How to manage diarrhoea opd case
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I now have comprehensive information from multiple authoritative sources. Let me compile the full OPD management guide.
Management of Diarrhoea - OPD Case
Step 1: Initial Assessment
History
- Duration: Acute (<14 days) vs. persistent (14-28 days) vs. chronic (>28 days)
- Frequency and volume of stools
- Character: Watery, bloody (dysentery), mucoid, frothy
- Associated symptoms: Fever, vomiting, abdominal cramps, tenesmus
- Intake: Recent food/water history, travel history (traveller's diarrhoea)
- Contacts with similar illness (outbreak possibility)
- Medications: Antibiotics (C. difficile risk), laxatives
- Immunocompromised status
Severity Classification (WHO/IMCI)
| Severity | Signs |
|---|---|
| No dehydration | Alert, normal eyes, drinks normally, skin pinch returns immediately |
| Some dehydration | Restless/irritable, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly |
| Severe dehydration | Lethargic/unconscious, sunken eyes, not able to drink or drinks poorly, skin pinch goes back very slowly (>2 sec) |
For Traveller's diarrhoea (TD), classify as:
- Mild - Tolerable, not distressing, no impact on activity
- Moderate - Distressing, may interfere with planned activities
- Severe - Incapacitating or prevents planned activities
Step 2: Physical Examination
- Vital signs (pulse, BP, temp, RR)
- Signs of dehydration: dry mucous membranes, skin turgor, capillary refill, sunken eyes, fontanelle (infants)
- Abdominal exam: tenderness, bowel sounds, distension
- Look for blood in stool (perianal inspection or rectal exam if indicated)
Step 3: Investigations (selective, based on severity)
- Stool microscopy & culture - if bloody diarrhoea, fever, immunocompromised, or >3 days duration
- CBC, electrolytes, creatinine - if moderate-severe dehydration
- Stool for ova/cysts - if parasitic cause suspected (travel, prolonged illness)
- C. difficile toxin - if recent antibiotics or hospitalization
Step 4: OPD Management
A. Rehydration (Cornerstone of Treatment)
Plan A - No Dehydration (Treat at Home)
- Continue feeding/breastfeeding
- Give extra fluids after each loose stool:
- Children <2 years: 50-100 ml ORS after each loose stool
- Children ≥2 years: 100-200 ml ORS after each loose stool
- Give frequent small sips from a cup
- If vomits: wait 10 minutes, then continue more slowly
- Adults: ORS or clean fluids liberally
Plan B - Some Dehydration (Treat in OPD over 4 hours)
- Give ORS 75 ml/kg over 4 hours in OPD
- Reassess after 4 hours and reclassify
- Begin feeding during/after rehydration
- Give 2 ORS packets to take home
Plan C - Severe Dehydration: Refer urgently or admit for IV fluids (Ringer's lactate 100 ml/kg - 30 ml/kg fast, 70 ml/kg over remaining time)
B. Zinc Supplementation (Children 2 months - 5 years)
| Age | Dose | Duration |
|---|---|---|
| 2-6 months | 10 mg/day | 14 days |
| 6 months - 5 years | 20 mg/day | 14 days |
Zinc reduces duration and severity of diarrhoea and decreases recurrence for up to 3 months.
C. Dietary Management
- Never withhold food - early feeding reduces duration
- Continue breastfeeding throughout
- Avoid high-sugar drinks (cola, juice) - can worsen osmotic diarrhoea
- BRAT diet (banana, rice, apple, toast) can be offered
- Avoid dairy temporarily in post-infectious lactase deficiency
D. Antimotility Agents
- Loperamide (adults): 4 mg initially, then 2 mg after each loose stool (max 16 mg/day)
- Use in mild-moderate non-dysenteric diarrhoea
- Avoid in: bloody diarrhoea, fever, children <2 years, suspected C. difficile
- Bismuth subsalicylate: alternative in mild TD
E. Antibiotic Therapy (Targeted, not empiric for all)
| Indication | Drug of Choice | Alternative |
|---|---|---|
| Cholera | Doxycycline 300 mg single dose (adults) | Azithromycin 1 g single dose |
| Dysentery (Shigella) | Azithromycin 500 mg/day x 3 days | Ciprofloxacin 500 mg BD x 3 days |
| C. difficile (mild-mod) | Vancomycin 125 mg QID x 10 days OR Fidaxomicin | Metronidazole (only if above unavailable) |
| Giardiasis | Metronidazole 400 mg TID x 5-7 days | Tinidazole 2 g single dose |
| Entamoeba histolytica | Metronidazole 800 mg TID x 10 days + Diloxanide furoate (luminal cyst) | - |
| Traveller's diarrhoea (severe) | Azithromycin 1 g single dose or 500 mg x 3 days | Rifaximin (non-invasive only); Quinolones (2nd line) |
Note: Azithromycin is preferred as first-line for severe diarrhoea or diarrhoea acquired in Southeast/South Asia due to widespread quinolone resistance. - Harrison's Principles of Internal Medicine 22E
Antibiotics are NOT routinely needed for most acute watery diarrhoea cases (viral gastroenteritis is self-limiting in 3-7 days).
Step 5: Red Flags - Refer/Admit
- Severe dehydration with haemodynamic instability
- Bloody diarrhoea with high fever
- Unable to tolerate oral fluids
- Very young infants (<3 months)
- Elderly or immunocompromised with severe illness
- Suspected surgical cause (appendicitis, intussusception)
- Persistent diarrhoea despite treatment
Step 6: Patient Counselling & Discharge Instructions
- ORS preparation: 1 sachet in 1 litre of clean water; give after each loose stool
- Handwashing: Before food, after toilet - most important prevention
- Food safety: Avoid raw/street food; drink safe water
- When to return: Unable to take oral fluids, blood in stool, high fever, worsening condition, very frequent stools (>10/day)
- Zinc: Complete the 14-day course even after diarrhoea stops
- Avoid: Antibiotics without indication, OTC antidiarrhoeals in children
Quick Summary Algorithm
Diarrhoea patient (OPD)
|
Assess severity
|
┌──────┼──────────┐
No Some Severe
dehy. dehy. dehy.
| | |
Plan A Plan B Plan C
(home) (4hr OPD) (refer/admit)
|
+Zinc (children)
+Continue feeding
+Targeted antibiotics (if indicated: cholera, dysentery, parasites, TD-severe)
+Loperamide (adults, non-bloody)
Sources:
- Park's Textbook of Preventive and Social Medicine - IMCI diarrhoea classification and Plans A/B/C
- Harrison's Principles of Internal Medicine 22E - Traveller's diarrhoea management algorithm
- WHO IMCI guidelines - fluid and zinc therapy protocols
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