What is the treatment and evaluation for watery stools gastroenteritis?

Treatment and Evaluation of Watery Stools Gastroenteritis

The cornerstone of treatment for watery stools gastroenteritis is oral rehydration therapy with reduced osmolarity oral rehydration solution (ORS), while empiric antimicrobial therapy is generally not recommended for most cases of acute watery diarrhea without recent international travel. 1

Evaluation

Assessment of Dehydration

• Evaluate hydration status through:

  • General appearance
  • Eyes (sunken or not)
  • Mucous membranes (dry or moist)
  • Tears (present or absent)
  • Capillary refill time
  • Urine output
  • Vital signs (especially heart rate and blood pressure) 2

• Key physical findings that predict significant dehydration:

  • Abnormal capillary refill
  • Abnormal skin turgor
  • Abnormal respiratory pattern 3

Laboratory Testing

• For mild, self-limited watery diarrhea: No laboratory tests needed 4
• Consider stool studies when:
  • Symptoms persist >7 days
  • Bloody diarrhea is present
  • Severe symptoms occur
  • Recent antibiotic exposure (test for Clostridioides difficile) 4
  • Recent international travel 1

Treatment Algorithm

1. Rehydration Based on Dehydration Severity

Mild to Moderate Dehydration:

• First-line: Reduced osmolarity ORS 1

  • Composition: 75-90 mEq/L sodium, 20 mEq/L potassium, 65-80 mEq/L chloride, 10 mEq/L citrate, and 75-111 mmol/L glucose 2
  • Commercial products like Pedialyte (45 mEq/L sodium) are suitable 2
  • Target volume: At least 20-25 mL/kg (patients who tolerated ~25 mL/kg during rehydration had better outcomes than those who only tolerated ~11 mL/kg) 5

• If vomiting prevents oral intake:

  • Consider nasogastric administration of ORS 1
  • Consider ondansetron to improve tolerance of oral rehydration 2, 3

Severe Dehydration:

• Isotonic intravenous fluids (lactated Ringer's or normal saline) 1
• Continue IV rehydration until:
  • Pulse, perfusion, and mental status normalize
  • Patient awakens
  • No risk factors for aspiration
  • No evidence of ileus 1
• After initial IV rehydration, transition to ORS to replace remaining deficit 1

2. Antimicrobial Therapy

When to Avoid Antimicrobials:

• Most cases of acute watery diarrhea without recent international travel 1
• Persistent watery diarrhea lasting 14 days or more 1
• Infections attributed to STEC O157 and other Shiga toxin 2-producing organisms 1

When to Consider Antimicrobials:

• Immunocompromised patients with severe illness 1
• Ill-appearing young infants 1
• Recent international travel with fever ≥38.5°C and/or signs of sepsis 1
• Clinical features of sepsis with suspected enteric fever 1

Antimicrobial Selection (when indicated):

• Adults: Fluoroquinolone (e.g., ciprofloxacin) or azithromycin, based on local susceptibility patterns 1
• Children:
  • Infants <3 months: Third-generation cephalosporin 1
  • Others: Azithromycin, based on local susceptibility patterns 1

3. Diet and Nutrition

• Continue breastfeeding throughout the diarrheal episode 2
• Resume age-appropriate usual diet during or immediately after rehydration 2
• Consider BRAT diet (bread, rice, applesauce, toast) 2
• Avoid:
  • Spices, coffee, alcohol
  • Foods high in simple sugars and fats
  • Consider temporary lactose restriction if suspected intolerance 2

Special Considerations

Asymptomatic Contacts

• Do not offer empiric or preventive therapy 1
• Advise appropriate infection prevention and control measures 1

Indications for Hospitalization

• Severe dehydration
• Persistent vomiting despite antiemetics
• Infants less than 3 months of age
• Elderly patients with comorbidities
• Immunocompromised patients
• Toxic appearance or signs of sepsis 2

Warning Signs Requiring Immediate Medical Attention

• No improvement within 48 hours
• Worsening symptoms
• Severe vomiting
• Persistent fever
• Abdominal distension
• Blood in stool 2

Common Pitfalls to Avoid

1. Overuse of antibiotics in mild, likely viral cases 2
2. Inadequate fluid replacement - ensure rate of replacement exceeds ongoing losses 2
3. Premature use of antimotility agents in dysentery 2
4. Ignoring warning signs of severe disease requiring hospitalization 2
5. Failing to consider local resistance patterns when selecting antibiotics 2
6. Treating without identifying the cause of chronic diarrhea 2
7. Overlooking medication-induced diarrhea (accounts for ~4% of chronic cases) 2