What is the best course of treatment for a 22-year-old with abdominal pain and diarrhea for five days?

Management of Acute Diarrhea in a 22-Year-Old

For a previously healthy 22-year-old with 5 days of abdominal pain and diarrhea, initiate oral rehydration as the absolute priority, followed by loperamide 4 mg initially then 2 mg after each loose stool (maximum 16 mg/day) if there is no fever >38.5°C or blood in the stool. 1

Initial Assessment - Red Flags to Exclude

Before initiating symptomatic treatment, you must determine if this is simple acute diarrhea or a more serious condition:

• Check for bloody diarrhea (defined as fever >38.5°C AND/OR fresh blood in stool) - if present, antimotility agents are contraindicated 1
• Assess hydration status - mild-to-moderate dehydration can be managed with oral rehydration solution (ORS), but severe dehydration requires IV fluids 2
• Rule out high fever (>38.5°C), which suggests invasive bacterial infection and contraindicates loperamide 1

First-Line Treatment Algorithm

Step 1: Rehydration (Always First Priority)

• Oral rehydration solution is the cornerstone - use commercially available ORS containing 45-75 mEq/L sodium 2
• For mild-to-moderate dehydration, ORS alone is sufficient 2
• Patient should drink fluids containing glucose or electrolyte-rich soups 1
• Continue adequate fluid intake throughout the illness 1

Step 2: Symptomatic Treatment with Loperamide

If no contraindications are present (no bloody diarrhea, no high fever, age >18 years):

• Initial dose: 4 mg orally 1
• Maintenance: 2 mg after each unformed stool 1
• Maximum daily dose: 16 mg 3, 1
• Loperamide is the opioid of choice because it acts locally in the gut with minimal systemic absorption 3

Step 3: Dietary Management

• Continue eating according to appetite - do not restrict food 1
• Avoid fatty, heavy, spicy foods and caffeine 1
• For this age group, normal diet can be resumed as tolerated 1

When to Consider Antibiotics

Antibiotics are NOT routinely indicated but should be considered if: 1

• Diarrhea persists beyond 5 days (this patient is at day 5 - monitor closely)
• High fever or dysentery develops
• Specific pathogen identified on stool culture requiring treatment
• Moderate-to-severe traveler's diarrhea (if travel history present)

Critical Safety Monitoring

Stop self-treatment and seek immediate medical attention if: 1

• No improvement within 48 hours
• Symptoms worsen
• Development of fever, bloody stools, or severe abdominal pain
• Signs of severe dehydration (decreased urine output, lethargy, dizziness)

Common Pitfalls to Avoid

• Never use loperamide if bloody diarrhea or high fever present - risk of toxic megacolon and worsening invasive infection 1
• Do not exceed 16 mg loperamide daily - risk of paralytic ileus, though rare 3
• Do not withhold fluids or food - this delays recovery 1
• Do not start antibiotics empirically without clear indication - promotes resistance and may worsen certain infections 1

Duration of Treatment

• Loperamide should be discontinued once stools become formed
• If symptoms persist beyond 48 hours despite treatment, medical re-evaluation is mandatory 1
• At 5 days duration, this patient is approaching the threshold where further investigation may be warranted if symptoms continue