**Abstract**

Diarrhea is a common gastrointestinal problem characterized by loose watery stool and mild to severe dehydration. Annually, about 1.7–5 billion new cases of diarrhea were reported. In developing countries, it is more common, where young kids have diarrhea approximately three times/year. In 2013, 1.26 million deaths occurred due to diarrhea, whereas in 1990, the figure was slightly higher (2.58 million). In 2012, diarrhea was the second most common reason of death (11%, n = 0.76 million) in children less than 5 years. Although various synthetic drugs are being prescribed as standard therapy for diarrhea, they have side effects. It is possible to prescribe the herbal medicine for diarrhea, which is safe and effective. In this study, medicinal plants discussed are proven to be scientifically active in diarrheal diseases. This study reviews about current medicinal plants used in the treatment of diarrhea. The use of medicinal plants for diarrhea results in improvement of the symptom. Moreover, studies on large scale are needed to characterize the beneficial role of medicinal plants in the treatment of diarrhea.

**Keywords:** diarrhea, infectious disease, medicinal plants, efficacy, literature review

#### **1. Introduction**

Diarrhea increased the frequency of bowel movements. Diarrhea is a clinical syndrome of diverse etiology associated with loose or watery stools often with vomiting and fever. Various bacteria, viruses, and parasites cause diarrhea. The most common causes of acute diarrhea are infectious agents [1]. In the Western world, normal fecal weight is less than 200 grams/day with firm to hard consistency of the stools. In India, greater dietary fiber content of the diet increases the fecal mass and its water content. Therefore, it is better to define diarrhea as the condition in which fecal mass and water content are greater than usual. Diarrhea is of two types. One type is called infectious and other is called noninfectious. Bacterium, virus, and parasites cause infectious diseases. Diarrhea affects all age groups but it is most commonly seen in children. Transmission of infection mostly occurs through the fecal-oral pathway. Microscopy and stool cultures are diagnostic investigation for diarrhea. Diarrhea is prevented by precaution such as handwashing. Acute diarrhea


#### **Table 1.**

*Medicinal plants having antidiarrheal activity.*

may also be caused by drugs or toxins. Infectious agents are also responsible for chronic diarrhea. Foods additives, medications, irritable bowel syndrome, malabsorption, and inflammatory bowel diseases are other causes of diarrhea. Diarrhea occurs due to various drugs. Digoxin is usually prescribed for treatment of heart disorders; sometimes diarrhea is seen in the patients taking digoxin. Antibiotics are prescribed for treatment of various ailments including diarrhea, but sometimes it has been observed that diarrhea occurs in the patient taking antibiotics. Diverticulitis is another cause of diarrhea. Infarction of bowel is also responsible for diarrhea [2]. *Salmonella* infection also causes diarrhea that is endemic in Southeast Asia. Other bacterial infections include *Shigella*, *Campylobacter*, *Clostridium difficile*, and *Yersinia*. Toxins of *Staphylococcus aureus*, *Vibrio cholerae*, and *E. coli* are

**53**

*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea*

also responsible for diarrhea [3]. Medicinal plants are one of the most popular forms of complementary and alternative medicine. In rural areas, people use medicinal plants as self-medication, and they know medicine for their efficacy in chronic disorders. Therefore, they do not come to doctor for common ailments. Traditional medicine nourishes the body or systems of the body. Medicinal plants have been used since ancient times. This precocious knowledge is transferred from generation to generation. The herbal pharmacopeia has been developed by refining and updating this practice. Gonçalves et al. reported the in vitro anti-rotavirus activity of some medicinal plants used in Brazil against diarrhea [4]. Ojewole et al. reported the antidiarrheal activity of *Psidium guajava* Linn. (Myrtaceae) leaf aqueous extract in rodents [5]. Joshi et al. reported the antidiarrheal activity and chemical profile of *Berberis aristata* [6]. In all cases, the source of diarrhea should be ascertained, and appropriate treatment should then follow. Various modern medicines are originated from plant sources such as aspirin. Plants exert their effects by secondary metabolites present in them. Though a large number of medicinal plants used to treat diarrhea are identified, scientific validation of the medicinal plants of antidiarrheal properties is imperative (**Table 1**). This chapter has shown that multiple plant prescriptions are most commonly used for the management of diarrhea in different

Acute diarrhea remains less than 2 weeks. Protozoa, bacteria, virus, food intolerance,

The large intestine is involved in inflammatory diarrhea by invasive parasites or bacteria. Signs and symptoms include fecal urgency, tenesmus, abdominal cramps,

The small intestine is involved in noninflammatory diarrhea. In this type, toxins or viruses affect the small intestine that interferes with water and salt balance. Signs and symptoms include cramps, vomiting, nausea, and large-volume watery diarrhea [9].

Causes of diarrhea can be divided into two categories: environmental factors and

*DOI: http://dx.doi.org/10.5772/intechopen.82649*

systems of medicines.

**1.1 Types of diarrhea**

and emotional stress cause acute diarrhea [7].

Chronic diarrhea remains more than 4 weeks.

fever, small-volume stools, and bloody stool [8].

*1.1.1 Acute diarrhea*

*1.1.2 Chronic diarrhea*

*1.1.2.1 Types of acute diarrhea*

Inflammatory diarrhea. Noninflammatory diarrhea.

