Treatment if diarrhea
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"diarrhea"[MeSH Terms] AND "treatment"[MeSH Terms]
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"acute diarrhea" AND management
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Treatment of Diarrhea
Based on ROSEN's Emergency Medicine and Sleisenger & Fordtran's Gastrointestinal and Liver Disease
1. Definitions
- Acute diarrhea: sudden onset, lasts < 14 days (usually infectious/gastroenteritis)
- Chronic/persistent diarrhea: > 14 days - requires different workup and management
- Dysentery: diarrhea with blood and mucus - implies compromised bowel wall
2. Rehydration (Most Important Step)
Rehydration is the cornerstone of diarrhea treatment regardless of cause.
Oral Rehydration Therapy (ORT) - Preferred
The sodium co-transport mechanism (Na+ coupled with glucose absorption) typically remains intact during acute diarrhea, making ORT effective. The WHO/UNICEF standard Oral Rehydration Solution (ORS) contains:
| Component | Amount per liter |
|---|---|
| Sodium chloride | 3.5 g |
| Trisodium citrate | 2.9 g |
| Potassium chloride | 1.5 g |
| Glucose | 20 g |
- ORS should be given frequently in small amounts (5 mL/kg every 1-2 minutes for mild dehydration)
- If vomiting occurs, wait 5-10 minutes and restart more slowly
- Commercial drinks (Gatorade, Pedialyte) are alternatives
- Clear fluids alone (water, broth, flat soda) are NOT adequate substitutes
Assessing dehydration degree:
| Degree | Features | ORT |
|---|---|---|
| Mild (<5% body wt loss) | Thirsty, slightly dry mucous membranes | 50 mL/kg over 4 hrs |
| Moderate (5-10%) | Dry mouth, tachycardia, decreased skin turgor, sunken eyes | 100 mL/kg over 4 hrs |
| Severe (>10%) | Markedly ill, lethargy, hypotension, shock | IV fluids |
IV Rehydration (Severe Dehydration/Shock)
- 20 mL/kg of isotonic crystalloid (0.9% saline) IV or IO
- Repeat boluses until clinical improvement
- If > 60 mL/kg without improvement, consider: septic shock, hemorrhage, capillary leak, adrenal insufficiency
- Avoid rapid sodium correction (risk of CNS complications)
- After initial resuscitation, switch to deficit replacement fluids (e.g., 0.45% NaCl with 20 mEq/L KCl)
3. Dietary Management
- Do NOT fast - continue feeding to maintain intestinal integrity
- In children: continue breastfeeding; resume age-appropriate diet within 24 hours of starting ORT
- Avoid high-fat, high-sugar foods (worsen osmotic diarrhea)
- The BRAT diet (bananas, rice, applesauce, toast) is commonly used but not strictly evidence-based
- Lactose-containing foods: temporary avoidance may help in some cases of post-infectious lactase deficiency
4. Antiemetics
Used to reduce vomiting and improve ORT tolerance:
| Drug | Dose | Notes |
|---|---|---|
| Ondansetron (preferred) | 0.15 mg/kg IV or 4-8 mg oral ODT | Drug of choice; reduces vomiting and IV fluid need |
| Metoclopramide | 0.1-0.2 mg/kg | Second-line; risk of extrapyramidal effects in children |
| Promethazine | Avoid in children < 2 yrs | Risk of apnea |
5. Antimotility Agents
- Loperamide (Imodium): reduces stool frequency; use in mild-moderate non-dysenteric adult diarrhea
- Avoid in: dysentery, bloody diarrhea, suspected C. difficile, children < 2 years
- Bismuth subsalicylate (Pepto-Bismol): useful for traveler's diarrhea; some antimicrobial and antisecretory effects
6. Antibiotic Therapy
Most acute infectious diarrhea is self-limiting and does NOT require antibiotics. Antibiotics are indicated in:
| Indication | First-line Treatment |
|---|---|
| Traveler's diarrhea (moderate-severe) | Azithromycin 1 g single dose or ciprofloxacin 500 mg BID x 3 days |
| Shigella | Azithromycin or fluoroquinolone (based on susceptibility) |
| Salmonella (invasive/bacteremia risk) | Fluoroquinolone or ceftriaxone |
| Campylobacter | Azithromycin 500 mg/day x 3 days |
| Clostridioides difficile | Vancomycin PO 125 mg QID x 10 days (preferred) or fidaxomicin; metronidazole for mild cases |
| Giardia | Metronidazole 250 mg TID x 5-7 days or tinidazole single dose |
| Cryptosporidium (immunocompetent) | Usually self-limiting; nitazoxanide if needed |
| Cholera | Doxycycline single dose + aggressive ORT |
Note: Antibiotics may prolong Salmonella carriage and are generally avoided unless invasive disease is suspected. For Shiga toxin-producing E. coli (STEC/O157:H7), antibiotics increase risk of hemolytic uremic syndrome (HUS) and are contraindicated.
7. Probiotics
- Evidence for reducing duration of diarrhea (especially in children): modest benefit
- Lactobacillus rhamnosus GG and Saccharomyces boulardii have the best evidence
- Most useful in antibiotic-associated and rotavirus diarrhea
- Safe and reasonable adjunct therapy
8. Zinc Supplementation
- WHO recommendation: zinc 10-20 mg/day x 10-14 days in children with acute diarrhea
- Reduces duration and severity, especially in developing world settings
- Mechanism: restores intestinal mucosal integrity and immune function
9. Special Situations
Infants and Young Children
- Higher risk due to larger extracellular fluid compartments and higher fluid turnover
- Early ORT is paramount; avoid hypotonic fluids (risk of hyponatremia)
- Glucose monitoring needed (risk of hypoglycemia)
Elderly
- Higher risk of dehydration and electrolyte disturbances
- Lower threshold for IV hydration
Immunocompromised (HIV/AIDS)
- Broader differential: Cryptosporidium, CMV, MAC, Microsporidium, C. difficile
- Antiretroviral therapy (HAART) itself can cause diarrhea
- Treat underlying CD4 depletion with HAART; treat identified pathogens specifically
Traveler's Diarrhea
- Prevention: azithromycin or rifaximin prophylaxis in high-risk settings
- Treatment: azithromycin (drug of choice, especially in SE Asia due to fluoroquinolone-resistant Campylobacter)
10. When to Admit / Escalate
Admit patients with:
- Severe dehydration or shock
- Inability to tolerate oral fluids
- Bloody diarrhea with systemic illness
- Age < 3 months or premature/low birth weight
- Immunosuppression
- Electrolyte abnormalities (hypo/hypernatremia, hypokalemia)
- Altered mental status
Sources: ROSEN's Emergency Medicine, Concepts and Clinical Practice; Sleisenger and Fordtran's Gastrointestinal and Liver Disease
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