What is the management approach for acute diarrhea (loose motion)?

Management of Acute Diarrhea (Loose Motion)

For acute diarrhea management, prioritize oral rehydration therapy with small, frequent volumes of reduced osmolarity ORS (65-70 mEq/L sodium), resume age-appropriate diet within 4-6 hours, and avoid antimotility agents in children under 18 years or in cases of bloody diarrhea. 1

Assessment and Classification

• Assess severity of dehydration:

  • Mild: Thirst, dry mouth, normal activity
  • Moderate: Sunken eyes, decreased skin turgor, irritability
  • Severe: Sunken eyes, disorientation, respiratory distress, poor perfusion (>9% weight loss) 1

• Monitor warning signs requiring escalation:

  • Worsening symptoms despite treatment
  • Bloody stools
  • Persistent fever
  • Abdominal distention
  • Symptoms persisting >48 hours 1

Rehydration Therapy (First-Line Treatment)

Oral Rehydration

• For mild to moderate dehydration:
  • Provide oral rehydration solution (ORS) in small volumes (5 mL every minute)
  • Administer via spoon or syringe if necessary
  • Gradually increase amount as tolerated
  • Provide 100-200 mL after each loose stool 1
  • Use reduced osmolarity ORS (65-70 mEq/L sodium) 1

Intravenous Rehydration

• For severe dehydration:
  • Immediate IV fluid resuscitation with isotonic solutions (lactated Ringer's or normal saline)
  • Initial bolus of 20 mL/kg
  • Continue rapid infusion until clinical signs of hypovolemia improve 1
  • Consider nasogastric administration if oral intake not tolerated 1

Dietary Management

• Resume age-appropriate diet immediately after initial rehydration (within 4-6 hours)
• Offer food every 3-4 hours
• Avoid foods high in simple sugars and fats
• Continue breastfeeding throughout illness (for infants) 1
• Provide freshly prepared foods including mixes of cereal with beans or meat with vegetable oil 1

Medication Therapy

Antibiotics

• Consider only if:
  • Blood in stool
  • High fever suggesting bacterial infection
  • Severe dehydration with systemic symptoms 1
• Avoid antibiotics if E. coli O157:H7 or other STEC is suspected (risk of hemolytic uremic syndrome) 1

First-line antibiotic treatments (when indicated):

• Shigella: Azithromycin (alternative: TMP-SMX if susceptible)
• Campylobacter: Azithromycin (alternative: Erythromycin)
• Enterotoxigenic E. coli: TMP-SMX (if susceptible) or Azithromycin
• Bacterial gastroenteritis: Third-generation cephalosporin or Azithromycin 1

Antimotility Agents

• Loperamide is indicated for control and symptomatic relief of acute nonspecific diarrhea in patients 2 years and older 2
• However, antimotility agents should not be given to children <18 years with acute diarrhea
• Avoid in bloody diarrhea or suspected inflammatory conditions 1

Special Considerations

• Immunocompromised patients: At risk for severe, prolonged, and potentially fatal diarrhea 1
• Premature infants: Increased risk for hospitalization from diarrheal disease 1
• Malnourished children: At risk for cycle of diarrhea and malnutrition 1

Prevention

• Proper hand hygiene after toilet use and before food preparation 1
• Monitor for signs of dehydration:
  • Urine output (target ≥0.5 ml/kg/h)
  • Vital signs, especially blood pressure and heart rate
  • Electrolytes, particularly sodium levels 1

When to Investigate Further

• Persistent diarrhea (>14 days) with unidentified source should prompt evaluation for non-infectious conditions:
  • Food allergies
  • Inflammatory bowel disease
  • Congenital diarrheas and enteropathies 1