*1.1.2.1.1 Inflammatory diarrhea*

*1.1.2.1.2 Noninflammatory diarrhea*

**1.2 Causes of diarrhea**

causative agents.

*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea DOI: http://dx.doi.org/10.5772/intechopen.82649*

also responsible for diarrhea [3]. Medicinal plants are one of the most popular forms of complementary and alternative medicine. In rural areas, people use medicinal plants as self-medication, and they know medicine for their efficacy in chronic disorders. Therefore, they do not come to doctor for common ailments. Traditional medicine nourishes the body or systems of the body. Medicinal plants have been used since ancient times. This precocious knowledge is transferred from generation to generation. The herbal pharmacopeia has been developed by refining and updating this practice. Gonçalves et al. reported the in vitro anti-rotavirus activity of some medicinal plants used in Brazil against diarrhea [4]. Ojewole et al. reported the antidiarrheal activity of *Psidium guajava* Linn. (Myrtaceae) leaf aqueous extract in rodents [5]. Joshi et al. reported the antidiarrheal activity and chemical profile of *Berberis aristata* [6]. In all cases, the source of diarrhea should be ascertained, and appropriate treatment should then follow. Various modern medicines are originated from plant sources such as aspirin. Plants exert their effects by secondary metabolites present in them. Though a large number of medicinal plants used to treat diarrhea are identified, scientific validation of the medicinal plants of antidiarrheal properties is imperative (**Table 1**). This chapter has shown that multiple plant prescriptions are most commonly used for the management of diarrhea in different systems of medicines.

#### **1.1 Types of diarrhea**

#### *1.1.1 Acute diarrhea*

*Perspective of Recent Advances in Acute Diarrhea*

*Cynodon dactylon* Poaceae Leaves and

*Calotropis gigantea* Apocynaceae Roots, bark,

stems

*Ziziphus mauritiana* Rhamnaceae Roots Antidiarrheal [53]

and leaves

*Punica granatum* Lythraceae Seeds Antidiarrheal [36] *Asparagus racemosus* Asparagaceae Roots Antidiarrheal [54] *Xylocarpus moluccensis* Meliaceae Bark, fruit Antidiarrheal [55] *Xylocarpus granatum* Meliaceae Bark Antidiarrheal [56] *Psidium guajava* Myrtaceae Leaf Antidiarrheal [57] *Rhizophora mucronata* Rhizophoraceae Bark Antidiarrheal [58] *Ixora coccinea* Linn. Rubiaceae Flowers Antidiarrheal [59] *Diospyros peregrine* Ebenaceae Bark Antidiarrheal [56] *Moringa oleifera* Moringaceae Leaf Antidiarrheal [60] *Elettaria cardamomum* Zingiberaceae Fruit Antidiarrheal [61]

*Mimosa pudica* Fabaceae Root, leaves Antidiarrheal, antidepressant,

*Nymphaea alba* Nymphaeaceae Roots, flowers Antidiarrheal, anxiolytic,

*Paederia foetida* Linn. Rubiaceae Roots, leaves Antidiarrheal,

*Mangifera indica* Anacardiaceae Seed Antidiarrheal,

*Anthocephalus cadamba* Rubiaceae Flowering tops Antidiarrheal [63] *Alchornea cordifolia* Euphorbiaceae Leaves Antidiarrheal [64]

*Nelumbo nucifera* Nelumbonaceae Rhizome Antidiarrheal [66]

*Piper nigrum* L. Piperaceae Fruit Antidiarrheal [69] *Mimosa pudica* Fabaceae Leaves Antidiarrheal [70] *Cyperus rotundus* Cyperaceae Roots Antidiarrheal [71]

Caesalpiniaceae Leaves Antidiarrheal, Anti-

Antidiarrheal, antiinflammatory, chemopreventive

hypolipidemic

anticancer

anti-inflammatory

immunomodulant, hypoglycemic

inflammatory, antipyretic, analgesic

Antidiarrheal [16]

[52]

[62]

[65]

[67]

[52]

[68]

may also be caused by drugs or toxins. Infectious agents are also responsible for chronic diarrhea. Foods additives, medications, irritable bowel syndrome, malabsorption, and inflammatory bowel diseases are other causes of diarrhea. Diarrhea occurs due to various drugs. Digoxin is usually prescribed for treatment of heart disorders; sometimes diarrhea is seen in the patients taking digoxin. Antibiotics are prescribed for treatment of various ailments including diarrhea, but sometimes it has been observed that diarrhea occurs in the patient taking antibiotics. Diverticulitis is another cause of diarrhea. Infarction of bowel is also responsible for diarrhea [2]. *Salmonella* infection also causes diarrhea that is endemic in Southeast Asia. Other bacterial infections include *Shigella*, *Campylobacter*, *Clostridium difficile*, and *Yersinia*. Toxins of *Staphylococcus aureus*, *Vibrio cholerae*, and *E. coli* are

**52**

*Mezoneuron benthamianum* Baill.

**Table 1.**

*Medicinal plants having antidiarrheal activity.*

Acute diarrhea remains less than 2 weeks. Protozoa, bacteria, virus, food intolerance, and emotional stress cause acute diarrhea [7].

#### *1.1.2 Chronic diarrhea*

Chronic diarrhea remains more than 4 weeks.

