Cure for

If diarrhea continues for more than 4 weeks, it is considered as chronic diarrhea. Chronic diarrhea requires evaluation to rule out underlying pathology. Compared to causes of acute diarrhea, most of the causes of chronic diarrhea are noninfectious.

Principle of treatment of chronic diarrhea:

Treatment of chronic diarrhea depends on the specific cause of diarrhea and it is directed towards the cause of diarrhea, which may be curative, suppressive, or empirical. If the cause can be removed or eradicated, the treatment of chronic diarrhea is curative as with resection of a colorectal cancer, antibiotic administration for Whipple’s disease, or discontinuation of a drug (if any drug is the cause of chronic diarrhea).

For many chronic conditions, diarrhea can be controlled by suppression of the underlying mechanism which is causing the chronic diarrhea. Examples are elimination of dietary lactose for lactase deficiency or gluten (gluten free diet) for celiac sprue, use of glucocorticoids or other anti-inflammatory agents for idiopathic IBDs (inflammatory bowel diseases), adsorptive agents such as cholestyramine for ileal bile acid malabsorption etc. Other examples are use of proton pump inhibitors such as omeprazole for the gastric hypersecretion of gastrinomas, somatostatin analogues such as octreotide for malignant carcinoid syndrome, prostaglandin inhibitors such as indomethacin for medullary carcinoma of the thyroid, and pancreatic enzyme replacement if there is any pancreatic insufficiency.

But if the specific cause or mechanism of chronic diarrhea can not be pinpointed, empirical therapy may be beneficial. For example loperamide, is often helpful in mild or moderate watery diarrhea. For those with more severe diarrhea, codeine or tincture of opium may be beneficial. Such antimotility agents should be avoided with IBD, as there may be precipitation of toxic megacolon. Clonidine, an alpha-2 adrenergic agonist, may allow control of diabetic diarrhea.

General measures:

Fluid and electrolyte replacement is an important and essential component of management for all cases of chronic diarrhea. Replacement of fat-soluble vitamins may also be necessary in patients with chronic steatorrhea (lipids can not be absorbed or fat malabsorption).

Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency and with a typical Western diet stool weight of more than 200 grams can be considered as diarrhea. 

Principle of treatment of acute diarrhea:

In acute diarrhea the most important part of treatment is the replacement of lost fluid and electrolytes. Fluid replacement should be gradual and over a period of time. In mild cases of acute diarrhea fluid replacement is all that may be required. Oral sugar-electrolyte solutions used in sports as drinks or designed formulations should be started promptly with severe diarrhea to limit dehydration, as severe ehydration is the major cause of death in severe diarrhea. If dehydration is very severe, especially infants and the elderly, require IV (intravenous) re-hydration for maintaining patients’ health.

If the dehydration is moderate as seen in non-febrile and non-bloody diarrhea, anti-motility and anti-secretory agents such as loperamide can be used. But drugs like loperamide should be avoided if the diarrhea patient is suffering from febrile dysentery, which may cause prolongation of diarrhea.

Role of antibiotics in acute diarrhea:

Use of antibiotics may sometimes reduce the severity and duration of diarrhea in some selected cases. Ciprofloxacin (500 mg twice a day for 3 to 5 days) is used by many doctors’ for treatment of severely ill patients with febrile dysentery empirically without diagnostic evaluation. If the cause of diarrhea is suspected to be due to giardiasis, metronidazole (250 mg 4 times a day for 7 days) can be used successfully. Antibiotic coverage has to be given whether or not a causative organism is discovered in patients who are immune deficient, have mechanical heart valves or recent vascular grafts, or are elderly.

Antibiotic prophylaxis should be given for certain patients traveling to high-risk countries in whom the likelihood or seriousness of acquired diarrhea would be especially high, including those with immunocompromise, IBD (inflammatory bowel disease e.g. ulcerative colitis), hemochromatosis, or gastric achlorhydria (absence of acid in stomach). For prophylaxis the use of trimethoprim/sulfamethoxazole (Bactrim), ciprofloxacin, or rifaximin (rifaximin not be suitable for invasive disease) may reduce bacterial diarrhea in such travelers by 90%. Finally, physicians should be vigilant to identify if an outbreak of diarrheal illness is occurring and to alert the public health authorities promptly, which may reduce the ultimate size of the diarrhea affected population.  

Drug addiction being an international problem which does not spare any nation should be adequately addressed and treated. For a successful drug addiction treatment the best approach is a holistic approach, which covers not only the medical and psychological aspects of the drug addict, but also covers the emotional and spiritual needs of the addict. For successful drug treatment or drug addiction treatment the role of psychiatrist is the most important as well as psychological counseling.  

The drug treatment of the addicts is not an easy task, as the addicts are usually not interested in getting good treatment and lead a drug free life. Many addicts can not even imagine a drug free life and to treat these drug addicts it is a gigantic task, which need coordinated approach of professional doctors, other technical staffs, supporting staffs, family members (of the addict) and friends of the drug addicts. The govt. help in addressing the social evil of drug addiction is very important. The help of former drug addicts is also very important to motivate the addicts and should be sought. Drug addiction is basically a social problem but the first step of management of the problem of drug addiction, is a medical management.

