What is the treatment for diarrhea with blood?

Treatment of Diarrhea with Blood

Bloody diarrhea requires immediate medical evaluation and aggressive management, as it may indicate bacterial or parasitic infection requiring antimicrobial therapy, and oral rehydration therapy alone is insufficient. 1

Immediate Assessment and Risk Stratification

Evaluate hydration status immediately by checking skin turgor, mucous membrane moisture, mental status, capillary refill time, and vital signs to categorize severity: mild (3-5% fluid deficit), moderate (6-9% fluid deficit), or severe (≥10% fluid deficit). 2

Assess for complications that define "complicated diarrhea" requiring hospitalization: 1

• Fever or signs of sepsis
• Severe dehydration or hemodynamic instability
• Neutropenia or immunocompromised status
• Severe abdominal cramping (often a harbinger of severe disease)
• Diminished performance status

Rehydration Strategy

For mild to moderate dehydration: Administer oral rehydration solution (ORS) with 50-90 mEq/L sodium at 50-100 mL/kg over 2-4 hours, giving small volumes (5-10 mL) every 1-2 minutes via spoon or syringe to prevent vomiting, gradually increasing the amount. 2

For severe dehydration or shock: Initiate immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize. 2 Continue rapid fluid administration until clinical signs of hypovolemia improve, aiming for adequate central venous pressure and urine output >0.5 mL/kg/h. 1

Critical Diagnostic Testing

Send stool studies immediately for: 2, 3

• Bacterial culture (Salmonella, Shigella, Campylobacter, Yersinia)
• Shiga toxin-producing E. coli (STEC) including O157:H7
• Clostridioides difficile toxin
• Fecal leukocytes

Obtain complete blood count and comprehensive metabolic panel to assess for electrolyte abnormalities, anemia, and neutropenia. 1

Antibiotic Decision Algorithm

DO NOT give antibiotics empirically in most cases while awaiting stool culture results. 2, 3

Give empiric antibiotics ONLY if: 2, 3

• Age <3 months with suspected bacterial etiology
• Documented fever with severe illness, abdominal pain, and bacillary dysentery pattern (presumed Shigella)
• Immunocompromised status with severe illness
• Recent international travel with temperature ≥38.5°C or signs of sepsis

Antibiotic selection when indicated: 2, 3

• Adults: Fluoroquinolone or azithromycin based on local susceptibility patterns
• Infants <3 months or neurologic involvement: Third-generation cephalosporin
• Children: Azithromycin based on local susceptibility patterns

Critical Safety Warnings

NEVER give antibiotics if STEC (Shiga toxin-producing E. coli) is suspected or confirmed, as antimicrobial therapy significantly increases the risk of hemolytic uremic syndrome and mortality. 2, 3 This is the most important pitfall to avoid.

NEVER give antiperistaltic agents (loperamide, diphenoxylate) to patients with bloody diarrhea or high fever, as these medications increase the risk of complications including toxic megacolon and prolonged bacterial shedding. 2, 3

Management of Complicated Cases Requiring Hospitalization

For patients with severe dehydration, fever, sepsis, neutropenia, or grade 3-4 diarrhea: 1

• IV fluids for aggressive rehydration
• Octreotide 100-150 μg subcutaneously three times daily or IV (25-50 μg/h) if severely dehydrated, with dose escalation up to 500 μg three times daily until diarrhea is controlled 1
• Empiric fluoroquinolone (if appropriate based on criteria above)
• Broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms if neutropenic enterocolitis suspected (piperacillin-tazobactam or imipenem-cilastatin, or cefepime/ceftazidime plus metronidazole) 1
• Blood transfusions may be necessary as bloody diarrhea can be severe 1

Ongoing Management

Resume age-appropriate diet as soon as rehydrated—early refeeding does not prolong diarrhea and improves outcomes. 2 Avoid lactose-containing products, alcohol, and high-osmolar supplements initially. 1

Reassess hydration status frequently during the first 2-4 hours and continue replacing ongoing losses. 2 Consider noninfectious causes (inflammatory bowel disease, ischemic colitis) if symptoms persist beyond 14 days. 2, 3

Infection Control

Use soap and water for handwashing (not alcohol-based sanitizers) when C. difficile is suspected, as alcohol does not kill spores. 2 Implement contact precautions with gloves and gowns if C. difficile is confirmed. 2