#### *1.1.2.1 Types of acute diarrhea*

Inflammatory diarrhea. Noninflammatory diarrhea.

#### *1.1.2.1.1 Inflammatory diarrhea*

The large intestine is involved in inflammatory diarrhea by invasive parasites or bacteria. Signs and symptoms include fecal urgency, tenesmus, abdominal cramps, fever, small-volume stools, and bloody stool [8].

#### *1.1.2.1.2 Noninflammatory diarrhea*

The small intestine is involved in noninflammatory diarrhea. In this type, toxins or viruses affect the small intestine that interferes with water and salt balance. Signs and symptoms include cramps, vomiting, nausea, and large-volume watery diarrhea [9].

#### **1.2 Causes of diarrhea**

Causes of diarrhea can be divided into two categories: environmental factors and causative agents.

#### *1.2.1 Environmental factors*

Diarrhea is common in bottle-fed children than in breast-fed children. Unhygienic preparations of milk feed, the use of unhygienic bottles, and their contamination by flies and insects may lead to infection of milk, which is an excellent media for the growth and multiplication of organism. On the contrary, breast milk is clean, and it inhibits the growth of organism due to the presence of lactoferrin, lysozymes, leucocytes, macrophages, lactobacillus, and antibodies in it. Infected water and food are also responsible for frequent diarrhea in older children and adults.

#### *1.2.2 Causative agents*

Acute diarrhea may be secretory or invasive. Secretory types of diarrhea are caused by bacteria *Vibrio cholerae* and *E. coli*; *Shigella*, *Salmonella*, and *Staphylococcus* may cause invasive diarrhea. Acute diarrhea is also caused by viruses; *Rotavirus* is responsible for 50% of diarrhea in children. Newer viruses like adenoviruses and Norwalk viruses have been found causing diarrhea in children and adults.

#### *1.2.2.1 Cholera*

Cholera is a severe acute gastrointestinal infection cause by *Vibrio cholerae*. Transmission is by food or water contaminated by feces from a patient or carrier. Spread may occur from case to case through direct contact with feces. It occurs mostly in hot humid season. *Vibrio cholerae* attach to microvilli of brush border of intestinal epithelium being helped by mucinase. Cholera enterotoxin is released and diarrhea occurs. Stools resemble rice water and contain mucus, epithelial cells, and vibrios. Diagnosis is usually clinical. The presence of rapidly motile vibrios in fresh stool by dark-field illumination is diagnostic. Culture of stool or rectal swabs should be taken [10].

#### *1.2.2.2 Escherichia coli*

It consists of two subunits A and B. Subunit B binds to a glycolipid in microvillus membrane. Subunit A enters into cell and inactivates 60S ribosomal subunit. Protein synthesis is stopped and sloughing off of dead cells occurs, and as a result bloody diarrhea occurs [6].

#### *1.2.2.3 Rotavirus*

This virus causes typical clinical symptoms of diarrhea preceded or followed by vomiting and fever. It is responsible for 50% diarrheal cases, in children between 6 months and 2 years of age. In developing countries, *Rotavirus* infection is devastating, and lack of treatment leads to high morbidity and mortality [11].

#### *1.2.2.4 Shigella*

*Shigella* dysentery is due to *S. flexneri*, *S. sonnei*, *S. boydii*, and *S. dysenteri*. These four types of serotypes of *Shigella* group produce watery diarrhea and dysentery. *Shigella* dysentery is severe with high mortality. It is a common disease of children below 5 years of age [12].

#### *1.2.2.5 Salmonella*

This genus consists of 200 serotypes, which cause diarrhea both in man and animals. *Salmonella* group of organisms causes acute fatal gastroenteritis, enteric

**55**

*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea*

fever, bacteremia, and localized infections. These organisms invade the intracellular epithelial cells small intestine. The children are affected more and may continue excrete the organisms up to 2 months after diarrhea has stopped. Indiscriminate use of antibiotics may cause resistance in the organism. Animals are main reservoir, and transmission is passed through food; waterborne and person-to-person transmission is also possible. Enteric fever is a clinical syndrome characterized by gastrointestinal symptoms. Typhoid is the typical form of enteric fever that is caused by *Salmonella typhi*, while a similar less severe illness known as paratyphoid is caused by *Salmonella paratyphi* A, B, or C. Signs and symptoms of typhoid fever include headache, body ache, malaise, sore throat, anorexia, diarrhea, vomiting, stepladder fever, cough, relative bradycardia, palpable spleen, and rose spot rashes [13].

It is a spore-bearing bacillus. It causes primarily abdominal cramps and watery diarrhea. Organisms are transmitted through food. In cooked stored food, vegetative cells are destroyed by heat, but spores germinate into vegetative cells on cooling

They contain enterotoxins, which are responsible for vomiting and diarrhea. It is a common inhabitant of the human nose, throat, feces, and skin. Foodstuffs like meat and potato stuffs are favorable media for its growth. Enterotoxin being heat

It contaminates soil-grown food and milk. It causes diarrhea and abdominal cramps. It may stimulate staphylococcal food poisoning characterized by nausea and vomiting. Its spores survive at high temperature and boiling and multiply