The drug addiction treatment is not complete without the drug rehabilitation. For drug rehabilitation, after successful drug treatment the govt., social workers play the most important role. Without good drug rehabilitation the rate of relapse of drug addiction (after successful treatment of drug addiction) may be very high. To reduce the relapse rate of drug addiction social activists and the govt. should play a major role with cooperation from the drug treatment centers.

Treatment of spasmodic dysmenorrhea can be following:

• Explanation of physiology of menstruation, sex education and reassurance to the patient are important aspects of management of spasmodic dysmenorrhea.
• Proper nutrition with balanced nutritious diet, regular physical activity (spasmodic dysmenorrhea is more common among women with sedentary lifestyle), and proper treatment of constipation and adaptation of healthy lifestyle are very much essential in the treatment of spasmodic dysmenorrhea.
• Initially spasmodic dysmenorrhea should be treated with simple analgesics (pain killers) like aspirin, paracetamol and codeine. Antispasmodics with atropine derivatives, Buscopan (hyoscine bromide), Baralgan etc. are also helpful. With any of the above a tranquillizer is beneficial.
• Prostaglandin synthetase (inhibit the actions of prostaglandins) inhibitors are successful in the treatment of spasmodic dysmenorrhea. Prostaglandin synthetase inhibitors reduce the activity of myometrium of uterus and reduce pain. The drugs are mefanamic acid (500 mg daily), flufenamic acid (200 mg daily), indomethacin (50 mg daily), and naproxen sodium (200 mg daily) etc. The side effects of these drugs are headache, GIT manifestations like vomiting, reduced menstruation, blurring of vision, acute renal problem etc. due to prolonged use.
• Endocrine treatment: oral contraceptive (steroids) pills can be of very good use in treatment of dysmenorrhea especially women who want contraception. The cure rate is very good, but the biggest disadvantage is the need of taking contraceptive pills for 21 days for the pain of few days (2 to 3 days) besides side effects and contraindications of oral pills.
• Danazol a drug which suppress hypothalamic-pituitary-ovarian axis is sometimes helpful in treatment of dysmenorrhea. 
• Surgical dilatation of cervix is also useful in treatment of dysmenorrhea. But the relief may be temporary and excessive and forcible dilatation may lead to complications like premature labor, habitual abortion due to cervical incompetence in subsequent pregnancies. This is therefore not recommended.
• Presacral sympathectomy is a surgical procedure that is reserved for patients for whom all other measures have failed. But this surgery does not guarantee benefits.
• Hysterectomy is reserved for the cases for patients there is also pathology pelvis like fibroids and those who have completed their family and do not want any more children. 

Diabetic neuropathy can not be treated well. Its treatment is not satisfactory. So the main aim of treatment of diabetic neuropathy is control of blood sugar aggressively. But despite good control of blood sugar there may not be any improvement of diabetic neuropathy symptoms. Even the control of blood glucose may be problematic, as diabetic neuropathy can make a diabetic patient less aware of his/her hypoglycemia, thereby prolonging the hypoglycemic episodes and making the patient more prone to effects of hypoglycemia.

There may be loss of sensation in the feet and this can place the patient at risk of ulceration of feet and its sequalae. If patient is having some signs or symptoms of neuropathy, he should examine the feet daily and take precautions like wearing footwear regularly to prevent ulceration and calluses in the feet. Patient education for prevention of injury or ulceration of feet is of paramount importance in the management of diabetic neuropathy. If there is any foot deformity a podiatrist should be consulted.     

Risk factors of neuropathy should also be treated. Common risk factors of neuropathy are hypertension and hypertriglyceridemia. Neurotoxins like alcohol should be avoided. Stopping of smoking, supplementation of possible deficiency of vitamins like folic acid and vitamin B₁₂ and symptomatic treatment is the mainstay of treatment of diabetic neuropathy.

Chronic and painful diabetic nephropathy is very difficult to treat, but anti depressants (selective serotonin norepinephrine reuptake inhibitors such as duloxetine or tricyclic antidepressants such as amitriptyline, desipramine, nortriptyline, imipramine) or anticonvulsants (gabapentin, pregabalin, carbamazepine, lamotrigine) may be useful. USFDA has approved duloxetine and pregabalin for treatment of pain associated with diabetic neuropathy. But due to lack of study on these drugs, it is recommended that the treatment of neuropathic pain should be started with tricyclic antidepressant and switching if there is no response or if side effects develop.

The patient of diabetic neuropathy may require to be referred to a pain management center. Pain of acute diabetic neuropathy may resolve over time as there is progressive neuronal damage from diabetes and the medications can be withdrawn.

