Patients with diarrhea may focus on the need (bra nonprescription medication to stop the frequent bowel movements. The practitioner should remind them that most episodes of acute diarrhea stop after 48 hours, and that preventing dehydration is the most important component of treating the problem. Counseling on the two-step treatment of dehydration and the need for dietary management should follow. For infants and children, educating parents and caregivers on the appropriate use of an OKS (including appropriate volumes to administer, rates of administration, and use in vomiting) and of dietary management is very important in preventive care. For patient safety reasons, premixed solutions are preferred. Importantly, if dry powder oral rehydration solution is selected, the practitioner should give parents (or caregivers) explicit directions for mixing and verify that they understand the directions. For families with infants, the Centers for Disease Control and Prevention recommends a home supply of oral rehydration solution. because early administration of an oral rehydration solution at home is vital Read more [...]

To evaluate a patient with diarrhea, the practitioner differentiates symptoms and makes clinical judgments. This triage function is based on the patient's responses to questions designed to help determine the cause of the specific signs and symptoms, their characteristics, and their severity. The practitioner should therefore ask the patient about vomiting, high and/or prolonged fever, and other symptoms to determine the patient's susceptibility to complications. Persistent diarrhea, chronic diarrhea, or presence of high fever (greater than 102.2°F |39°C]), protracted vomiting, abdominal pain in patients older than 50 years, or blood or mucus in the stool precludes self-treatment and requires immediate medical referral. If none of these significant findings is present, the degree of dehydration is the next important assessment; the practitioner should ask about the nature and amount of fluid intake. Severity of dehydration can be accurately assessed by evaluating changes in body weight. For example, in children, mild dehydration is associated with a 3% to 5% loss of body weight, whereas severe Read more [...]

Probiotics, including several Lactobadllus species. Bifuloboctcria hulls, and Saccharomyces boulardii, are commonly used to manage or prevent acute, uncomplicated diarrhea. As normal inhabitants of the human Cl tract, these lactic acid-producing bacteria help maintain normal CI flora and reduce colonization by pathogenic bacteria. The exact mechanisms underlying the effects of these bacteria are not clear: Lactobadllus is suggested to enhance immune responses, produce antimicrobial substances, and compete with bacteria for intestinal mucosal binding sites. Evidence demonstrates that probiotic therapy, especially with Lactobadllus rhamnosus GG (but also Lactobacillus casei, Lactobadllus addophilus, and Lactobadllus rented), prevents or shortens the course of mild viral diarrhea in infants and young children rhamnosus GG therapy can shorten duration of acute infectious diarrhea in children by an average of 0.7 days and reduce diarrhea frequency on day 2 of treatment by an average of 1.6 stools.Therapy with L. rhamnosus GG, L. addophilus, and .S. boulardii may also offer clinical benefit in antibiotic-associated Read more [...]

Although most acute nonspecific diarrhea in the United States is self-limiting, nonprescription antidiarrheal products may provide relief and will usually do no harm when used according to label instructions. Table Recommended Dosages of Antidiarrheal Agents for Acute Diarrhea lists dosage and administration guidelines for these agents. Scientific evidence that pharmacologic agents, with the exception of loperamide and Bismuth subsalicylate. reduce stool frequency or duration of disease in adults is lacking. Likewise, antidiarrheal drugs have not been shown to significantly improve clinical outcomes of acute nonspecific diarrhea in infants and children. Importantly, a change in stool consistency toward more formed stools does not necessarily indicate that antidiarrheal therapy has successfully treated the underlying problem. Comparison of Electrolyte and Dextrose Concentrations of Household Fluids Clear Liquids Sodium (mEq/L) Potassium (mEq/L) Bicarbonate (mEq/L) Dextrose (g/L) Osmolarity (mOsm/L) Cola 2 0.1 13 50-150 dextrose and fructose 550 Ginger ale 3 1 4 50-150 Read more [...]

Treatment Goals The goals of self-treatment are to (1) prevent or correct fluid and electrolyte loss and acid base disturbance. (2) relieve symptoms, (3) identify and treat the cause, and (4) prevent acute morbidity and mortality. General Treatment Approach Infectious diarrhea is often self-limiting. Symptomatic relief and correction of fluid and electrolyte loss are generally adequate for mild-to-moderate, uncomplicated diarrhea. Initial self-management for adults and children should focus on fluid and electrolyte replacement by administering commercially available oral solutions (e.g.. Pedialyte) in adequate doses. Simultaneous implementation of oral rehydration and specific dietary measures is appropriate for treating mild-to-moderate diarrheal illness. Symptomatic relief can also be achieved by using nonprescription antidiarrheal drugs, such as loperamide in carefully selected patients. Normal function of the alimentary tract is often restored in 24 to 72 hours without additional treatment. Severe diarrhea constitutes a medical emergency, especially in young children, and requires immediate Read more [...]

