Diarrhoea and vomiting

Diarrhoea and vomiting are common symptoms of disease and infection across the whole life course.  They can affect anyone at any time but are most commonly seen in the young and the elderly among whom it can have a pronounced clinical impact leading to hospitalisation (National Institute for Health and Care Excellence (NICE), 2021a). Diarrhoea and vomiting may occur together or separately, in either case they can be either quite minor or they can lead to significant effects on the individual which may lead to hospitalisation and, in extreme cases, even death.

Diarrhoea may be chronic, or acute, with chronic diarrhoea being associated with diseases and other health conditions. For the most part, this condition will discuss diarrhoea which is acute in onset. Vomiting is also usually an acute issue, although some diseases and treatments predispose people to chronic vomiting, again this paper will mainly discuss acute vomiting.

Acute diarrhoea

The signs and symptoms of diarrhoea include:

• passing loose or watery stool
• passing stools frequently
• abdominal pain and/or cramps
• stool may include mucus and/or blood

The signs and symptoms of vomiting include:

• nausea
• retching
• ejecting stomach contents through the mouth
• pain and/or burning sensation in the oesophagus

If left untreated, or where the diarrhoea and/or vomiting persist, they can give rise to other issues which include:

• dehydration (Lacey et al, 2019)
• acute kidney injury (NICE, 2021c)

Diarrhoea and or vomiting can also give rise to secondary symptoms which the nurse may need to consider the management of, e.g. the need to barrier creams and mouth care, as well as considering issues of support and reassurance alongside privacy and dignity (Collie and Hunter, 2015).  

There are multiple reasons an individual may develop diarrhoea and/or vomiting. In children the leading causes relate to viral or bacterial gastrointestinal infections, while these also occur in adults (Tam et al, 2012), especially older adults, the causes of diarrhoea and/or vomiting in adults frequently include other diseases.

Viral causes of diarrhoea and/or vomiting

Viral causes of diarrhoea and/or vomiting are frequently seen in outbreaks which occur wherever people live together in close proximity, such as in homes, care homes and hospitals and often affect multiple individuals. Viral causes of diarrhoea and vomiting often give rise to both symptoms. Common examples include:

• norovirus
• rotavirus
• astrovirus
• adenovirus (Bányai et al, 2018)

Viruses are usually transmitted person to person via contact with infected vomit or diarrhoea especially when individuals have not washed their hands thoroughly. 

Bacterial causes of diarrhoea and/or vomiting

There are some bacteria which when they enter the gastrointestinal tract

The cause of diarrhoea and/or vomiting needs to be investigated so that treatment to cure and/or prevent further symptoms can be started. This requires that the nurse takes a thorough history, although in some cases the cause will be obvious.

Diagnosis will often involve the nurse securing specimens to be sent for microscopy, sensitivity and culture. The nurses will also need to be thorough and clear in their recording of the quantity and nature of the diarrhoea and vomit affecting the patient.

The Bristol stool chart can be used as a means of classifying the nature of diarrhoea a patient is experiencing, as well as discussing issues such as usual bowel habit, incontinence and urgency in order to clarify the nature of the problem (Crombie et al, 2013).

The assessment of vomiting tends towards understanding the patients lived experience of it, e.g. with chemotherapy induced vomiting (Wood et al, 2011),

The fundamental key to the management of diarrhoea and/or vomiting is the removal, or reversal of the cause where this is possible as well as the management of the signs and symptoms of diarrhoea and/or vomiting. This requires a structured and thorough approach to assessment of the individual patient which then indicates the treatment required. 

The nature of the management will also depend on the cause of the diarrhoea and/or vomiting as well as the presence of additional symptoms and concomitant illness. Management will focus on:

Pharmacological support

For diarrhoea this includes:

• antibiotics, only where an organism has been isolated
• antimotility agents such as loperamide and codeine phosphate – except in infective diarrhoea (Martin et al, 2021)
• fluid and electrolyte replacement, for dehydration, this may include oral rehydration (Binder et al, 2014), or for more severe dehydration, intravenous fluids may be indicated (NICE, 2017)

For vomiting this includes:

• antiemetics, with

References

Arasaradnam RP, Brown S, Forbes A. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018;67(8): 1380-1399

Bányai K, Estes MK, Martella V, Parashar UD. Viral gastroenteritis. The Lancet. 2018;392(10142):175-186. https://doi.org/10.1016/S0140-6736(18)31128-0.

Barrett J, Fhogartaigh CN. Bacterial gastroenteritis. Medicine. 2017;45(11):683-689. https://doi.org/10.1016/j.mpmed.2017.08.002.

Binder HJ, Brown I, Ramakrishna BS, Young GP. Oral rehydration therapy in the second decade of the twenty-first century. Curr Gastroenterol Rep. 2014;16:376. https://doi.org/10.1007/s11894-014-0376-2.

Collie M, Hunter DJ. Assisting Patients with their elimination needs. In: Delves-Yates (ed.) Essentials of Nursing Practice. Sage; 2015 pp.533-556.

Crombie H, Gallagher R, Hall V. Assessment and Management of Diarrhoea. Nursing Times. 2013;109(30):22-24

Guarino A, Guandalini S, Lo Vecchio A. Probiotics for Prevention and Treatment of Diarrhea. J Clinical Gastroenterology. 2015;49:S37-S45 https://doi.org/10.1097/MCG.0000000000000349. 

Kelly B, Ward K. Nausea and Vomiting in Palliative Care. Nursing Times. 2013;109(39):16-19.

Lacey J, Corbett J, Forni L et al. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Annals of Medicine. 2019;51(3-4), 232-251.