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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