It invades the large intestine and causes dysentery. Trophozoites containing RBC in stool or cysts are diagnostic. Trophozoites are not infectious but cysts are infectious. Encystment does not occur outside the body. It is passed through uncooked food, water, and from person to person. Cysts of *Entamoeba histolytica* are ingested in water or uncooked food, which has been contaminated by human feces. In the colon, trophozoite forms emerge from the cysts, invading the mucus membrane of the large bowel. The cecum is maximally affected, but any part of the colon may be affected producing flask-shaped ulcers. Sometimes a localized granuloma (ame-

It causes watery diarrhea, loose and foul-smelling stools. Abdominal cramps, anorexia, and distension of abdomen are common. Cysts of *Giardia lamblia* are passed through the excreta of man and animals, which infect food. It is also passed through water and person-to-person contact. Infection with *Giardia lamblia* is common in tropical countries. They attach to the mucosa of the duodenum and jejunum and produce inflammation and partial villous atrophy. Signs and symptoms of

boma) may present as a palpable mass in the rectum [16].

*DOI: http://dx.doi.org/10.5772/intechopen.82649*

*1.2.2.6 Clostridium perfringens*

or storing the food [14].

*1.2.2.8 Bacillus cereus*

*1.2.2.7 Staphylococcus aureus*

stable is not destroyed on heating [15].

rapidly on cooling and storage.

*1.2.2.9 Entamoeba histolytica*

*1.2.2.10 Giardia lamblia*

*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea DOI: http://dx.doi.org/10.5772/intechopen.82649*

fever, bacteremia, and localized infections. These organisms invade the intracellular epithelial cells small intestine. The children are affected more and may continue excrete the organisms up to 2 months after diarrhea has stopped. Indiscriminate use of antibiotics may cause resistance in the organism. Animals are main reservoir, and transmission is passed through food; waterborne and person-to-person transmission is also possible. Enteric fever is a clinical syndrome characterized by gastrointestinal symptoms. Typhoid is the typical form of enteric fever that is caused by *Salmonella typhi*, while a similar less severe illness known as paratyphoid is caused by *Salmonella paratyphi* A, B, or C. Signs and symptoms of typhoid fever include headache, body ache, malaise, sore throat, anorexia, diarrhea, vomiting, stepladder fever, cough, relative bradycardia, palpable spleen, and rose spot rashes [13].

#### *1.2.2.6 Clostridium perfringens*

*Perspective of Recent Advances in Acute Diarrhea*

Diarrhea is common in bottle-fed children than in breast-fed children. Unhygienic preparations of milk feed, the use of unhygienic bottles, and their contamination by flies and insects may lead to infection of milk, which is an excellent media for the growth and multiplication of organism. On the contrary, breast milk is clean, and it inhibits the growth of organism due to the presence of lactoferrin, lysozymes, leucocytes, macrophages, lactobacillus, and antibodies in it. Infected water and food are also responsible for frequent diarrhea in older children and adults.

Acute diarrhea may be secretory or invasive. Secretory types of diarrhea are caused by bacteria *Vibrio cholerae* and *E. coli*; *Shigella*, *Salmonella*, and

Cholera is a severe acute gastrointestinal infection cause by *Vibrio cholerae*. Transmission is by food or water contaminated by feces from a patient or carrier. Spread may occur from case to case through direct contact with feces. It occurs mostly in hot humid season. *Vibrio cholerae* attach to microvilli of brush border of intestinal epithelium being helped by mucinase. Cholera enterotoxin is released and diarrhea occurs. Stools resemble rice water and contain mucus, epithelial cells, and vibrios. Diagnosis is usually clinical. The presence of rapidly motile vibrios in fresh stool by dark-field illumination is diagnostic. Culture of stool or rectal swabs should be taken [10].

It consists of two subunits A and B. Subunit B binds to a glycolipid in microvillus membrane. Subunit A enters into cell and inactivates 60S ribosomal subunit. Protein synthesis is stopped and sloughing off of dead cells occurs, and as a result

This virus causes typical clinical symptoms of diarrhea preceded or followed by vomiting and fever. It is responsible for 50% diarrheal cases, in children between 6 months and 2 years of age. In developing countries, *Rotavirus* infection is devas-

*Shigella* dysentery is due to *S. flexneri*, *S. sonnei*, *S. boydii*, and *S. dysenteri*. These four types of serotypes of *Shigella* group produce watery diarrhea and dysentery. *Shigella* dysentery is severe with high mortality. It is a common disease of children

This genus consists of 200 serotypes, which cause diarrhea both in man and animals. *Salmonella* group of organisms causes acute fatal gastroenteritis, enteric

tating, and lack of treatment leads to high morbidity and mortality [11].

*Staphylococcus* may cause invasive diarrhea. Acute diarrhea is also caused by viruses; *Rotavirus* is responsible for 50% of diarrhea in children. Newer viruses like adenoviruses and Norwalk viruses have been found causing diarrhea in children and adults.

*1.2.1 Environmental factors*

*1.2.2 Causative agents*

*1.2.2.1 Cholera*

*1.2.2.2 Escherichia coli*

*1.2.2.3 Rotavirus*

*1.2.2.4 Shigella*

below 5 years of age [12].

*1.2.2.5 Salmonella*

bloody diarrhea occurs [6].

**54**

It is a spore-bearing bacillus. It causes primarily abdominal cramps and watery diarrhea. Organisms are transmitted through food. In cooked stored food, vegetative cells are destroyed by heat, but spores germinate into vegetative cells on cooling or storing the food [14].

