Evaluation and Management of Constant Watery Burning Diarrhea
Immediately assess hydration status and begin oral rehydration solution (ORS) as first-line therapy, avoiding empiric antibiotics unless the patient has bloody stools, high fever, severe illness, or is immunocompromised. 1
Immediate Assessment Priorities
Hydration Status Evaluation:
- Check for severe dehydration signs: prolonged skin tenting, cool poorly perfused extremities, decreased capillary refill, rapid deep breathing, and altered consciousness 2
- Mild dehydration = 3-5% fluid deficit; moderate = 6-9%; severe = ≥10% 3
- Weigh the patient to establish baseline for monitoring response 3
Stool Characteristics:
- Determine if watery (non-inflammatory) versus bloody/mucoid (inflammatory) 2, 4
- The "burning" sensation typically indicates watery diarrhea with perianal irritation from frequent passage 4
- Bloody or mucoid stools require different management with empiric antibiotics 2
Rehydration Protocol
For Mild to Moderate Dehydration (Most Cases):
- Administer reduced osmolarity ORS containing 50-90 mEq/L sodium 1, 3
- Give 50 mL/kg over 2-4 hours for mild dehydration 2
- Give 100 mL/kg over 2-4 hours for moderate dehydration 1, 3
- Replace ongoing losses with 10 mL/kg ORS for each additional watery stool 1, 3
For Severe Dehydration:
- Switch immediately to intravenous isotonic fluids (lactated Ringer's or normal saline) 1
- Give 20 mL/kg IV boluses if shock, altered mental status, or ≥10% fluid deficit present 2, 3
- Continue IV rehydration until pulse, perfusion, and mental status normalize 5
Antibiotic Decision Algorithm
DO NOT give antibiotics if: 1
- Watery diarrhea without fever or blood (most common scenario)
- Duration <5 days in immunocompetent adults
- No recent international travel
- No signs of sepsis
CONSIDER antibiotics only if: 1, 3
- Bloody or mucoid stools (dysentery) present 2
- High fever with diarrhea 2
- Watery diarrhea persisting >5 days 3
- Patient is immunocompromised 1
- Clinical features of sepsis present 1
- Young infant who appears ill 1
The Infectious Diseases Society of America explicitly recommends avoiding empiric antimicrobial therapy for acute watery diarrhea without recent international travel, as antibiotics promote resistance without benefit and do not help viral infections (which cause most cases). 1
Symptomatic Management
Antimotility Agents:
- Loperamide may be used in immunocompetent adults with watery diarrhea without fever or blood 1
- Never give loperamide to children <18 years of age 5, 1
- Avoid loperamide if any suspicion of inflammatory diarrhea, fever, or bloody stools (risk of toxic megacolon) 5
Antiemetics:
- Ondansetron may be given to children >4 years and adults with vomiting to facilitate ORS tolerance 5, 1
Probiotics:
- May be offered to reduce symptom severity and duration in immunocompetent patients (weak recommendation) 5, 1
Nutritional Management
Feeding Protocol:
- Continue breastfeeding throughout illness in infants 5, 1
- Resume age-appropriate usual diet immediately after rehydration is completed 5, 1
- Do not restrict diet during or after rehydration—early feeding improves outcomes 1, 3
Diagnostic Testing Indications
Most patients do NOT need stool studies. 4, 6 Order diagnostic tests only if: 4, 6
- Bloody or mucoid stools present
- Persistent fever
- Severe dehydration or illness
- Immunosuppression
- Suspected nosocomial infection or outbreak
- Symptoms persisting >5-7 days
If testing indicated, molecular studies are preferred over traditional stool cultures. 4
Critical Pitfalls to Avoid
- Do not delay rehydration while awaiting diagnostic results 2
- Do not prescribe empiric antibiotics for uncomplicated watery diarrhea—this promotes resistance without benefit 1, 3
- Never use antibiotics if STEC (Shiga toxin-producing E. coli) is suspected, as this worsens outcomes and precipitates hemolytic uremic syndrome 1
- Do not give antimotility agents to children or to any patient with fever, blood in stool, or suspected inflammatory diarrhea 5, 1