What is the treatment for diarrhea?

Treatment of Diarrhea

The cornerstone of diarrhea treatment is rehydration therapy, with oral rehydration solution (ORS) as first-line treatment for mild to moderate dehydration and intravenous fluids for severe dehydration. 1

Assessment of Dehydration

• Evaluate degree of dehydration to guide treatment approach 1:
  • Mild dehydration (3-5% fluid deficit): increased thirst, slightly dry mucous membranes
  • Moderate dehydration (6-9% fluid deficit): loss of skin turgor, tenting of skin, dry mucous membranes
  • Severe dehydration (≥10% fluid deficit): lethargy, altered consciousness, prolonged skin tenting (>2 seconds), cool extremities, decreased capillary refill

Rehydration Therapy

Oral Rehydration

• For mild dehydration (3-5% fluid deficit) 1:

  • Administer ORS containing 50-90 mEq/L sodium
  • Give 50 mL/kg over 2-4 hours
  • Start with small volumes (1 teaspoon) and gradually increase
  • Reassess hydration status after 2-4 hours

• For moderate dehydration (6-9% fluid deficit) 1:

  • Use same approach as mild dehydration but increase fluid amount to 100 mL/kg over 2-4 hours

• Reduced osmolarity ORS is recommended as first-line therapy for mild to moderate dehydration in all age groups 1

• Nasogastric administration of ORS may be considered for those who cannot tolerate oral intake or refuse to drink adequately 1

Intravenous Rehydration

• For severe dehydration (≥10% fluid deficit) 1:
  • Begin immediate IV rehydration with boluses (20 mL/kg) of Ringer's lactate or normal saline
  • Continue until pulse, perfusion, and mental status normalize
  • Once consciousness returns, remaining deficit can be replaced orally
  • Monitor hydration status frequently

Replacement of Ongoing Losses

• During both rehydration and maintenance phases, replace ongoing fluid losses 1:
  • 10 mL/kg of ORS for each watery stool
  • 2 mL/kg for each episode of vomiting
  • Or 1 mL of ORS per gram of diarrheal stool if accurate measurement is possible

Dietary Management

• Breast-fed infants should continue nursing on demand 1
• For bottle-fed infants, resume full-strength, lactose-free or lactose-reduced formulas immediately upon rehydration 1
• Resume age-appropriate usual diet during or immediately after rehydration 1
• Early refeeding is recommended rather than fasting or "gut rest" 1

Pharmacologic Treatment

• Antimotility agents 1, 2:

  • Loperamide may be given to immunocompetent adults with acute watery diarrhea
  • Starting dose: 4 mg followed by 2 mg after each loose stool (maximum 16 mg daily)
  • Should NOT be given to children under 18 years with acute diarrhea

• Antimicrobial therapy 1:

  • Not recommended for most people with acute watery diarrhea without recent international travel
  • May be considered for immunocompromised patients or ill-appearing young infants
  • Should be avoided in patients with persistent watery diarrhea lasting 14 days or more
  • Should be modified or discontinued when a causative organism is identified

• For cancer patients with diarrhea 1:

  • Loperamide can be started at 4 mg followed by 2 mg every 2-4 hours
  • Other options include octreotide (100-150 μg subcutaneous/IV three times daily)
  • Bile acid sequestrants may help if bile salt malabsorption is present

Special Considerations

• Stool cultures are indicated for bloody diarrhea but not needed for typical acute watery diarrhea in immunocompetent patients 1

• Antimotility drugs should be avoided in patients with bloody diarrhea 1, 3

• For severe or persistent diarrhea, consider underlying causes such as infectious agents, medication side effects, or other medical conditions 4

• In patients with cancer, diarrhea may be caused by anticancer treatments, infections, antibiotic use, dietary changes, or fecal impaction 1