#### *1.2.2.7 Staphylococcus aureus*

They contain enterotoxins, which are responsible for vomiting and diarrhea. It is a common inhabitant of the human nose, throat, feces, and skin. Foodstuffs like meat and potato stuffs are favorable media for its growth. Enterotoxin being heat stable is not destroyed on heating [15].

#### *1.2.2.8 Bacillus cereus*

It contaminates soil-grown food and milk. It causes diarrhea and abdominal cramps. It may stimulate staphylococcal food poisoning characterized by nausea and vomiting. Its spores survive at high temperature and boiling and multiply rapidly on cooling and storage.

#### *1.2.2.9 Entamoeba histolytica*

It invades the large intestine and causes dysentery. Trophozoites containing RBC in stool or cysts are diagnostic. Trophozoites are not infectious but cysts are infectious. Encystment does not occur outside the body. It is passed through uncooked food, water, and from person to person. Cysts of *Entamoeba histolytica* are ingested in water or uncooked food, which has been contaminated by human feces. In the colon, trophozoite forms emerge from the cysts, invading the mucus membrane of the large bowel. The cecum is maximally affected, but any part of the colon may be affected producing flask-shaped ulcers. Sometimes a localized granuloma (ameboma) may present as a palpable mass in the rectum [16].

#### *1.2.2.10 Giardia lamblia*

It causes watery diarrhea, loose and foul-smelling stools. Abdominal cramps, anorexia, and distension of abdomen are common. Cysts of *Giardia lamblia* are passed through the excreta of man and animals, which infect food. It is also passed through water and person-to-person contact. Infection with *Giardia lamblia* is common in tropical countries. They attach to the mucosa of the duodenum and jejunum and produce inflammation and partial villous atrophy. Signs and symptoms of

*Giardia lamblia* include loose pale stool, abdominal discomfort, lethargy, nausea, epigastric pain, flatulence, and abdominal distension. For diagnosis, three specimens of stool are collected at 2–3 days interval and examined for cysts within an hour of collections. Duodenal fluid aspiration or jejunal biopsy during endoscopy shows *Giardia lamblia*. For treatment, tinidazole (Fasigyn 500 mg) initially four tabs as a single dose then two tabs daily are given for 5–7 days. Tab. Metronidazole (Flagyl 400 mg) is given three times daily for 5 days [17].

### **1.3 Levels of dehydration in children with acute diarrhea**

## *1.3.1 Hydration*

Sign and symptom of hydration include skin pinch (immediate), drinking (normal), eyes (not sunken), and alertness (normal) [18].

#### *1.3.2 Mild dehydration*

Signs and symptoms of mild dehydration include restlessness or irritability, slow skin pinch, drinking eagerly, and sunken eyes [19].

#### *1.3.3 Severe dehydration*

Severe dehydration includes very slow skin pinch, drinking poorly or not at all, sunken eyes, and abnormally sleepy or lethargic [20].

#### *1.3.4 Etiology*

Etiology of diarrhea includes entero-adhesive *E. coli*, enteropathic *E. coli*, enterotoxigenic *E. coli*, *Shigella*, *Cryptosporidium*, *Giardia lamblia*, *Campylobacter jejuni*, *Salmonella*, disaccharidase deficiency, lactulose, Zollinger-Ellison syndrome (gastrin), phenolphthalein, cascara, senna, partial gastrectomy, blind loop with bacterial overgrowth, lymphoma, adenocarcinoma, radiation enteritis, chronic pancreatitis, pancreatic carcinoma, vagotomy, scleroderma, fistula, small intestinal diverticulitis, allopurinol, celiac disease, tropical sprue, Whipple syndrome, eosinophilic gastroenteritis, Kaposi sarcoma, sarcoidosis, retroperitoneal fibrosis, SSRIs, cholinesterase inhibitors, NSAIDs, proton pump inhibitors, angiotensin II receptor blockers, metformin, ulcerative colitis, Crohn's disease, microscopic colitis, sorbitol, laxative, vipoma, carcinoid, medullary carcinoma of thyroid (calcitonin), and antacids [21].

#### *1.3.5 Host factors*

Host factors include malnutrition [22], lactose intolerance, and repeated bouts of diarrhea.

#### *1.3.6 Investigation of diarrhea*

Investigation of stool includes stool analysis, stool culture in bloody diarrhea, serum electrolytes, serum urea and creatinine, and sigmoidoscopy if ulcerative colitis is suspected [23].

