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Diarrhoea

Definition

The term ‘diarrhoea’ originates from the Greek for ‘to flow through’ (Bell [19]) and can be characterized according to its onset and duration (acute or chronic) or by type (e.g. secretory, osmotic or malabsorptive). Diarrhoea can also be defined in terms of stool frequency, consistency, volume or weight (Metcalf [145]). The World Health Organization defines diarrhoea as the passage of three or more loose stools per day, or more frequently than is normal for the individual (WHO [246]).

Related theory

Diarrhoea is a serious global public health problem, in particularly in low‐ and middle‐income countries due to poor sanitation. There are almost 1.7 billion cases of diarrhoeal disease each year, with approximately 600,000 children each year dying as a result (WHO [246]). The disease pathogens are most commonly transmitted via the faecal–oral route (Ejemot‐Nwadiaro et al. [72]). Diarrhoea should be classified according to time (acute or chronic) and the characteristics of the stools (see the Bristol Stool Chart in Figure 6.3) (Baldi et al. [11]).

Acute diarrhoea

Acute diarrhoea is very common, is usually self‐limiting, generally lasts less than 2 weeks and often requires no investigation or treatment (Carlson et al. [46]). Causes of acute diarrhoea include:

dietary indiscretion (eating too much fruit, or alcohol misuse)
allergy to food constituents
infective:
- travel associated
- viral
- bacterial (usually associated with food)
- antibiotic related.

One of the most common causes of acute diarrhoea in the adult population worldwide is viral gastroenteritis resulting from norovirus. Its low infectious dose, its resistance to extreme temperatures and to many household cleaning products, and its viral shedding (before and after symptoms are apparent) have resulted in this virus being prolific during the colder months and becoming widely known as the winter vomiting bug (Krenzer [114]).

Chronic diarrhoea

Chronic diarrhoea generally lasts longer than 2–4 weeks and may have more complex origins. Chronic causes can be divided as follows (Arasaradnam et al. [9]):

colonic: colonic neoplasia, ulcerative colitis and Crohn's disease, microscopic colitis
small bowel: small bowel bacterial overgrowth, coeliac disease, Crohn's disease, Whipple's disease, bile acid malabsorption, disaccharidase deficiency, mesenteric ischaemia, radiation enteritis, lymphoma, giardiasis
pancreatic: chronic pancreatitis, pancreatic carcinoma, pancreatic insufficiency, cystic fibrosis
endocrine: hyperthyroidism, diabetes, hypoparathyroidism, Addison's disease, hormone‐secreting tumours
other causes: laxative misuse, drugs, alcohol, autonomic neuropathy, small bowel resection or intestinal fistulas, radiation enteritis.

Pre‐procedural considerations

Assessment

The cause of diarrhoea needs to be identified before effective treatment can be instigated. This may include clinical investigations such as stool cultures for bacterial, fungal and viral pathogens or a more formal medical evaluation of the gastrointestinal tract (Bossi et al. [32]).

Ongoing nursing assessment is essential to ensure individualized management and care. Nurses need to be aware of contributing factors and be sensitive to patients’ beliefs and values in order to provide holistic care. A comprehensive assessment is therefore essential and should include the all the aspects outlined in Box 6.2.

Box 6.2

Assessment of a patient experiencing diarrhoea

Assessment should cover:

History of onset, frequency and duration of diarrhoea: patient's perception of diarrhoea is often related to stool consistency (Arasaradnam et al. [9]).
Consistency, colour and form of stool, including the presence of blood, fat and mucus. Stools can be graded using a scale such as the Bristol Stool Chart (see Figure 6.3), where diarrhoea would be classified as above type 5 (Arasaradnam et al. [9]).
Associated symptoms: pain, nausea, vomiting, fatigue, weight loss or fever.
Physical examination: check for gaping anus, rectal prolapse and prolapsed haemorrhoids (Nazarko [155]).
Recent lifestyle changes, emotional disturbances or travel abroad.
Fluid intake and dietary history, including any cause‐and‐effect relationships between food consumption and bowel action.
Regular medication, including antibiotics, laxatives, oral hypoglycaemics, appetite suppressants, antidepressants, statins, digoxin or chemotherapy (Nazarko [155]).
Effectiveness of antidiarrhoeal medication (dose and frequency).
Significant past medical history: bowel resection, pancreatitis or pelvic radiotherapy.
Hydration status: evaluation of mucous membranes and skin turgor.
Perianal or peristomal skin integrity: enzymes present in faecal fluid can cause rapid breakdown of the skin (Beeckman et al. [16]).
Stool cultures for bacterial, fungal and viral pathogens: to check for infective diarrhoea (Kelly et al. [110]). Treatment may not be commenced until results are available except if the patient has been infected by Clostridioides difficile in the past.
Blood tests: full blood count, urea and electrolytes, liver function tests, vitamin B₁₂, folate, calcium, ferritin, erythrocyte sedimentation rate (ESR) and C‐reactive protein.
Patient's preferences and own coping strategies including non‐pharmacological interventions and their effectiveness (Arasaradnam et al. [9]).

