What is the treatment for diarrhea?

Treatment of Diarrhea

The cornerstone of diarrhea treatment is oral rehydration solution (ORS) for fluid replacement, combined with early refeeding and age-appropriate diet, while avoiding antimicrobials in most cases of acute watery diarrhea. 1

Immediate Assessment and Hydration Strategy

Rehydration Phase

• Reduced osmolarity ORS is the first-line therapy for mild to moderate dehydration in all age groups 1
• Administer ORS in small volumes (5-10 mL) every 1-2 minutes via spoon or syringe, gradually increasing the amount—never allow ad libitum drinking from a cup, as this commonly triggers vomiting 1
• For moderate dehydration with vomiting or inability to drink, consider nasogastric ORS administration 1
• Switch to intravenous fluids (lactated Ringer's or normal saline) only when severe dehydration, shock, altered mental status, or ileus is present 1

Maintenance Phase

• Once rehydrated, replace ongoing stool losses with ORS until diarrhea resolves 1
• Continue human milk feeding throughout the illness in infants 1
• Resume age-appropriate usual diet immediately after rehydration is completed—do not delay feeding 1

Antimotility and Symptomatic Agents

Adults

• Loperamide may be given to immunocompetent adults with acute watery diarrhea: initial dose 4 mg, then 2 mg every 2-4 hours or after each unformed stool (maximum 16 mg/day) 1, 2
• Use only after adequate hydration is achieved 1

Pediatric Patients

• Antimotility drugs (including loperamide) are contraindicated in children <18 years of age due to risks of ileus, lethargy, respiratory depression, and cardiac adverse reactions 1, 2
• Loperamide is specifically contraindicated in children <2 years due to serious cardiac adverse reactions and respiratory depression 2

Additional Symptomatic Agents

• Antiemetics or antinausea agents can be considered once hydration is adequate, but are not substitutes for fluid therapy 1
• For cancer patients with refractory diarrhea, octreotide 100-150 mcg subcutaneously/IV three times daily can be used 1

When to Use Antimicrobials

Avoid Antibiotics In:

• Most cases of acute watery diarrhea without recent international travel 1
• Persistent watery diarrhea lasting ≥14 days 1
• STEC O157 and other Shiga toxin 2-producing E. coli infections—antibiotics may worsen outcomes 1

Consider Antibiotics For:

• Suspected enteric fever (typhoid): start empiric broad-spectrum therapy after cultures, then narrow based on susceptibilities 1
• Shigellosis, campylobacteriosis, traveler's diarrhea, and protozoal infections when appropriately diagnosed 3
• Immunocompromised patients or ill-appearing young infants with acute watery diarrhea 1

Dietary Modifications

• Avoid spices, coffee, alcohol, and reduce insoluble fiber intake 1
• Consider avoiding milk and dairy products (except yogurt and firm cheeses) during chemotherapy-induced diarrhea 1
• Do not practice "gut rest"—fasting reduces enterocyte renewal and increases intestinal permeability 1
• BRAT diet (bread, rice, applesauce, toast) can be used for grade 1-2 diarrhea in palliative care settings 1

Special Populations

Cancer Patients with Immunotherapy-Induced Diarrhea

• Grade 1: symptomatic treatment with ORS and loperamide 1
• Grade 2: add budesonide 9 mg once daily if no bloody diarrhea; escalate to oral corticosteroids (0.5-1 mg/kg/day prednisone equivalent) if symptoms persist >3 days 1
• Grade 3-4: IV corticosteroids 1-2 mg/kg/day; avoid loperamide and opioids; add infliximab 5 mg/kg if no improvement after 3-5 days 1

Hypernatremic Dehydration

• Do not use standard ORS protocols—they contain 50-90 mEq/L sodium and will not correct hypernatremia 4
• Correct sodium slowly at maximum rate of 3 mOsm/kg/H2O per hour to avoid cerebral edema 4

Critical Pitfalls to Avoid

• Never allow rapid, large-volume ORS consumption—this is the most common cause of ORT failure 1
• Do not withhold food during or after rehydration—early feeding improves outcomes 1
• Avoid loperamide in patients with bloody diarrhea, fever, or suspected inflammatory/invasive pathogens 1, 2
• Do not use loperamide at higher than recommended doses due to cardiac risks including QT prolongation and torsades de pointes 2
• Asymptomatic contacts should never receive empiric or preventive antimicrobial therapy 1