC None for most avoid ibuprofen Paracetamol for stomach cramps D&V is the body s response to an organism inside the digestive tract, and it serves the purpose of eliminating that organism. Although medicines are available to control the symptoms, they should only be used where clinically necessary. Ibuprofen is a stomach irritant which should not be taken if the digestive tract is inflamed; the risk of gastric erosions and haematemesis is much higher. It may also precipitate renal failure in the presence of dehydration. Paracetamol is safe. 15

16 Severe D&V consider prescription / OTC Diarrhoea: loperamide 2mg, 2 capsules immediately then one after each loose motion, maximum 8 daily Vomiting: buccal prochlorperazine, 3mg tablets, one or two twice daily Loperamide (Imodium) is usually effective in stopping diarrhoea; sometimes so effective that the patient becomes severely constipated afterwards. The dose regime is therefore designed to reduce the dose as the symptoms come under control. It is licensed for use in children of four and over, but we do not recommend its use in children. Its effect of slowing intestinal peristalsis means that the pathogen will be in contact with the gut mucosa for a longer period, so systemic infection is more likely. There is therefore a risk that the patient will feel more unwell even though they have less diarrhoea. Occasionally anti-emetic medication is justified, for example in a patient with diabetes who otherwise would need hospital admission. Swallowing anti-emetic tablets will be ineffective if they are immediately vomited up. Proclorperazine is an effective anti-emetic which has a buccal preparation which is available over the counter (Buccastem). This is dissolved under the upper lip and absorbed directly into the circulation. It may rarely cause an oculo-gyric crisis, which is commoner in young people under 25. We do not recommend it in this age group. 16

17 D&V - caution: Blood in stool or vomit Diabetes Immunocompromised Bowel disease Abdominal tenderness Patients who are bleeding from the GI tract need assessment by a doctor. Unless you are a diabetes specialist it is also wise to seek help for patients with diabetes who develop D&V, as their condition may destabilise rapidly. They should not stop taking their insulin or tablets, should maintain their carbohydrate intake, monitor their glucose regularly and check their urine for ketones. Immunocompromised patients may have infections with unusual organism and are more likely to need antibiotics. Patients with pre-existing inflammatory bowel disease or diverticular disease may need special treatment Abdominal tenderness on examination may require a surgical assessment. 17

18 Travellers diarrhoea: antibiotics for dysentery or at-risk travellers Ciprofloxacin 750 mg as a single dose Or ciprofloxacin 500 mg twice daily for 3 days Patients who have developed diarrhoea after travel outside UK/Europe are more likely to have bacterial infections, but generally these do not require antibiotics unless the symptoms are severe or the patient is immunocompromised. Using antibiotics may prolong the excretion of the organism, and increases the risk of developing resistance. If antibiotics are used then ciprofloxacin is the best choice. However microbiologists discourage its use because of fears of increasing bacterial resistance and the risk of clostridium difficile superinfection. Reference de Bruyn, G., Hahn, S. and Borwick, A. (2000) Antibiotic treatment for travellers' diarrhoea. The Cochrane Library. Issue 3. Chichester, UK: John Wiley & Sons, Ltd. 18

19 The National Minor Illness Centre Diarrhoea and Vomiting Update September