#### *1.3.7 Principle of treatment*

Immune-enhancing drugs should be prescribed to enhance immunity. Diaphoretic drugs are given to control fever. Antimicrobial drugs are prescribed to

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*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea*

saline or Ringer's lactate is given to restore water and electrolytes [25].

treat bacterial diarrhea. Anti-inflammatory drugs are given in case of cytotoxins. Gastrointestinal antiseptic herbs can be prescribed. Antiprotozoal herbs are given

Soups are advised to patients with diarrhea. Patients are encouraged to take fruit drinks. Caffeine, alcohol, milk products, fats, and high-fiber diets are avoided to rest bowel. Fluids are given at the rate of 5–200 mg/kg/d depending on the hydration state. Intravenous fluids are preferred in patients with severe diarrhea. Normal

Oral rehydration is given to check or prevent fluid and electrolyte losses and disturbances in all cases of diarrhea of all etiologies. It replaces all fluid and electrolytes in continuing diarrhea. Glucose will provide energy to the body. Glucose by coupling mechanism facilitates absorption of sodium and water. In rural areas where glucose is not available, sucrose of ordinary cane sugar may be used in place of glucose though it is no better than glucose. Sodium and water given orally are poorly absorbed in the small intestine in the absence of glucose. Any safe water can be used for oral rehydration fluid. In case of doubtful hygienic water, it should be boiled and cooled before mixing ingredients in it. In rural areas, the shallow well water are always infected water; therefore boiled and cool water sufficiently treated with bleaching powder should be used. Adequate replacement of potassium loss is particularly important in malnourished children. Sodium bicarbonate rapidly corrects acidosis. Sodium bicarbonate is absorbed during diarrhea. Mild transient alkalosis is of little importance. Its absence from oral rehydration solution shall not lead to bicarbonate bound sodium absorption. This will not only delay the correction of acidosis, but in its absence, acidosis may also become irreversible in many cases.

Antimuscarinics such as atropine, mepenzolate, propantheline, and dicyclomine are effective in diarrhea. Loperamide is prescribed in diarrhea. Loperamide reduces the intestinal motility. Loperamide only reduces the symptoms of diarrhea.

Metronidazole is prescribed to patients with amebiasis and giardiasis [27]. In acute diarrhea, ciprofloxacin at dose of 200–500 mg twice daily is prescribed for 3 days [28].

This is a somatostatin analogue, which inhibits secretion of local hormones of gastrointestinal tract like gastrin, motilin, VIP, glucagon, and serotonin. Octreotides are prescribed in diarrhea caused by carcinoid tumor, VIPoma, vagotomy, dumping syndrome, short bowel syndrome, and AIDs. Adverse effects include nausea and GIT upsets. Prolonged therapy may cause effects of excessive somatostatin like

*DOI: http://dx.doi.org/10.5772/intechopen.82649*

in case of protozoal infection [24].

*1.3.9 Oral rehydration therapy*

**1.4 Antidiarrheal agents**

*1.4.1 Anti-motility drugs*

*1.4.2 Antibiotic therapy*

*1.4.3 Octreotide*

cholelithiasis [29].

Therefore, cause of diarrhea should be sought [26].

*1.3.8 Treatment*

*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea DOI: http://dx.doi.org/10.5772/intechopen.82649*

treat bacterial diarrhea. Anti-inflammatory drugs are given in case of cytotoxins. Gastrointestinal antiseptic herbs can be prescribed. Antiprotozoal herbs are given in case of protozoal infection [24].

#### *1.3.8 Treatment*

*Perspective of Recent Advances in Acute Diarrhea*

*1.3.1 Hydration*

*1.3.2 Mild dehydration*

*1.3.3 Severe dehydration*

*1.3.4 Etiology*

*1.3.5 Host factors*

*1.3.6 Investigation of diarrhea*

colitis is suspected [23].

*1.3.7 Principle of treatment*

of diarrhea.

(Flagyl 400 mg) is given three times daily for 5 days [17].

**1.3 Levels of dehydration in children with acute diarrhea**

(normal), eyes (not sunken), and alertness (normal) [18].

skin pinch, drinking eagerly, and sunken eyes [19].

sunken eyes, and abnormally sleepy or lethargic [20].

*Giardia lamblia* include loose pale stool, abdominal discomfort, lethargy, nausea, epigastric pain, flatulence, and abdominal distension. For diagnosis, three specimens of stool are collected at 2–3 days interval and examined for cysts within an hour of collections. Duodenal fluid aspiration or jejunal biopsy during endoscopy shows *Giardia lamblia*. For treatment, tinidazole (Fasigyn 500 mg) initially four tabs as a single dose then two tabs daily are given for 5–7 days. Tab. Metronidazole

Sign and symptom of hydration include skin pinch (immediate), drinking

Signs and symptoms of mild dehydration include restlessness or irritability, slow

Severe dehydration includes very slow skin pinch, drinking poorly or not at all,

Etiology of diarrhea includes entero-adhesive *E. coli*, enteropathic *E. coli*, enterotoxigenic *E. coli*, *Shigella*, *Cryptosporidium*, *Giardia lamblia*, *Campylobacter jejuni*, *Salmonella*, disaccharidase deficiency, lactulose, Zollinger-Ellison syndrome (gastrin),

Host factors include malnutrition [22], lactose intolerance, and repeated bouts

Investigation of stool includes stool analysis, stool culture in bloody diarrhea, serum electrolytes, serum urea and creatinine, and sigmoidoscopy if ulcerative

Immune-enhancing drugs should be prescribed to enhance immunity. Diaphoretic drugs are given to control fever. Antimicrobial drugs are prescribed to

phenolphthalein, cascara, senna, partial gastrectomy, blind loop with bacterial overgrowth, lymphoma, adenocarcinoma, radiation enteritis, chronic pancreatitis, pancreatic carcinoma, vagotomy, scleroderma, fistula, small intestinal diverticulitis, allopurinol, celiac disease, tropical sprue, Whipple syndrome, eosinophilic gastroenteritis, Kaposi sarcoma, sarcoidosis, retroperitoneal fibrosis, SSRIs, cholinesterase inhibitors, NSAIDs, proton pump inhibitors, angiotensin II receptor blockers, metformin, ulcerative colitis, Crohn's disease, microscopic colitis, sorbitol, laxative, vipoma,

carcinoid, medullary carcinoma of thyroid (calcitonin), and antacids [21].

