What is the plan of care for a patient with acute diarrhea?

Management of Acute Diarrhea

For a patient with acute diarrhea lasting several days, begin immediate oral rehydration therapy with ORS or electrolyte-rich fluids, continue normal feeding as tolerated, and reserve antibiotics only for documented dysentery (high fever >38.5°C with frank blood in stool). 1

Immediate Assessment

First, evaluate hydration status by checking for:

• Thirst, dry mucous membranes, and decreased skin turgor 1
• Orthostatic vital sign changes and capillary refill time 1
• Mental status and urination frequency 1

Determine stool characteristics:

• Watery versus bloody/mucoid appearance 1
• Frequency and volume of stools 1

Identify warning signs requiring urgent medical attention:

• Frank blood in stool with fever >38.5°C (suggests invasive bacterial infection) 1
• Severe vomiting preventing oral intake 2
• Signs of severe dehydration (altered mental status, inability to maintain oral intake) 1
• Severe abdominal pain or distention 3

Rehydration Protocol

Oral rehydration is first-line therapy for all patients who can tolerate oral intake. 1

For mild dehydration: Administer 50 mL/kg of ORS over 2-4 hours 1

For moderate dehydration: Administer 100 mL/kg of ORS over 2-4 hours 1

For severe dehydration or shock: Immediate IV boluses of 20 mL/kg Ringer's lactate or normal saline until perfusion normalizes 1

Critical technique for patients with vomiting: Administer small volumes (5-10 mL) of ORS every 1-2 minutes via spoon or syringe, gradually increasing the amount. 2 A common pitfall is allowing thirsty patients to drink large volumes ad libitum, which worsens vomiting. 2

Acceptable alternatives to commercial ORS: Glucose-containing drinks (lemonades, sweet sodas, fruit juices) or electrolyte-rich soups 2

Dietary Management

Resume normal feeding immediately after rehydration is achieved—do not withhold food or enforce fasting. 1

Food intake should be guided by appetite with small, light meals. 2

Avoid fatty, heavy, spicy foods and caffeine (including cola drinks). 2

Consider avoiding lactose-containing foods if diarrhea persists beyond several days. 2

Pharmacological Management

Loperamide 4 mg initial dose, then 2 mg after each unformed stool (maximum 16 mg/day) is appropriate for uncomplicated watery diarrhea. 4

Contraindications to loperamide:

• Bloody diarrhea or dysentery 2
• High fever (>38.5°C) 2
• Abdominal distention 3
• Age less than 2 years 4

Do NOT use antimicrobials for simple acute watery diarrhea—this promotes resistance without clear benefit. 1

Reserve antibiotics ONLY for documented dysentery: high fever (>38.5°C) AND frank blood in stool 1

If antibiotics are indicated: Fluoroquinolones are first-line empirical treatment for invasive diarrhea 1

When to Seek Medical Evaluation

Immediate medical attention is required for:

• Inability to tolerate oral fluids despite small-volume technique 1
• Worsening dehydration signs 1
• Development of bloody diarrhea 1
• Significant increase in fever 1
• Altered mental status or severe lethargy 1

If no clinical improvement within 48 hours, discontinue loperamide and contact healthcare provider. 4

For elderly patients (>75 years) or those with significant comorbidities: Treat under physician supervision due to higher complication risk 2, 3

Critical Pitfalls to Avoid

Do not neglect rehydration while focusing solely on antimotility agents—dehydration is the primary cause of morbidity and mortality. 5

Do not use loperamide if inflammatory diarrhea is suspected (fever, blood in stool, severe abdominal pain). 3

Do not exceed recommended loperamide dosages—higher doses increase risk of cardiac arrhythmias, QT prolongation, and Torsades de Pointes. 4

In elderly patients, do not overlook fecal impaction with overflow diarrhea, which can present as alternating constipation and diarrhea. 3, 5