How to manage stomach pain, bloating, diarrhea, and vomiting without fever?

Management of Acute Gastroenteritis with Stomach Pain, Bloating, Diarrhea, and Vomiting

For this presentation of acute gastroenteritis without fever, the priority is oral rehydration therapy with reduced osmolarity ORS, early resumption of normal diet, and symptomatic management while avoiding antimotility agents until inflammatory causes are excluded. 1

Immediate Assessment and Red Flags

First, assess hydration status and exclude warning signs that would change management:

• Check for fever, bloody stools, or severe abdominal distention - these contraindicate antimotility agents and may require antibiotics 1, 2
• Evaluate dehydration severity by examining mucous membranes, skin turgor, urine output, and mental status 1
• The absence of fever is reassuring and suggests viral gastroenteritis rather than invasive bacterial infection 1, 3

Rehydration Strategy (First Priority)

Reduced osmolarity oral rehydration solution (ORS) is the cornerstone of treatment for mild to moderate dehydration 1:

• Start ORS immediately to replace fluid losses from vomiting and diarrhea 1
• For ongoing vomiting, give small frequent volumes (5 mL every minute) using a spoon or syringe rather than large amounts 1, 4
• Continue ORS despite vomiting - most fluid is retained even when some is vomited, and vomiting typically decreases as rehydration progresses 1, 5
• Replace each episode of vomiting or diarrhea with additional ORS to prevent recurrent dehydration 1

If severe dehydration, shock, altered mental status, or failure of oral rehydration occurs, intravenous fluids (lactated Ringer's or normal saline) are required 1.

Dietary Management (Second Priority)

Resume normal diet immediately once rehydration begins - do not restrict food 1:

• Continue usual age-appropriate diet including starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats as these may worsen symptoms 1
• Do not use the BRAT diet or prolonged dietary restrictions - early refeeding improves outcomes 1

Symptomatic Treatment Considerations

For Vomiting:

• Ondansetron may be considered for persistent vomiting in adults and children >4 years to facilitate oral rehydration (4-8 mg orally) 1, 4, 6
• Use only after attempting small-volume ORS rehydration first 1, 4
• Be aware of QT prolongation risk with ondansetron, especially with other QT-prolonging medications 6

For Diarrhea:

Do NOT use loperamide in this case until you confirm the absence of inflammatory diarrhea 1, 2:

• Loperamide is contraindicated with fever, bloody stools, or suspected inflammatory/infectious colitis due to toxic megacolon risk 1, 2, 7
• Since this patient had stomach pain and bloating, inflammatory causes must be excluded first 2
• If symptoms persist >48 hours or worsen, do not use loperamide - seek further evaluation 7, 3
• Only consider loperamide if watery diarrhea without fever/blood persists and patient is immunocompetent 1, 2

Adjunctive Therapies:

• Probiotics may reduce symptom duration and severity - reasonable to try for up to 12 weeks 1
• Antispasmodics may help abdominal pain and bloating but have side effects (dry mouth, dizziness) 1

When Antibiotics Are NOT Needed

Antibiotics should NOT be used in this case 1:

• No fever present - suggests viral rather than bacterial etiology 1, 3
• Antibiotics are only indicated when: dysentery (bloody diarrhea) with fever is present, watery diarrhea persists >5 days, or specific pathogens requiring treatment are identified 1

Critical Monitoring and Follow-Up

Instruct the patient to seek immediate care if 1, 4:

• Fever develops - suggests bacterial infection and contraindicates loperamide 1, 2
• Blood appears in stool - indicates inflammatory diarrhea requiring different management 1, 2, 7
• Abdominal distention or severe pain worsens - may indicate complications 2, 7, 6
• Signs of severe dehydration develop: decreased urine output, lethargy, altered mental status 1, 4
• Symptoms persist beyond 48 hours without improvement 7, 3

Common Pitfalls to Avoid

• Do not give antimotility agents empirically - the bloating and abdominal pain raise concern for possible inflammatory component 1, 2
• Do not use antiemetics as substitute for rehydration - they are adjunctive only 1, 4
• Do not restrict diet unnecessarily - early refeeding improves recovery 1
• Do not assume viral gastroenteritis is benign - dehydration causes significant morbidity if untreated 1, 8