**56**

Soups are advised to patients with diarrhea. Patients are encouraged to take fruit drinks. Caffeine, alcohol, milk products, fats, and high-fiber diets are avoided to rest bowel. Fluids are given at the rate of 5–200 mg/kg/d depending on the hydration state. Intravenous fluids are preferred in patients with severe diarrhea. Normal saline or Ringer's lactate is given to restore water and electrolytes [25].

#### *1.3.9 Oral rehydration therapy*

Oral rehydration is given to check or prevent fluid and electrolyte losses and disturbances in all cases of diarrhea of all etiologies. It replaces all fluid and electrolytes in continuing diarrhea. Glucose will provide energy to the body. Glucose by coupling mechanism facilitates absorption of sodium and water. In rural areas where glucose is not available, sucrose of ordinary cane sugar may be used in place of glucose though it is no better than glucose. Sodium and water given orally are poorly absorbed in the small intestine in the absence of glucose. Any safe water can be used for oral rehydration fluid. In case of doubtful hygienic water, it should be boiled and cooled before mixing ingredients in it. In rural areas, the shallow well water are always infected water; therefore boiled and cool water sufficiently treated with bleaching powder should be used. Adequate replacement of potassium loss is particularly important in malnourished children. Sodium bicarbonate rapidly corrects acidosis. Sodium bicarbonate is absorbed during diarrhea. Mild transient alkalosis is of little importance. Its absence from oral rehydration solution shall not lead to bicarbonate bound sodium absorption. This will not only delay the correction of acidosis, but in its absence, acidosis may also become irreversible in many cases.

#### **1.4 Antidiarrheal agents**

#### *1.4.1 Anti-motility drugs*

Antimuscarinics such as atropine, mepenzolate, propantheline, and dicyclomine are effective in diarrhea. Loperamide is prescribed in diarrhea. Loperamide reduces the intestinal motility. Loperamide only reduces the symptoms of diarrhea. Therefore, cause of diarrhea should be sought [26].

#### *1.4.2 Antibiotic therapy*

Metronidazole is prescribed to patients with amebiasis and giardiasis [27]. In acute diarrhea, ciprofloxacin at dose of 200–500 mg twice daily is prescribed for 3 days [28].

#### *1.4.3 Octreotide*

This is a somatostatin analogue, which inhibits secretion of local hormones of gastrointestinal tract like gastrin, motilin, VIP, glucagon, and serotonin. Octreotides are prescribed in diarrhea caused by carcinoid tumor, VIPoma, vagotomy, dumping syndrome, short bowel syndrome, and AIDs. Adverse effects include nausea and GIT upsets. Prolonged therapy may cause effects of excessive somatostatin like cholelithiasis [29].

#### *1.4.4 Diphenoxylate*

It is available in tablets containing diphenoxylate and atropine. Atropine is added to discourage the addiction liability with diphenoxylate. This combination of diphenoxylate with atropine is known as co-phenotrope [30].

#### *1.4.5 Adsorbents*

Kaolin, pectin, chalk, ispaghula, methylcellulose, and sterculia can be used in the treatment of diarrhea, but their effect is weak. Ispaghula, methylcellulose, and sterculia are used in cases of diverticular disease, ileostomy, and colostomy [31].

#### **1.5 Medicinal plants with antidiarrheal and related beneficial properties**

#### *1.5.1 Careya arborea Roxb*

It belongs to family Lecythidaceae. Leaves and stem are used treat diarrhea. Chemical constituents contain flavonoids, tannins, saponins, and triterpenoids. It is used in bronchitis, cancer, wounds, dysentery, jaundice, diarrhea, boil, ulcer, filaria, swelling, fever, ear pain, skin diseases, stomach diseases, smallpox, body pain, rheumatic pain, eye complaints, asthma, and dental disorders. It is anthelmintic, demulcent, tonic, anticancer, antipyretic, antidiarrheal, antioxidant, antileishmanial, hepatoprotective, and analgesic [11]. The methanol extract of this plant was used for study. Mice were selected for study. Castor oil-induced diarrhea was prevented by the use of *Careya arborea* Roxb. bark. This study indicated that plant has antidiarrheal activity [32].

#### *1.5.2 Berberis lyceum Royle*

It belongs to family Berberidaceae. Roots, fruits, leaves, and stem are used to treat diarrhea. Chemical constituents contain palmitine, berberine, iron, zinc, calcium, and vitamin C. It is used in gonorrhea, chronic diarrhea, piles, broken bones, wounds, acute conjunctivitis, jaundice, and diabetes [33]. Pharmacological activities include antioxidant, antidiarrheal, and wound healer [34]. Arshad et al. reported the ethnomedicinal use of this plant in diarrhea [35].

