Treatment of Acute Diarrhea in ADULTS
Acute diarrhea in most cases stops on its own in few days. If there is no fever or other debilitating symptom, you can continue with regular activities but avoid any excessive strain.
An adult with a mild diarrhea can drink plain water or tea, a cup (250 ml) at the time, and repeatedly through the day to maintain more than 200 ml of translucent or bright yellow morning urine and more than 500 ml of daily (overall) urine. In severe diarrhea, drinks with sugar and salt, like Gatorade or Rehydralyte, are recommended since they provide faster rehydration. Combination of diluted fruit juice (1:1) with salt crackers or salt broth is also appropriate. Drinks to avoid: alcohol, caffeinated and carbonated drinks and, in prolonged diarrhea, milk; they may all aggravate diarrhea.
Diarrhea Diet (Foods to Stop Diarrhea)
There is no reason for rough changes in a diet during acute diarrhea. It is good to avoid fat-rich, sugar-rich, spicy food, and eat what you feel comfortable with. The old BRAT (Bananas, Rice, Apple sauce, Toast) is fine, but there is no need to stick just with this.
Treatment of Acute Diarrhea in CHILDREN
A small child with an acute infectious diarrhea should stay at home to prevent the spread of an infection to others, and rest in bed to prevent complications, like viral pneumonia or myocarditis. An infant with diarrhea should be taken to the doctor, so parents can get exact instructions about required fluid replacement and eventual drugs.
Fluid Replacement in Small Children
Infants with diarrhea should continue with breastfeeding. Additionally, all infants and small children under age of 3 should be treated with oral rehydration solutions (ORS), like Infalyte, Pedialyte, Rehydralyte, which contain sodium, potassium, and sugar, which accelerate water absorption. Labels should be checked for appropriate dosage. Drinking is a must, even if a child vomits. If ORS is not available, a sport drink like Gatorade, diluted with water (1:1), can be used. Older children may drink diluted fruit juices or sport drinks, water, or tea with little sugar. Milk or milk formula is also fine. The sign of the adequate hydration is urinating at least once in 8 hours for a small child, and once in 12 hours for an older child. If a child refuses any fluid, or excretes only a small amount of urine, urgent intravenous re-hydration in hospital will be needed. Drinks to avoid: plain water, undiluted fruit juices.
Diarrhea Diet in Children
Breastfeeding or formula in infants should continue despite diarrhea or vomiting. Children on solid food should continue with their regular diet, only the most fatty, sugary, or spicy foods should be avoided.
When and Why to Visit a Doctor?
- In profuse or prolonged diarrhea, lasting for more than 3 days, lost fluid has to be replaced and the cause has to be found.
- Red or black diarrhea may be from bleeding. The origin of bleeding has to be found and treated to prevent anemia.
- Body temperature over 39°C (102°F) is suspicious for severe infection and a specific antibiotic might be needed.
- Strong abdominal pain may be due to intestinal obstruction or perforation; urgent surgery may be needed.
- Small amount of dark colored morning urine is a sign of severe dehydration – intravenous infusion of fluid with electrolytes will probably be needed.
Medications for Diarrhea
Antibiotics are prescribed only in heavy or prolonged bacterial or parasitic diarrhea, but not in viral diarrhea. Norfloxacin or ciprofloxacin may be taken immediately after the sample of stool was taken; when results are known, more targeted antibiotic may be used. Metronidazole is used in parasitic and Clostridium difficile infection. Tinidazole is effective in giardiasis and amebiasis. In exceptional cases, when someone “can’t afford” to get diarrhea, for example when travelling, an antibiotic can be taken in advance as per a doctor prescription (it prevents diarrhea in over 90% cases). Some antibiotics may cause serious nausea. Rarely, an allergic reaction with breathing difficulty or edema may occur, which requires immediate cessation of antibiotics; erythromycin may be used in this case.
NOTE: Atropine/Diphenoxylate (Lomotil) slows down the gut motility. It has many side effects (blurred vision, constipation, difficulty sleeping, dizziness, drowsiness, dry mouth, headache, nausea, nervousness, toxic megacolon) and is not recommended for use.
Over The Counter (OTC) Drugs
Loperamide (Imodium) is a slight narcotic, which slows down the gut motility. It can postpone the bowel movement, but it does not treat diarrhea itself. It should be not used in bloody diarrhea, in children, and pregnant women.
Bismuth sub-salicylate (BSS, Pepto-Bismol) has a slight antimicrobial action, it can bind some bacterial toxins, and reduce water secretion from the intestinal wall. It should be not taken by pregnant women and children. Pepto-Bismol may color the tongue and stool black. Side effects of Pepto-Bismol are tinnitus, constipation, nausea, bleeding.
Probiotics (yogurts or supplements like Culturelle) contain live bacteria (Lactobacillus acidophilus, Bifidobacterium bifidus) or yeasts (Saccharomyces boulardii), which may help to re-establish impaired gut flora after antibiotic treatment, and shorten the course of diarrhea. Until now, studies have shown low benefit from probiotics, but a strong placebo effect (1).
Prebiotics are carbohydrates (lactulose, inulin, oligofructose) which are not absorbed in intestine, but they promote the growth of beneficial intestinal bacteria. Natural sources of prebiotics are chicory root, Jerusalem artichokes, leeks, onions, garlic, bananas, tomatoes, asparagus, cucumber, chickpeas and sunflower seeds, and honey. A common side effect of prebiotics is bloating.
Clinical trials of probiotic treatment for IBD have yielded no convincing results (2). High-dose probiotic and prebiotic co-therapy can be safely and effectively used to treat active Crohn’s disease (3). VSL3 was proved to be useful in maintaining remission of inflammatory colitis (4).
Treatment of CHRONIC Diarrhea
Finding a Cause
In chronic diarrhea, its cause should be found by a stool test, diet tests, blood work, abdominal ultrasound, endoscopy or other investiagtion.
Gluten-free diet will lead to improvement of diarrhea in celiac disease, lactose-free diet in lactose intolerance, low fat diet in gallbladder, liver and pancreatic disease.
Antibiotics are needed in prolonged bacterial or parasitic diarrhea, or in small intestinal bacterial overgrowth.
Iron, zinc, calcium, magnesium, and vitamins (mostly A, B12, D, folate) are needed in chronic diarrhea, when low levels are detected in the blood. Taking these supplements without obvious reason is useless.
Pancreatic enzymes (lipase, protease, amylase) reduce pain and diarrhea caused by chronic pancreatic disease (5,6):
- Pancrelipase (Pancrease, Lipram), porcine source, by prescription;
- Pancreatin (Pancrezyme, Hi-Vegi-Lip), bovine, porcine or vegetable source, without prescription.
Lactase (Lactaid, SureLac) may be used in lactose intolerance (not in children under 4 years of age), it is available only by prescription.
Diverticula, which are constantly inflamed, and cause long term diarrhea, may be treated by surgery; a part of the distal colon will usually need to be removed.
Other indications for surgery in diarrhea:
- Crohn’s disease or ulcerative colitis (IBD), which does not respond to regular treatment;
- Megacolon in Hirschsprung’s disease;
- Toxic megacolon;
- Familial adenomatous polyposis (rare).