What is the management for a patient with vomiting and diarrhea?

Management of Vomiting and Diarrhea

The primary treatment for patients with vomiting and diarrhea is rehydration therapy, with reduced osmolarity oral rehydration solution (ORS) as the first-line treatment for mild to moderate dehydration. 1, 2

Assessment of Dehydration

Assess the level of dehydration:

• Mild dehydration (3-5%): Increased thirst, slightly dry mucous membranes
• Moderate dehydration (6-9%): Loss of skin turgor, dry mucous membranes
• Severe dehydration (≥10%): Severe lethargy, altered consciousness 2

Rehydration Protocol

Mild to Moderate Dehydration

• Oral Rehydration Solution (ORS): First-line therapy 1, 2

  • Use reduced osmolarity ORS containing 65-70 mEq/L sodium and 75-90 mmol/L glucose
  • Continue until clinical dehydration is corrected

• For patients with vomiting:

  • Administer small, frequent volumes (e.g., 5 mL every minute) via spoon or syringe 2
  • Wait 10 minutes after vomiting episode before continuing ORS 3
  • Gradually increase volume as tolerated

Severe Dehydration

• Intravenous (IV) Fluids: Required for severe dehydration, shock, altered mental status, or when ORS fails 1, 2

  • Use isotonic fluids such as lactated Ringer's or normal saline
  • Continue IV rehydration until pulse, perfusion, and mental status normalize 1
  • Once stabilized, transition to ORS to replace remaining deficit 1

• Nasogastric Administration: Consider for patients with moderate dehydration who cannot tolerate oral intake 1

Nutritional Management

• Continue breastfeeding in infants throughout the diarrheal episode 1, 2
• Resume age-appropriate diet during or immediately after rehydration 1, 2
• For older patients, emphasize starches, cereals, yogurt, fruits, and vegetables 2
• Avoid foods high in simple sugars and fats 2

Pharmacologic Interventions

Antiemetics

• Ondansetron may be given to patients >4 years of age to facilitate oral rehydration 1, 2
• Only administer after adequate hydration has begun 2
• Do not substitute antiemetics for fluid and electrolyte therapy 1

Antimotility Agents

• Loperamide:
  • Contraindicated in children <18 years 1, 2
  • May be given to immunocompetent adults with acute watery diarrhea 1
  • Dosing: 4 mg initial dose, then 2 mg after each loose stool (max 16 mg/day) 2, 4
  • Avoid in patients with:
    • Fever
    • Bloody diarrhea (inflammatory diarrhea)
    • Risk of toxic megacolon 1
    • Cardiac conditions or taking medications that prolong QT interval 4

Antimicrobial Therapy

• Generally not indicated for most cases of acute watery diarrhea 1, 2
• Consider only for:
  • Immunocompromised patients
  • Ill-appearing young infants
  • Dysentery (bloody diarrhea)
  • High fever
  • Watery diarrhea lasting >5 days 2

Adjunctive Therapies

• Probiotics: May reduce symptom severity and duration in immunocompetent patients 1, 2
• Zinc supplementation: Beneficial for children 6 months to 5 years with malnutrition 1, 2

Monitoring and Follow-up

• Monitor for:

  • Improvement in hydration status
  • Resolution of vomiting and diarrhea
  • Tolerance of oral intake

• Warning signs requiring immediate medical attention:

  • Persistent vomiting
  • Bloody diarrhea
  • Signs of worsening dehydration
  • Altered mental status
  • High fever 2

Prevention of Transmission

• Implement proper hand hygiene
• Use appropriate infection control measures
• Asymptomatic contacts should not receive preventive therapy 1, 2

Common Pitfalls to Avoid

1. Overuse of IV fluids when ORS would be sufficient 5
2. Delaying reintroduction of feeding after rehydration 5
3. Withholding ORS from vomiting patients 3, 5
4. Using antimotility drugs in children or in patients with inflammatory diarrhea 1, 2
5. Unnecessary use of antibiotics for uncomplicated cases 1

Remember that most cases of vomiting and diarrhea can be successfully managed with ORS, even when vomiting is present, as most of the fluid administered is retained despite appearances 3.