What is the treatment for acute diarrhea?

Treatment of Acute Diarrhea

Oral rehydration therapy (ORT) is the cornerstone of treatment for acute diarrhea, with appropriate fluid replacement based on the degree of dehydration being the primary intervention to reduce morbidity and mortality. 1

Assessment of Dehydration

First, determine the degree of dehydration:

• Mild dehydration (3-5%): Slightly dry mucous membranes, increased thirst, normal or slightly increased heart rate
• Moderate dehydration (6-9%): Dry mucous membranes, sunken eyes, decreased skin turgor, irritability
• Severe dehydration (≥10%): Very dry mucous membranes, deeply sunken eyes, poor skin turgor, lethargy/unconsciousness, rapid and weak pulse 2, 1

Rehydration Protocol

Mild Dehydration (3-5%)

• Administer 50 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours
• Start with small volumes (1 teaspoon) and gradually increase as tolerated 2, 1

Moderate Dehydration (6-9%)

• Administer 100 mL/kg of ORS over 2-4 hours
• Use the same small-volume approach as for mild dehydration 2, 1

Severe Dehydration (≥10%)

• This is a medical emergency requiring immediate IV rehydration
• Administer 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize
• Once the patient is stabilized, transition to oral rehydration 2, 1

No Dehydration

• Skip rehydration phase and proceed directly to maintenance therapy 2

Replacement of Ongoing Losses

During both rehydration and maintenance phases:

• Replace each watery stool with 10 mL/kg of ORS
• Replace each episode of vomiting with 2 mL/kg of ORS
• If losses can be measured, replace with 1 mL ORS per gram of diarrheal stool 2, 1

Dietary Management

• Breastfed infants: Continue nursing on demand throughout the diarrheal episode 2
• Bottle-fed infants: Use full-strength, lactose-free or lactose-reduced formulas immediately upon rehydration
• Older children and adults: Resume normal diet during or immediately after rehydration 2

Important dietary principles:

• Early feeding speeds recovery of intestinal function
• Avoid "gut rest" approach as it can worsen outcomes
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables
• Avoid foods high in simple sugars and fats 2

Pharmacological Treatment

Antimotility Agents

• Loperamide: Can be used for symptomatic relief in adults and children over 2 years with watery (non-bloody) diarrhea 3, 4
• Caution: Avoid in bloody diarrhea, severe dehydration, or in children under 2 years due to risk of serious cardiac adverse reactions and respiratory depression 3

Antibiotics

• Generally not recommended for most cases of acute watery diarrhea 2, 4
• Consider only in specific circumstances:
  • Immunocompromised patients
  • Ill-appearing young infants
  • Bloody diarrhea (dysentery)
  • Confirmed bacterial pathogens that warrant treatment 2, 5

Common Pitfalls to Avoid

1. Using inappropriate fluids: Avoid plain water, fruit juices, sodas, or sports drinks as they lack proper electrolyte balance and can worsen diarrhea 2

2. Delaying refeeding: Early reintroduction of food is beneficial, not harmful 2

3. Overusing antimotility agents: These can mask symptoms and prolong illness in cases of invasive pathogens 3, 4

4. Unnecessary antibiotic use: Most acute diarrhea is viral and self-limiting; antibiotics can disrupt gut flora and promote resistance 2, 4

5. Neglecting ongoing losses: Continuous replacement of fluid losses is essential throughout the illness 2, 1

By following this structured approach to rehydration, dietary management, and selective use of medications, most cases of acute diarrhea can be managed effectively with minimal complications.