What is the treatment for diarrhea?

Treatment of Diarrhea

The primary treatment for diarrhea is oral rehydration therapy (ORT) combined with appropriate dietary management, with antimotility agents like loperamide reserved for adults with non-infectious watery diarrhea. 1

Assessment and Classification

• Evaluate the degree of dehydration based on clinical signs such as skin turgor, mental status, mucous membranes, and capillary refill time 1
• Assess for warning signs requiring medical attention: high fever (>38.5°C), bloody stools, severe vomiting, or signs of severe dehydration 1
• Laboratory studies are rarely needed except in cases of suspected electrolyte abnormalities or bloody diarrhea (dysentery) 1

Rehydration Therapy

Mild to Moderate Dehydration (3-9% fluid deficit)

• Administer oral rehydration solution (ORS) containing 50-90 mEq/L of sodium 1
• For mild dehydration (3-5%): give 50 mL/kg over 2-4 hours 1
• For moderate dehydration (6-9%): give 100 mL/kg over 2-4 hours 1
• Start with small volumes (1 teaspoon) and gradually increase as tolerated 1
• Reassess hydration status after 2-4 hours and adjust therapy accordingly 1

Severe Dehydration (≥10% fluid deficit)

• This constitutes a medical emergency requiring immediate IV rehydration 1
• Administer boluses of 20 mL/kg of Ringer's lactate solution or normal saline until pulse, perfusion, and mental status normalize 1
• Once the patient is alert, transition to oral rehydration 1

Replacement of Ongoing Losses

• Replace ongoing stool losses with 10 mL/kg of ORS for each watery stool 1
• Replace vomiting losses with 2 mL/kg of fluid for each episode 1

Dietary Management

• Continue feeding during diarrheal episodes - early refeeding speeds recovery 1
• Breastfed infants should continue nursing on demand 1
• For adults, maintain adequate fluid intake as indicated by thirst 1
• Consume small, light meals based on appetite 1
• Avoid spicy foods, caffeine, alcohol, and high-fat meals 1
• Consider temporarily avoiding milk and dairy products (except yogurt and firm cheeses) 1

Pharmacologic Therapy

Antimotility Agents

• Loperamide is the drug of choice for adults with non-bloody, non-febrile diarrhea 1, 2
  • Initial dose: 4 mg followed by 2 mg after each loose stool (maximum 16 mg/day) 1, 2
• Do not use loperamide in children under 18 years of age due to risk of respiratory depression and cardiac adverse reactions 1, 2
• Avoid loperamide in patients with bloody diarrhea, high fever, or suspected infectious colitis 2

Antibiotics

• Not indicated for routine acute watery diarrhea 1, 3
• Consider antibiotics only for:
  • Dysentery (bloody diarrhea) 1
  • Suspected cholera 1, 4
  • Traveler's diarrhea (azithromycin 500 mg single dose is preferred) 3
  • Specific parasitic infections like giardiasis or amebiasis 4

Special Considerations

Cancer Patients with Treatment-Related Diarrhea

• For grade 1-2 diarrhea: hydration, electrolyte replacement, and bland/BRAT diet 1
• Consider anticholinergic agents (hyoscyamine, atropine) for grade 2 diarrhea 1
• For persistent grade 2 or grades 3-4 diarrhea: inpatient treatment with IV fluids and octreotide 1

When to Seek Medical Care

• No improvement within 48 hours 1
• Worsening symptoms or development of warning signs 1
• Signs of severe dehydration 1
• Bloody stools, persistent high fever, or severe abdominal pain 1

Common Pitfalls to Avoid

• Delaying rehydration therapy while awaiting diagnostic tests 1
• Using antimotility agents in children or patients with bloody diarrhea 1, 2
• Restricting food during diarrheal episodes, which can worsen nutritional status 1
• Failing to replace ongoing fluid losses during both rehydration and maintenance phases 1