What is the recommended treatment for diarrhea?

Treatment of Diarrhea

The primary recommended treatment for diarrhea is oral rehydration solution (ORS), with antimotility agents like loperamide appropriate only for adults with watery diarrhea after adequate hydration is achieved. 1

Assessment of Severity

First, determine the severity of diarrhea:

• Mild to moderate dehydration: Alert, thirsty, dry mucous membranes, decreased skin turgor
• Severe dehydration: Altered mental status, tachycardia, hypotension, significantly reduced skin turgor

Treatment Algorithm

Step 1: Rehydration (First Priority)

For mild to moderate dehydration:

• Reduced osmolarity ORS is first-line therapy for all age groups 1
• Adults: 200-400 mL after each loose stool
• Children: 50-100 mL/kg over 3-4 hours

For severe dehydration:

• Isotonic IV fluids (lactated Ringer's or normal saline) at 60-100 mL/kg over 2-4 hours 1, 2
• Continue until pulse, perfusion, and mental status normalize
• Then transition to ORS for remaining deficit

Step 2: Diet Management

• Continue feeding during diarrheal episodes 1
• Infants: Continue breastfeeding throughout illness 1
• Resume age-appropriate diet during or immediately after rehydration 1
• Avoid fatty, spicy foods and caffeine 1
• Temporarily avoid lactose-containing foods if diarrhea is prolonged 1

Step 3: Pharmacologic Interventions

Antimotility agents:

• Loperamide (for adults only):
  • Initial dose: 4 mg followed by 2 mg after each loose stool (maximum 16 mg/day) 1, 3
  • Contraindicated in children under 18 years 1
  • Contraindicated in inflammatory diarrhea with fever or bloody stools 1, 3
  • Discontinue after 12-hour diarrhea-free interval 1

Antiemetics:

• Ondansetron may be given to children >4 years and adolescents with vomiting to facilitate oral rehydration 1

Probiotics:

• May be offered to reduce symptom severity and duration in immunocompetent patients 1

Zinc supplementation:

• Beneficial for children 6 months to 5 years in areas with high prevalence of zinc deficiency 1

Special Considerations

When to seek medical care:

• No improvement after 48 hours 1
• Worsening symptoms 1
• Development of warning signs: severe vomiting, high fever (>38.5°C), bloody stools, abdominal distension 1

Antimicrobial therapy:

• Not recommended for routine watery diarrhea 1
• Consider only for specific indications:
  • Dysentery (bloody diarrhea)
  • Cholera
  • Severe traveler's diarrhea
  • Immunocompromised patients

Common Pitfalls to Avoid

1. Overuse of IV fluids when ORS would be sufficient 4
2. Inappropriate use of antimotility drugs in children or in inflammatory diarrhea 1, 5
3. Unnecessary use of antibiotics in viral or non-specific diarrhea 5
4. Delaying reintroduction of feeding after rehydration 4
5. Withholding ORS from patients who are vomiting 4

Cardiac Risk Warning for Loperamide

Loperamide carries risks of cardiac adverse reactions including QT prolongation and Torsades de Pointes, especially at higher than recommended doses. Avoid in patients:

• Taking medications that prolong QT interval
• With risk factors for QT prolongation
• With congenital long QT syndrome or history of cardiac arrhythmias 3

Remember that rehydration is the cornerstone of diarrhea management, with other interventions being secondary and situation-dependent.