Treatment of orthostatic hypotension secondary to autonomic neuropathy is also difficult. Many drugs like fludrocortisone, midodrine, clonidine, octreotide, and yohimbine are used with limited success and more side effects for this purpose. Nonpharmacologic maneuvers like adequate salt intake, avoidance of dehydration, avoidance of diuretics, and support to lower extremity etc. may provide some relief from pain due to diabetic neuropathy.

The most effective therapy of diabetic nephropathy is prevention (like diabetic retinopathy) by controlling hyperglycemia. As part of comprehensive diabetes management microalbuminuria should be detected as early as possible and effective therapy started. For detecting microalbuminuria annual urine analysis is done by ‘spot collection’ method. If a sample of urine is tested positive for microalbuminuria, repeat the test after 3-6 months and if tow tests are positive out of three, than treatment for diabetic nephropathy is started. Annual measurement of serum creatinine is also done to find out GFR (glomerular filtration rate) to find out renal function.

The following treatment modalities are used to slow down progression of microalbuminuria to macroalbuminoria:

1. Control of blood glucose: If blood glucose level is controlled within normal limit the progression to retinopathy (from microalbuminuria to macroalbuminoria) is much less, both in type 1 and type 2 diabetes. But once macroalbuminoria is established it is not clear if control of blood sugar can slow down the progression of renal disease. If renal function is much less than normal insulin requirement is lees, because kidneys are the main site of degradation of insulin. Many oral hypoglycemic agents like metformin and sulfonylureas are contraindicated during renal insufficiency.   
2. Control of blood pressure: High blood pressure is a common accompanying disease in diabetics of type1 and type2. Strict blood pressure control is required to prevent diabetic nephropathy in diabetics. Many studies have shown that control of blood pressure to <130/80 mm Hg can reduce diabetic retinopathy and decline in renal function. If microalbuminuria has already set in little lower blood pressure should be maintained (< 125/75 mm Hg).
3. Administration of ACE (angitensin converting enzyme) inhibitors or ARBs (angitensin receptor blockers): ACE inhibitors or ARBs should be used to reduce progression of microalbuminuria to macroalbuminoria and decline in GFR. Most authors believe that bothe ACE inhibitiors and ARBs are equally efficacious in preventing retinopathy in diabetes by controlling blood pressure. ARBs are used as alternative if there is development of side effects with ACE inhibitors like cough, angioedema etc. The dose of ACE inhibitors is increased till microalbuminuria disappear or maximum dose is reached. If either groups can not be used than beta blockers, calcium channel blockers or diuretics are used though the benefit is not as good as the two groups (ACE inhibitors and ARBs). The best benefit is seen with these two groups only in case of diabetes.

ADA (American diabetic association) recommends slight reduction of protein intake for patients with microalbuminuria to 0.8 gm/kg per day and with macroalbuminoria to less than 0.08 gm/kg per day or no more than 10% of daily total calorie intake.

Expert nephrology consultation is required if GFR is less than 60 ml/min per 1.743 m². If macroalbuminoria develops the chances of end stage renal disease is very high. Dialysis of diabetic patients can lead to more complications than a non diabetic patient and survival is also much less in them.  

Diabetic Retinopathy is a very severe and common complication of long standing diabetes. There is no effective treatment available at the moment. The most effective therapy of diabetic retinopathy is prevention of Diabetic Retinopathy from developing.

Regular and complete examinations of eyes are required for the diabetic patients. If detected early the most eye complications including diabetic retinopathy can be treated successfully. Regular examination of the eyes by the diabetologist or primary care giver is not enough; the disease is required to be examined by ophthalmologist (eye doctor). If detected early laser photocoagulation is very successful in treating diabetic retinopathy and also in preserving vision. Proliferative type of diabetic retinopathy is treated with panretinal (entire retina) laser photocoagulation and that of macular edema is treated by focal laser photocoagulation (photocoagulation done on the focus of edema).

Most of the eye doctors (ophthalmologist) advice individuals with advanced diabetic eye disease (diabetic retinopathy and macular edema) to limit physical activities associated with repeated Valsalva maneuvers (blowing of the nose after closing the nose), but it has not been proved that exercise worsen proliferative diabetic retinopathy.

Prevention: Most effective therapy of diabetic retinopathy being prevention, patients of diabetes (both type1 and type2) should know how to prevent eye complications of diabetes. The best way to prevent complication (all complications including eye complications) is to have strict glycemic control (blood sugar within normal limit) and blood pressure control. This will delay the development or slow the progression of retinopathy in individuals with either type1 or type2 diabetes. Diabetics with known diabetic retinopathy can be given prophylactic (preventive) photocoagulation when initiating intensive therapy. During the first 6–12 months of improved glycemic control, established diabetic retinopathy may transiently worsen, but it is temporary in nature and in the long run there will be less chances of developing diabetic retinopathy. If advanced retinopathy develops, improved glycemic control will be less beneficial, although adequate ophthalmologic care will prevent most blindness’s due to diabetic retinopathy.