The most common signs and symptoms of acute infectious diarrhea! illnesses are shown in Table Common Infectious Diarrheas and Their Treatment. Variability in the causes of diarrhea makes identification of the pathophysiologic mechanisms difficult. The etiology, and subsequently the pathophysiology, can be determined by a thorough medical history in most cases. However, a complete medical assessment, including clinical laboratory evaluation, may be required to identify the cause in a subset of patients with severe or persistent diarrhea. Diarrhea can be classified as osmotic, secretory, inflammatory, or motor, depending on the underlying pathophysiologic mechanisms that disrupt normal intestinal function. The common mechanisms of acute diarrhea are osmotic and secretory, whereas motor and exudative mechanisms commonly underlie chronic diarrheal illnesses. Table Clinical Classification of Diarrhea correlates the clinical groups and mechanism with their most common causes. Bacterial and viral enterotoxins play a role in the pathophysiology ol secretory diarrheas. Enterotoxins elaborated by E. Read more [...]

The specific causes of acute diarrhea differ between developing and developed countries. In the United States, viral and food-borne diarrhea] illnesses are common; however, in the majority of cases, the causes cannot be determined. In developing countries, poor sanitation and poor hygiene lead to infectious diarrhea caused by parasites, bacteria, and viruses. Bacterial causes are as common as viral infections in these countries. Table Common Infectious Diarrheas and Their Treatment highlights some of the common viral, bacterial, and protozoal diarrheas and their treatment. Epidemiologic factors that increase the risk for particular infectious diarrhea] diseases or their spread include attendance or employment at day care centers, occupation as a food handler or caregiver, congregate living conditions (e.g., nursing homes, prisons, and multifamily dwellings), consumption of unsafe foods (e.g., raw meat, eggs, and shellfish), and presence of medical conditions, such as acquired immunodeficiency syndrome, that predispose to infectious diarrhea. Acute diarrhea may also be caused by poisoning, Read more [...]

Secretory diarrhea (SD) results from the active secretion of electrolytes (sodium ion [Na+], potassium ion [K+], chlorine ion [Cl~], and bicarbonate ion [HC03-]), the failure to absorb these electrolytes, or both processes. A secretory component can occur in diarrheal diseases owing to enteric infections, inflammatory conditions, or ectopic hormone or neurotransmitter release. The primary clinical features of SD include daily stool weights exceeding 200 g/d, watery stools, and a stool osmolarity accounted for almost entirely by twice the stool concentration of Na+ plus K+. This latter point is usually established by measuring stool K+ and Na+ concentrations and calculating the osmotic gap by subtracting twice the concentrations of stool sodium and potassium from 290 mOsm/kg, the osmolality of stool within the body. In SD, the osmotic gap is characteristically < 100 mOsm/kg and is usually < 50 mOsm/kg. In most cases, SD persists despite fasting for 1 to 2 days, although it frequently decreases in amount. In this chapter, treatment of SD is briefly reviewed. Not discussed are diarrheal diseases Read more [...]

A number of different agents are used to control acute and long-term chronic diarrhea. As pointed out above, definitive treatment requires a correct diagnosis. In this section, the general use of pharmacologic agents in SD is dealt with, and in the following section, specific comments on some of the specific diseases are made. Opiates and synthetic long-acting somatostatin analogues (octreotide, lanreotide) are the most commonly used. Other agents that may be helpful are a2-adrenergic agonists, corticosteroids, absorbent agents, prostaglandin synthetase inhibitors, calcium channel blockers, and phenothiazines. The use of each is briefly discussed below. Opiates Opiates are usually the first-line therapy for most mild to moderate diarrheas. Commonly used preparations include paregoric, tincture of opium, codeine, Lomotil (diphenoxylate with atropine), Imodium (loperamide), and difenoxin with atropine. These agents inhibit transit throughout the gastrointestinal (gastrointestinal) tract; therefore, they increase the contact time between intestinal luminal contents and the mucosa, increasing absorption. Read more [...]

Clonidine These agents slow gastrointestinal transit as well as promote absorption. Clonidine is the frequently used drug in this class and has been recommended particularly for diabetic diarrhea based on a small number of reports. It also has been used to treat diarrhea associated with short bowel syndrome, usually in combination with opiates. Clonidine is usually started at 0.1 mg/d and increased slowly to 0.1 to 0.3 mg 3 times a day. A major limitation to the use of clonidine is its anti-hypertensive effect mediated centrally, resulting in postural hypotension. Clonidine should be reserved for patients with SDs that are refractory to opiates. When clonidine is discontinued, the dose should be tapered slowly over 3 to 5 days to avoid rebound symptoms (hypertension, nausea, vomiting, headache). This agent is discussed in the chapter on diabetic diarrhea. Glucocorticoids Glucocorticoids stimulate absorption of water and electrolytes and have been used in refractory patients with VIPomas. The recommended dose is 60 mg of prednisone per day. If it is effective, the dosage can be decreased to the Read more [...]