What is the diagnosis and treatment for a patient with diarrhea?

From the Guidelines

For a patient with loose bowels, I recommend starting with oral rehydration therapy using water, clear broths, or commercial rehydration solutions like Pedialyte to prevent dehydration, as stated in the 2018 ESMO clinical practice guidelines for diarrhea in adult cancer patients 1. The goal of treatment is to prevent dehydration, reduce diarrhea frequency, and manage symptoms.

• Oral rehydration therapy is the most critical therapy in diarrheal illness, with solutions that contain water, salt, and sugar, as recommended by the 2018 ESMO clinical practice guidelines 1.
• Over-the-counter medications such as loperamide (Imodium) can help reduce diarrhea frequency, with a recommended dose of 4 mg initially, followed by 2 mg every 2-4 hours or after every unformed stool, with a maximum daily dose of 16 mg, as stated in the 2018 ESMO clinical practice guidelines 1.
• The BRAT diet (bananas, rice, applesauce, toast) can be followed temporarily, while avoiding dairy, caffeine, alcohol, fatty foods, and high-fiber items.
• If symptoms persist beyond 2-3 days, are accompanied by fever over 102°F (39°C), severe abdominal pain, bloody stools, or signs of dehydration (decreased urination, extreme thirst, dizziness), seek medical attention immediately, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea 1. Most cases of loose bowels are caused by viral infections, food intolerances, or mild bacterial infections that resolve within a few days, as stated in the 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea 1. The recommended treatments work by slowing intestinal motility, absorbing excess fluid, or providing gentle nutrition while the digestive system recovers. It is essential to note that patients with underlying conditions, such as cancer, may require more aggressive management, including hospitalization and evaluation by a multidisciplinary team, as recommended by the 2018 ESMO clinical practice guidelines for diarrhea in adult cancer patients 1.

From the FDA Drug Label

Dehydration Fluid and electrolyte depletion often occur in patients who have diarrhea In such cases, administration of appropriate fluid and electrolytes is very important. The use of loperamide hydrochloride does not preclude the need for appropriate fluid and electrolyte therapy Gastrointestinal Disorders In general, loperamide hydrochloride should not be used when inhibition of peristalsis is to be avoided due to the possible risk of significant sequelae including ileus, megacolon and toxic megacolon. Treatment of diarrhea with loperamide hydrochloride is only symptomatic. Whenever an underlying etiology can be determined, specific treatment should be given when appropriate (or when indicated).

Loperamide can be used to treat diarrhea in patients with loose bowels. However, it is essential to:

• Administer appropriate fluid and electrolyte therapy to prevent dehydration
• Use loperamide with caution, as it may inhibit peristalsis and increase the risk of significant sequelae, such as ileus, megacolon, and toxic megacolon
• Determine the underlying etiology of the diarrhea and provide specific treatment when appropriate 2

From the Research

Treatment Options for Loose Bowels

• Loperamide is a safe and effective antidiarrheal for the treatment of acute diarrhea, as shown in studies 3, 4, 5.
• Loperamide is more effective than bismuth subsalicylate in reducing the average number of unformed bowel movements and providing faster relief 4, 5.
• Bismuth subsalicylate can also be used to treat acute diarrhea, especially in infants and young children, and is a safe and effective adjunct to oral rehydration therapy 6.
• Antimicrobial agents are not recommended for prevention of travelers' diarrhea, but can be used for treatment in severe cases 7.

Comparison of Loperamide and Bismuth Subsalicylate

• Loperamide significantly reduced the average number of unformed bowel movements compared to bismuth subsalicylate 4, 5.
• Loperamide provided faster and more effective relief than bismuth subsalicylate 4, 5.
• Bismuth subsalicylate decreased the duration of diarrhea and was a safe and effective adjunct to oral rehydration therapy in infants and young children 6.

Safety and Efficacy

• Loperamide is a safe drug with few adverse reactions reported worldwide and lacks significant abuse potential 3.
• Bismuth subsalicylate is also safe and well-tolerated, with no significant adverse reactions reported 6.
• Both loperamide and bismuth subsalicylate can be used to treat acute diarrhea, but loperamide may be more effective in some cases 4, 5.