What is the management of diarrhea in a patient?

Management of Diarrhoea

Oral rehydration solution (ORS) is the cornerstone of diarrhoea management for all patients with mild to moderate dehydration, with reduced osmolarity ORS (50-90 mEq/L sodium) being first-line therapy regardless of age or cause. 1

Initial Assessment

Assess dehydration severity using clinical signs, as this determines all subsequent management:

• Mild dehydration (3-5% deficit): Increased thirst, slightly dry mucous membranes 1
• Moderate dehydration (6-9% deficit): Loss of skin turgor, skin tenting when pinched, dry mucous membranes 1
• Severe dehydration (≥10% deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool and poorly perfused extremities, decreased capillary refill, rapid deep breathing indicating acidosis 1

Capillary refill time is the most reliable predictor of dehydration, more so than sunken fontanelle or absent tears. 1

Obtain body weight to establish baseline and calculate fluid deficit. 1

Rehydration Protocol by Severity

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 1
• Use small volumes initially (one teaspoon) and gradually increase as tolerated 1

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 1
• If oral intake fails, consider nasogastric administration of ORS in patients who cannot tolerate oral intake or are too weak to drink 1

Severe Dehydration (≥10% deficit)

This is a medical emergency requiring immediate intravenous therapy. 1

• Administer 20 mL/kg boluses of lactated Ringer's or normal saline IV immediately until pulse, perfusion, and mental status normalize 1
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 1
• Once consciousness returns and patient can tolerate oral intake, transition to ORS for remaining deficit 1

Ongoing Loss Replacement

Replace ongoing losses continuously throughout treatment:

• 10 mL/kg of ORS for each watery stool 1
• 2 mL/kg of ORS for each vomiting episode 1
• Continue ORS replacement until diarrhoea and vomiting resolve 1

Nutritional Management

Resume age-appropriate normal diet immediately after rehydration or during the rehydration process—do not delay feeding. 1

• Continue breastfeeding throughout the entire diarrhoeal episode without interruption 1
• Early feeding promotes intestinal cell renewal and prevents nutritional deterioration 2
• Avoid "bowel rest"—there is no justification for withholding food 3

Antimicrobial Therapy

In most patients with acute watery diarrhoea without recent international travel, empiric antimicrobial therapy is NOT recommended. 1

Exceptions where empiric treatment may be considered:

• Immunocompromised patients 1
• Young infants who are ill-appearing 1
• Patients with clinical features of sepsis 1

Antimicrobial treatment should be modified or discontinued when a clinically plausible organism is identified. 1

Avoid empiric treatment in persistent watery diarrhoea lasting ≥14 days. 1

Adjunctive Pharmacotherapy

Antimotility Agents (Loperamide)

Loperamide is absolutely contraindicated in all children <18 years of age due to risks of respiratory depression and serious cardiac adverse reactions. 1, 4

In adults:

• Loperamide may be given to immunocompetent adults with acute watery diarrhoea ONLY after adequate rehydration 1
• Avoid loperamide in any patient with fever, bloody stools, or suspected inflammatory diarrhoea due to risk of toxic megacolon 1
• Avoid doses higher than recommended due to risk of cardiac arrhythmias, QT prolongation, and sudden death 4
• Contraindicated in patients taking CYP3A4 inhibitors, CYP2C8 inhibitors, or P-glycoprotein inhibitors due to increased systemic exposure 4

Antiemetics

• Ondansetron may be given to children >4 years and adolescents with vomiting to facilitate tolerance of ORS 1
• Consider ondansetron in adults with persistent vomiting preventing adequate oral intake 2

Probiotics

• Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent adults and children with infectious or antimicrobial-associated diarrhoea 1

Zinc Supplementation

• Oral zinc supplementation reduces duration of diarrhoea in children 6 months to 5 years of age in countries with high prevalence of zinc deficiency or signs of malnutrition 1

Monitoring and Reassessment

• Reassess hydration status after 2-4 hours of rehydration therapy 1
• If rehydrated, transition to maintenance phase with ongoing loss replacement 1
• If still dehydrated, reestimate fluid deficit and restart rehydration 1

Criteria for successful rehydration include: normal pulse and perfusion, improved mental status, moist mucous membranes, adequate urine output, and ability to tolerate oral fluids 2

Critical Pitfalls to Avoid

• Do not use cola drinks, soft drinks, or juices for rehydration—they contain inadequate sodium and excessive osmolality that worsens diarrhoea 3
• Do not routinely order stool cultures or laboratory tests for mild-moderate diarrhoea without specific indications (bloody stool, persistent fever, severe dehydration, immunosuppression, suspected outbreak) 1, 5
• Do not give antimotility agents to children or to any patient with fever/bloody stools 1, 4
• Do not prescribe empiric antibiotics for uncomplicated watery diarrhoea—this promotes resistance without benefit 1, 6
• Do not delay rehydration while awaiting diagnostic results 6

Indications for Hospitalization

• Severe dehydration (≥10% deficit) or shock 1
• Failure of ORS therapy despite proper technique 2
• Altered mental status 1
• Severe acidosis 1
• Inability to maintain hydration with ongoing losses 2
• Stool output exceeding 10 mL/kg/hour 3