Diarrhoea treatment
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"diarrhea" AND "treatment"
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Diarrhoea - Treatment
Definition & Key Principle
Diarrhoea is defined as the passage of 3 or more loose/watery stools per day. Regardless of the causative agent (bacterial, viral, parasitic) or the patient's age, the cornerstone of treatment is Oral Rehydration Therapy (ORT). Up to 90-95% of all cases, including cholera, can be managed with oral fluids alone.
1. Oral Rehydration Therapy (ORT)
WHO Reduced Osmolarity ORS (current standard since 2004)
| Component | g/litre | mmol/litre |
|---|---|---|
| Sodium chloride | 2.6 | Na⁺: 75 |
| Glucose (anhydrous) | 13.5 | Glucose: 75 |
| Potassium chloride | 1.5 | K⁺: 20 |
| Trisodium citrate | 2.9 | Citrate: 10 |
| Total osmolarity | 20.5 g | 245 mOsm/L |
This reduced-osmolarity ORS (245 mOsm/L) replaced the older standard ORS (311 mOsm/L). In children with acute non-cholera diarrhoea, it reduced the need for IV therapy by 33%, decreased stool output by 20%, and reduced vomiting by 30%. It is also safe and effective for cholera.
Home-made substitute (if ORS packet unavailable): 1 level teaspoon of salt + 6 level teaspoons of sugar dissolved in 1 litre of drinking water.
Fluids to avoid: Sweetened carbonated drinks, commercial fruit juices, sweetened tea (cause osmotic diarrhoea and hypernatraemia); coffee and purgative herbal infusions (diuretic/purgative effects).
2. Dehydration Assessment & Treatment Plans
Assessing Dehydration
| Feature | Mild (4-5% body wt loss) | Severe (≥10% body wt loss) |
|---|---|---|
| Appearance | Thirsty, alert, restless | Drowsy, limp, cold/sweaty, possibly comatose |
| Pulse | Normal rate & volume | Rapid, feeble, sometimes impalpable |
| Blood pressure | Normal | <80 mmHg or unrecordable |
| Skin elasticity | Pinch retracts immediately | Retracts very slowly (>2 seconds) |
| Tongue | Moist | Very dry |
| Anterior fontanelle | Normal | Very sunken |
| Urine flow | Normal | Little or none |
| Fluid deficit | 40-50 mL/kg | 100-110 mL/kg |
ORS Volumes by Age (first 4 hours)
| Age | <4 months | 4-11 months | 1-2 yrs | 2-4 yrs | 5-14 yrs | ≥15 yrs |
|---|---|---|---|---|---|---|
| ORS (mL) | 200-400 | 400-600 | 600-800 | 800-1200 | 1200-2200 | 2200-4000 |
Tip: If weight is known, calculate ORS as approximately 75 mL/kg over the first 4 hours.
The Three WHO Treatment Plans
Plan A - No Dehydration (Home Treatment):
- Continue breastfeeding; give extra fluids after each loose stool
- Increase fluid intake; continue normal diet
- Give zinc (see below)
- Watch for worsening
Plan B - Some Dehydration (ORS-based rehydration):
- Give ORS solution over 4 hours (75 mL/kg)
- If child vomits, wait 10 minutes then resume slowly (spoonful every 2-3 minutes)
- If breast-feeding, continue alongside ORS
- Reassess after 4 hours
Plan C - Severe Dehydration (IV fluids, urgent):
- Transfer to hospital; IV rehydration required
- Ringer's Lactate (Hartmann's solution) is the preferred IV fluid
- Normal saline if Ringer's unavailable
- Give ORS en route if the patient can drink
3. Intravenous Rehydration
Reserved for:
- Severely dehydrated patients in shock
- Patients unable to drink (intractable vomiting, unconsciousness)
- Recommended IV fluids: Ringer's Lactate (Hartmann's solution) - first choice; Normal saline as alternative
4. Feeding During Diarrhoea
The old practice of "resting the gut" is incorrect. Current guidelines state:
- Never withhold food - continue normal diet as soon as the patient can eat
- Never dilute the child's usual food
- Breast-feeding must be continued throughout diarrhoeal illness
- After rehydration, increase food intake to recover nutritional losses
- Children with watery diarrhoea typically regain appetite once dehydration is corrected; those with bloody diarrhoea may eat poorly until illness resolves - encourage early feeding
5. Zinc Supplementation
WHO and UNICEF recommend zinc for all children with acute diarrhoea:
- <6 months: 10 mg/day for 10-14 days
- >6 months: 20 mg/day for 10-14 days
- Reduces the duration and severity of the current episode AND reduces diarrhoea incidence in the following 2-3 months
6. Antibiotics (Selective Use Only)
Antibiotics are not routinely recommended. They should only be used when the causative organism is clearly identified:
| Disease | Drug of Choice |
|---|---|
| Cholera | Doxycycline, tetracycline, TMP-SMX, erythromycin, azithromycin, fluoroquinolones |
| Shigella (dysentery) | Ciprofloxacin (Shigella is usually resistant to ampicillin and TMP-SMX) |
| Typhoid | Ciprofloxacin, ceftriaxone, azithromycin |
Key difference - Cholera vs. Shigella:
| Feature | Cholera | Shigella |
|---|---|---|
| Stool | Watery, rice-water | Bloody/mucoid |
| Fever | Absent | Present |
| Vomiting | Yes | No |
| Rectal pain | No | Yes |
In cholera, antibiotics are given only after vomiting has stopped (usually 3-4 hours after starting ORT). Injectable antibiotics have no advantage over oral routes.
7. Drugs That Should NOT Be Used
The following are contraindicated or of no value in diarrhoea:
- Neomycin - damages intestinal mucosa, causes malabsorption
- Purgatives - worsen diarrhoea and dehydration
- Tincture of opium / atropine - dangerous in children and dysentery (slows transit, can worsen illness)
- Cardiotonics (e.g., Coramine) - shock must be corrected with IV fluids, not drugs
- Steroids - expensive, useless, cause adverse effects
- Charcoal, kaolin, pectin, bismuth - no proven value
- Mexaform - no value, potentially dangerous
8. Special Situations
Diarrhoea in HIV/AIDS
In the HAART era, diarrhoea is most commonly medication-induced (antiretroviral drugs) or caused by disorders unrelated to HIV. Opportunistic infections (Cryptosporidium, CMV, MAC, Microsporidium) dominate in advanced disease. Treat the underlying cause; immune reconstitution with HAART is the most effective long-term strategy.
Cholera (severe secretory diarrhoea)
Mortality has been reduced to <1% with effective rehydration. Management follows the same ORT/IV principles above, with adjunct antibiotics once vomiting stops.
Summary
| Priority | Intervention |
|---|---|
| 1st | Oral rehydration with WHO reduced-osmolarity ORS |
| 2nd | Continue feeding (never withhold food) |
| 3rd | Zinc supplementation (10-20 mg/day x 10-14 days in children) |
| 4th | IV fluids only for severe dehydration/shock |
| 5th | Antibiotics only for confirmed cholera, shigella, or typhoid |
Sources: Park's Textbook of Preventive and Social Medicine; Sleisenger and Fordtran's Gastrointestinal and Liver Disease
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