#### *1.5.3 Punica granatum*

It belongs to family Lythraceae. Parts used are twig exudates, fruit, flowers, and stem. Chemical constituents contain copper, potassium, phosphorus, sulfur, carotene, vitamin c, fiber, pectin, pelletierine, isopelletierine, iron, calcium, magnesium, calcium, and carbohydrates. It is used in diabetes mellitus, cancer, and cardiovascular disorders. It is antiviral, antibacterial, antidiabetic, chemopreventive, antioxidant, and cardioprotective [36] reported the antidiarrheal activity of *Punica granatum* seed extract in rats. Methanol extract of this plant was used for antidiarrheal activity. Rat models were selected for study. Castor oil-induced diarrhea was prevented by the use of *Punica granatum* seed extract. Charcoal meal test was also performed in rats. Gastrointestinal motility was decreased in rat by the use of extract. This study indicated that plant has antidiarrheal activity.

#### *1.5.4 Trichodesma indicum*

It belongs to family Boraginaceae. Parts used are roots. Chemical constituents contain lanast-5-en-3β-D-glucopyranosyl-21 (24)-olide, stigmast-5-en-3β-ol-23-one,

**59**

*Current Knowledge and Therapeutic Strategies of Herbal Medicine for Acute Diarrhea*

n-dotriacont-9-one-13-ene, n-pentacos-9-one, stigmast-5-en-3β-ol-21(24)-olide, n-nonacosanyl palmitate, n-tetradecanyl laurate, and n-decanyl laurate. It is used in dysentery, skin diseases, leprosy, and fever. It is diuretic, antimicrobial, and antiinflammatory [37]. Antidiarrheal activity of *Trichodesma indicum* was investigated in rat model. Diarrhea was induced by castor oil. Castor oil-induced diarrhea was inhibited by *T. indicum*. This study validated its use in diarrheal disease [37].

It belongs to family Lamiaceae. Parts used are dried leaves and young twigs. It is used in diarrhea and dysentery. It is carminative, stimulant, antipyretic, antinociceptive, cytotoxic, insecticidal, calcium channel blocker, and antimicrobial [38]. *M. longifolia* was investigated for its efficacy to treat diarrhea. For this purpose, diarrhea was induced by castor oil. About 100–1000 mg/kg of *M. longifolia* extract exhibited antidiarrheal effect similar to loperamide. High potassium-induced jejunum contraction was inhibited in isolated rabbit jejunum preparations. This indicated its antispasmodic activity through blockage of calcium channels. Calcium concentration curve was shifted rightward with the use of *Mentha longifolia.* This response was similar to verapamil. Inhibition of high K-induced contraction and shifting of calcium concentration curve rightward was also observed by the use of loperamide. Most active fraction was petroleum spirit. This study showed *M. longifolia* antispasmodic and antidiarrheal potential via calcium channel blockade [39].

It belongs to family Mimosaceae. Parts used are leaves and pods. It is used in diarrhea, dysentery, gonorrhea, diabetes mellitus, sore throat, and cancer [40]. It is anti-plasmodial, chemopreventive, larvicidal, antidiarrheal, hypotensive, and immunomodulant [41]. Antidiarrheal activity of *Acacia nilotica* was investigated. Aqueous, methanol, and petroleum ether extracts were used. Methanol extract exhibited significant antidiarrheal activity. Diarrhea was induced by magnesium sulfate and castor oil. Peristalsis was induced by barium chloride in Swiss albino mice. Antimicrobial activity of *A. nilotica* was investigated against diarrhea-causing organisms. Extract exhibited antidiarrheal potential against magnesium and castor oil-induced diarrhea. Barium chloride peristaltic movements in mice were also reduced by the use of extract. Extract also showed antimicrobial potential against diarrhea-causing organisms. This study validates its use in diarrhea in traditional system of medicine [38].

It belongs to family Apocynaceae. Parts used are barks. Chemical constituents contain porphyrin, alstonine, echitamine, picrinine, detamine, and strictamine. This plant has been used in diarrhea, dysentery, and hypertension [42]. It is bronchodilator, antimalarial, spasmolytic, antidiarrheal, anticancer, and neuroleptic. Castor oil-induced diarrhea was prevented by the crude extract of *Alstonia scholaris.* Effective dose of extract was 100–1000 mg/kg. The activity of extract was comparable to standard drug loperamide. This study indicated that plant can be used in diarrhea [39].

It belongs to family Capparaceae. Parts used are flowers and leaves. It is used in diarrhea, cardiovascular disorders, and pyrexia. It is antidiarrheal, antipyretic, antimicrobial, anti-ulcer, and immunostimulant [43]. Methanolic extract of this plant

*DOI: http://dx.doi.org/10.5772/intechopen.82649*

*1.5.5 Mentha longifolia*

*1.5.5.1 Acacia nilotica Willd*

*1.5.5.2 Alstonia scholaris*

*1.5.5.3 Capparis zeylanica L*

n-dotriacont-9-one-13-ene, n-pentacos-9-one, stigmast-5-en-3β-ol-21(24)-olide, n-nonacosanyl palmitate, n-tetradecanyl laurate, and n-decanyl laurate. It is used in dysentery, skin diseases, leprosy, and fever. It is diuretic, antimicrobial, and antiinflammatory [37]. Antidiarrheal activity of *Trichodesma indicum* was investigated in rat model. Diarrhea was induced by castor oil. Castor oil-induced diarrhea was inhibited by *T. indicum*. This study validated its use in diarrheal disease [37].
