What is the treatment for loose stools?

Treatment of Loose Stools

For most cases of loose stools, the recommended first-line treatment is loperamide at an initial dose of 4 mg followed by 2 mg after each unformed stool (maximum 16 mg/day), along with oral rehydration and dietary modifications. 1, 2

Initial Assessment and Classification

Loose stools (diarrhea) can be classified as:

• Uncomplicated: Mild to moderate symptoms without complicating factors
• Complicated: Severe symptoms with dehydration, fever, bleeding, or significant electrolyte disturbances

Red flags requiring urgent medical attention:

• Severe dehydration
• Bloody stools
• Persistent fever
• Immunocompromised status
• Severe abdominal pain
• Weight loss
• Signs of sepsis

Treatment Algorithm

1. Rehydration

• Maintain adequate fluid intake based on thirst 3
• For mild cases: Glucose-containing drinks (lemonades, sweet sodas) or electrolyte-rich soups 3
• For moderate to severe cases: Oral rehydration solution (ORS) with proper sodium content (90 mmol/L or higher) 3, 1
  • ORS recipe: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 1
  • Commercial sports drinks typically have insufficient sodium and excessive sugar 3

2. Antimotility Agents

• First-line: Loperamide 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) 3, 1, 2
  • Take 30 minutes before meals for maximum effectiveness 3
  • Higher doses may be needed in patients with short bowel syndrome 3
• Alternative: Codeine phosphate (less preferred due to sedative effects and addiction potential) 3
• Avoid antimotility agents in bloody diarrhea or suspected infectious colitis 1

3. Dietary Management

• General approach: Maintain food intake guided by appetite 3
• Recommended foods: Small, light meals; bananas, rice, applesauce, toast (BRAT diet) 1
• Foods to avoid:
  • Fatty, heavy, spicy foods
  • Caffeine (including cola drinks)
  • Lactose-containing foods during prolonged episodes 3
  • High-osmolar dietary supplements 3

4. Additional Treatments Based on Specific Causes

For secretory diarrhea:

• Consider antisecretory medications:
  • Proton pump inhibitors (e.g., omeprazole 40 mg daily) 3
  • H2 antagonists (e.g., ranitidine 300 mg twice daily) 3
  • For severe cases: octreotide 100-150 μg subcutaneously three times daily 3

For infectious diarrhea:

• Antibiotics only if indicated (not for routine use):
  • Fluoroquinolones for suspected bacterial etiology in adults 3, 1
  • Metronidazole for suspected anaerobic infections 3
  • Avoid antibiotics in suspected STEC O157 infections 1

For high-output stoma/ileostomy:

• Restrict oral hypotonic fluids to less than 500 ml daily 3
• Add salt to diet (0.5-1 teaspoon per day) 3
• Consider sodium chloride capsules (500 mg) if needed 3

Special Considerations

Short Bowel Syndrome

• May require higher doses of loperamide 3
• Careful fluid management with ORS containing at least 90 mmol/L sodium 3
• Consider antisecretory medications 3

Cancer-Related Diarrhea

• For uncomplicated cases: standard loperamide protocol 3
• For complicated cases: hospitalization, IV fluids, octreotide, and appropriate antibiotics 3

Elderly Patients

• Use standard doses but monitor more carefully for dehydration 2
• Avoid loperamide in elderly patients taking QT-prolonging medications 2

Common Pitfalls to Avoid

1. Excessive water intake - Can paradoxically increase stool output, especially in short bowel syndrome 3
2. Inadequate sodium in rehydration solutions - Commercial sports drinks often have insufficient sodium 3
3. Overuse of antibiotics - Not indicated for most cases of acute diarrhea 1
4. Inadequate dosing of loperamide - Higher doses may be needed, especially in short bowel syndrome 3
5. Failure to recognize dehydration - Monitor for decreased urine output, dizziness, dry mouth 3

By following this structured approach to treating loose stools, focusing on rehydration, antimotility agents, and appropriate dietary modifications, most cases can be effectively managed with significant improvement within 48 hours.