What is the treatment for diarrhea and viral gastroenteritis?

From the Guidelines

Treatment for diarrhea and viral gastroenteritis focuses primarily on preventing dehydration through oral rehydration therapy, and symptom relief can be achieved with loperamide in adults, while avoiding its use in children under 18 years of age, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1, 2.

Key Recommendations

• Drink plenty of clear fluids like water, clear broths, or commercial oral rehydration solutions such as Pedialyte, Gatorade, or homemade solutions (1 teaspoon salt, 8 teaspoons sugar in 1 liter of clean water) to prevent dehydration.
• Adults should consume at least 2-3 liters daily, while children need frequent small sips.
• For symptom relief, loperamide (Imodium) can be taken at 4mg initially, then 2mg after each loose stool (maximum 16mg/day) for adults, but avoid in children under 18 years of age, or if there's blood in stool or high fever, as stated in the guidelines 1.
• Bismuth subsalicylate (Pepto-Bismol) is another option at 30ml or 2 tablets every 30 minutes to 1 hour (maximum 8 doses/24 hours).
• Follow the BRAT diet (bananas, rice, applesauce, toast) initially, then gradually return to normal eating.
• Probiotics like Lactobacillus or Saccharomyces boulardii may help restore gut flora.
• Most viral gastroenteritis resolves within 1-3 days without antibiotics, which are ineffective against viruses, as noted in the guidelines 3.
• Seek medical attention if symptoms persist beyond 3 days, if there's severe dehydration (decreased urination, extreme thirst, dizziness), blood in stool, or fever above 102°F (39°C).

Rationale

The guidelines from the 2017 Infectious Diseases Society of America 1, 2 provide the most recent and highest quality evidence for the treatment of diarrhea and viral gastroenteritis. The use of loperamide in adults is supported by the guidelines, but its use is not recommended in children under 18 years of age. The guidelines also emphasize the importance of oral rehydration therapy and the use of antimotility agents, such as loperamide, to shorten the duration of diarrhea in adults. Additionally, the guidelines recommend against the use of empiric antimicrobial therapy in most people with acute watery diarrhea, except in certain cases such as immunocompromised individuals or young infants who are ill-appearing 3.

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 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).

The treatment for diarrhea includes:

• Administration of appropriate fluid and electrolytes to prevent dehydration
• Loperamide hydrochloride for symptomatic treatment
• Specific treatment for the underlying etiology when determined For viral gastroenteritis, the treatment is similar, focusing on managing symptoms and preventing dehydration. 4

From the Research

Treatment for Diarrhea and Viral Gastroenteritis

• The primary goal in treating viral gastroenteritis is to prevent dehydration and manage symptoms 5, 6.
• Oral rehydration solutions, such as Pedialyte and Gatorade, are commonly used to treat dehydration in viral gastroenteritis, with some studies suggesting that they are effective in correcting dehydration and improving bowel symptoms 7.
• Probiotics, such as Lactobacillus caseii GG, Lactobacillus reuteri, and Saccharomyces boulardii, have been shown to be effective in shortening the duration of diarrhea and reducing the severity of symptoms in acute infectious gastroenteritis 8, 9.
• Continuation of breastfeeding is strongly recommended for infants with gastroenteritis, and early refeeding is also important for managing the condition 9.
• New treatments, such as antiemetics and antidiarrheal agents, are being proposed, but their use is not yet universally recommended 9.
• The management of acute gastroenteritis is often based on the principle of "doing the least," with a focus on oral rehydration solution administration, early refeeding, and avoiding unnecessary tests and drugs 9.

Oral Rehydration Solutions

• Pedialyte, Gatorade, and a New Oral Rehydration Solution (N-ORS) have been compared in a randomized, controlled trial, with results showing that all three solutions are effective in correcting dehydration and improving bowel symptoms 7.
• However, the study also found that hypokalemia persisted in the Gatorade group, suggesting that N-ORS and Pedialyte may be safer options 7.

Probiotics

• Probiotics have been shown to be effective in reducing the duration and severity of diarrhea in acute infectious gastroenteritis, with some strains, such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii, being recommended for use in managing the condition 8, 9.
• The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the European Society of Paediatric Infectious Diseases guidelines make a strong recommendation for the use of probiotics in managing acute gastroenteritis 9.