Diarrhoea

Gastrointestinal Conditions

Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.

Clinical features

May be associated with abdominal cramps, loss of appetite, nausea and vomiting and headache. Gastroenteritis (i.e. due to enteric infection with viruses, bacteria, or protozoa) is characterised by the sudden onset of diarrhoea, potentially with vomiting and other symptoms such as blood or mucus in the stool, and fever or malaise

Signs of dehydration or clinical shock. Signs of dehydration include: increased thirst, dry mouth, lethargy, decreased urine output, headache, dry skin and dizziness. [See NICE guideline CG84 for guidance on assessing dehydration severity and when hospital admission is recommended]

Blood (black or red) or mucus in the stools. This including when a child has a single acute episode of bloody diarrhoea due to possible vero cytotoxin-producing E. coli infection

Unable to retain fluids due to vomiting very soon after drinking; unable to drink fluids or have green or yellow vomit

Symptoms that disturb sleep, long-term change in bowel habit or any warning signs suggestive of cancer including unexplained weight loss (particularly in middle to older aged adults where colorectal cancer increases in prevalence).
Also, recurrent or chronic diarrhoea (with no identifiable cause or when it suggests an existing bowel condition is not well controlled) or suspected faecal impaction.
NB: unexplained chronic diarrhoea is an HIV indicator condition (as per the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020)

Diarrhoea associated with recent hospital stay or antibiotic use (see BNF for antibacterials associated with pseudomembranous colitis) or medicine-induced diarrhoea

Infants younger than 1 year of age, infants who were of low birthweight; infants who have stopped breastfeeding during their illness; a child with diarrhoea who has passed six or more stools in the past 24 hours (or have vomited three times or more in the past 24 hours)

Steatorrhoea or another reason to suspect a malabsorption syndrome such as lactose intolerance and coeliac disease

Suspected dysentery (for example, following foreign travel) which may present with blood/mucus in the stools and a high grade fever. Suspected giardiasis.

Most cases of diarrhoea in adults will resolve in 2 to 4 days. In the context of gastroenteritis, adults and older children should seek medical advice if there is no improvement within 48 hours. NHS advises calling 111 urgently if diarrhoea lasts more than 7 days or vomiting lasts more than 2 days

In children, duration of diarrhoea is usually 5 to 7 days (vomiting is one or two days). Diarrhoea should have stopped within 2 weeks (and in the case of vomiting, within 3 days). Refer if beyond these time frames or sooner if no sign of improvement or if deterioration occurs. NHS advises calling 111 urgently if diarrhoea lasts more than 7 days or vomiting lasts more than 2 days

Non-pharmacological advice

Keep children hydrated for example by giving frequent small sips of water, but avoid fruit juice and fizzy drinks. The priority is to correct fluid loss first (over solid food)

Adults should drink fluids containing salt, sugar and water (such as watered down fruit juices or soups)

After rehydration: small amounts of solid foods like potatoes, bananas, rice may be eaten as desired. Probably best to avoid spicy or fatty foods, or large meals (this advice obviously is aimed at adults and children rather than babies who don't normally have solid food as part of their diet)

If infective cause: ways to minimise spread of infection/cross-contamination measures - these include hand-washing after going to the toilet and before food preparation, washing soiled clothes in a hot wash, cleaning toilet and sink and other surfaces

Consider the consequences of patients’ medicines not being absorbed and provide appropriate advice (for example, in relation to contraceptives, medicines required to manage conditions such as epilepsy, mental health) which may include referral. Consider also that some medical conditions or medicines can exacerbate dehydration and renal failure, which again, may mean referral to the GP is best rather than self-care

Consider the impact of being infectious in the workplace and advise the patient to seek further guidance from their employer as necessary (for example, if the patient works in a care home, hospital etc.)

Advise the patient to report suspected food poisoning to enable further investigation of the vendor. The UK Health Security Agency (UKHSA) has a list of notifiable conditions. See NICE guidelines and local laboratory guidance for information on when stool samples should be obtained and which infections are notifiable
Safety net: typical time frames to resolution and when to seek medical advice (see previous tab). Also, how to recognise signs of deterioration, serious illness, dehydration and shock and what to do if these occur

Pharmacological advice

The priority in acute diarrhoea is to prevent or reverse fluid and electrolyte depletion (hydration). Oral rehydration solution (ORS) is considered for patients who are particularly at risk of dehydration, such as the elderly, frail individuals, young children (especially infants), and those with co-morbidities. Refer to NICE guideline CG84 and the NHS website for further detail on at-risk groups

Antimotility agents are not routinely required for gastroenteritis. However, loperamide may offer symptomatic benefit for adults with mild to moderate symptoms where prompt resolution is needed for practical reasons. It should be used for a short duration only, and the patient should seek medical advice if there is no improvement within a few days. Loperamide is contraindicated where there is blood or mucus in the stools, high fever, suspected or confirmed vero cytotoxin-producing E. coli O157 infection, or shigellosis. Warn patients about potential drowsiness or dizziness, particularly when driving or operating machinery. Note the different OTC age limits: 12 years and over for acute diarrhoea, but 18 years and over for diarrhoea associated with irritable bowel syndrome (check SmPC). Exercise caution in patients with a history of substance misuse

Pregnancy: be mindful of possible complications including dehydration which might require medical advice to be sought. Advise on adequate fluid intake and check individual ORS products prior to sale. Loperamide: BNF states that 'manufacturers advise avoid - no information available.' As previously stated, it may be prudent to involve the patient's doctor