Managing Diarrhea After Alcohol Withdrawal
Diarrhea during alcohol withdrawal should be managed with oral rehydration solution (ORS) as first-line therapy, thiamine supplementation, and avoidance of routine intravenous fluids unless severe dehydration develops. 1, 2
Immediate Assessment and Hydration Status
Evaluate the patient's hydration status by checking:
- Skin turgor and mucous membrane moisture 1
- Mental status and perfusion 1
- Vital signs including heart rate and blood pressure 1
For mild to moderate dehydration (most common scenario), administer ORS containing 50-90 mEq/L of sodium at 50-100 mL/kg over 2-4 hours. 1, 3 This is safer and more physiologic than IV fluids and avoids risks of phlebitis. 1
Specific Considerations for Alcohol Withdrawal Context
Routine parenteral fluid administration to chronic and withdrawing alcoholics should be avoided. 4 The chronic effect of alcohol is to promote retention of water and electrolytes due to increased ADH levels, and with cessation of alcohol intake, this excess will be excreted over several days. 4
Administer thiamine 100-300 mg/day immediately to all patients with alcohol withdrawal syndrome, and maintain for 2-3 months following resolution of withdrawal symptoms. 1 This prevents Wernicke-Korsakoff syndrome and addresses the common thiamine deficiency in this population. 1
Oral Rehydration Protocol
Use commercially available ORS formulations such as:
Do NOT use apple juice, Gatorade, or commercial soft drinks for rehydration, as these have inappropriate osmolarity and electrolyte composition. 1
Start with small volumes (one teaspoon) and gradually increase as tolerated. 3 Replace ongoing stool losses with 10 mL/kg of ORS for each diarrheal episode. 3
Dietary Management
Resume an age-appropriate normal diet immediately after rehydration is complete or during the rehydration process. 1 Early feeding is as safe and effective as delayed feeding and improves nutritional outcomes. 1
Avoid fasting, as it reduces enterocyte renewal and increases intestinal permeability. 1
Pharmacologic Considerations
Continue benzodiazepines for alcohol withdrawal syndrome management (chlordiazepoxide, diazepam, or lorazepam) as these remain the cornerstone of AWS treatment. 1, 2, 5 The diarrhea should not alter this management.
For persistent diarrhea after rehydration:
- Consider loperamide or other antidiarrheal agents in adults 1
- Low doses of morphine concentrate can be considered if diarrhea persists 1
When to Escalate to IV Therapy
Switch to isotonic intravenous fluids (lactated Ringer's or normal saline) only if: 1, 3
- Severe dehydration develops
- Shock or altered mental status occurs
- Failure of ORS therapy
- Ileus is present
Critical Monitoring
Carefully observe bowel movements during alcohol withdrawal, even during hospitalization, as severe acute diarrhea can lead to lethal complications when combined with malnutrition and withdrawal. 6 This complication is often overlooked but can progress to shock. 6
Monitor for:
- Electrolyte abnormalities (particularly potassium and magnesium) 4
- Signs of worsening dehydration 1
- Complications such as delirium tremens, which typically peaks at 3-5 days after cessation 1
Common Pitfalls to Avoid
- Do not routinely administer IV fluids to withdrawing alcoholics, as they retain water and electrolytes chronically 4
- Do not use sports drinks or sodas for rehydration—they have excessive osmolarity and inadequate electrolyte composition 1, 7
- Do not withhold food—early feeding improves outcomes 1
- Do not forget thiamine—this is essential in all alcohol withdrawal patients 1, 2