All episodes of acute diarrhoea must be considered potentially infectious until proven otherwise. The immediate management should comply with local infection control guidelines on precautions and decontamination (RCN [207]); these will often include wearing gloves, aprons and gowns; disposing of all excreta immediately; and, ideally, nursing the patient in a side room with access to their own toilet. Advice should always be sought from the infection control team. At this stage, nursing care should also include educating patients about careful hand washing.

Diarrhoea can have profound physiological and psychosocial consequences for a patient. Severe or extended episodes of diarrhoea may result in dehydration, electrolyte imbalance and malnutrition. Patients not only have to cope with increased frequency of bowel movement but also may have abdominal pain, cramping, proctitis, and anal or perianal skin breakdown. Food aversions may develop or patients may stop eating altogether as they anticipate subsequent diarrhoea following intake. Consequently, this may lead to weight loss and malnutrition. Fatigue, sleep disturbances, and feelings of isolation and depression are all common consequences for those experiencing diarrhoea. The impact of severe diarrhoea should not be underestimated; it is highly debilitating and may cause patients on long‐term therapy to be non‐compliant (Bossi et al. [32]).

Once the cause of diarrhoea has been established, management should be focused on resolving the cause and providing physical and psychological support for the patient. Most cases of chronic diarrhoea will resolve once the underlying condition is treated, for example drug therapy for Crohn's disease or dietary management for coeliac disease. Episodes of acute diarrhoea, usually caused by bacteria or viruses, generally resolve spontaneously and rarely require professional input (Caramia et al. [45]).

Pharmacological support

The treatment for diarrhoea depends on the cause.

Antimotility drugs

Antimotility drugs such as loperamide or codeine phosphate may be useful in some cases, for example in blind loop syndrome and radiation enteritis. These drugs reduce gastrointestinal motility in order to relieve the symptoms of abdominal cramps and reduce the frequency of diarrhoea (Kaufman [108]). It is important to rule out any infective agent as the cause of diarrhoea before using any of these drugs, as the drugs may make the situation worse by slowing the clearance of the infective agent.

Antibiotics

Empirical antibiotic treatment can eradicate the normal bowel flora, which can increase the risk of potentially fatal infections and multidrug resistance organisms (Caramia et al. [45]). Therefore, treatment with antibiotics is recommended only in patients who are very symptomatic and show signs of systemic involvement. When dealing with antibiotic‐associated diarrhoea, most patients will notice a cessation of their symptoms with discontinuation of the antibiotic therapy. If diarrhoea persists, it is important to exclude pseudomembranous colitis by performing a sigmoidoscopy and sending a stool for cytotoxin analysis.

Over recent years there has been increasing evidence supporting the use of probiotics in cases of diarrhoea associated with antibiotics (Agamennone et al. [7]). Researchers believe that probiotics restore the microbial balance in the intestinal tract previously destroyed by the inciting antibiotics (Agamennone et al. [7]). There are a variety of probiotic products available and their effectiveness appears to be related to the strain of bacteria causing the diarrhoea (Łukasik and Szajewska [136]).

Fluid replacement

The prevention and/or correction of dehydration is the first step in managing an episode of diarrhoea. Adults normally require 1.5–2 L of fluid in 24 hours. A patient who has diarrhoea will require an additional 200 mL for each loose stool. Dehydration can be corrected by using intravenous fluids and electrolytes or by using oral rehydration solutions. The extent of dehydration dictates whether a patient can be managed at home or will need to be admitted to hospital. Nursing care should also include monitoring signs or symptoms of electrolyte imbalance, such as muscle weakness and cramps, hypokalaemia, tachycardia and hypernatraemia (NICE [175]).

Non‐pharmacological support

Maintaining dignity

Preserving the patient's privacy and dignity is essential during episodes of diarrhoea. The nurse has an important role in minimizing the patient's distress by adjusting language and using terms that are appropriate to the individual to reduce embarrassment and by listening to the patient's preferences for care (Ostaszkiewicz et al. [184]). Additionally, the use of deodorizers and air fresheners to remove the smell caused by offensive diarrhoea contributes to the person's dignity.

Skin care

It is important that the patient has easy access to clean toilet and washing facilities and that requests for assistance are answered promptly. Skin care is also essential to prevent bacteria present in faecal matter from destroying the skin's cellular defences and causing skin damage. This is particularly important with diarrhoea since it has high levels of faecal enzymes, which come into contact with the perianal skin (Gray et al. [91]). The anal area should be gently cleaned with warm water immediately after every episode of diarrhoea. Frequent washing of the skin can alter the pH and remove protective oils from the skin. Products aimed at maintaining healthy perianal skin should be used to protect patients with diarrhoea (RCN [207]). Soap should be avoided, unless it is an emollient, to avoid excessive drying of the skin. Gentle patting of the skin is preferred for drying to avoid friction damage. The use of incontinence pads should be carefully considered in a person with severe episodes of diarrhoea. This particular material does not absorb fluid stools, protect the skin from damage or contain smells.

Diet

A diet rich in fibre can cause diarrhoea. In such cases, individuals should be advised to reduce their intake of foods including cereals, fruit and vegetables and space them out over the day (RCN [207]). Chilli and other spices can irritate the bowel and should be avoided. Sorbitol (artificial sweetener), beer, stout and high doses of vitamins and minerals should also be avoided.