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Treatment of acute diarrhoea
Diarrhoeal diseases are the second leading cause of morbidity and mortality around the globe. The complexity of the disorder probably starts with its definition [ there are atleast 10 types of definition in the literature] . A practical and working definition would be , “ a decrease in consistency[ semi-solid to watery] and an increase in the frequency of bowel movements to more than 3 times per day”.
Intake of excess fruits with high glycemic index[mango , jack fruit,etc], foods highly rich in fibre and milk sweets are common causes of increased bowel movements which are often self-limiting.
In a patient presenting with an acute diarrhoeal disorder our history and clinical examination should consider the following aspects: 1. Pattern of loose stools [ frequency, whether it is watery or admixed with blood / mucus ,volume of stools, whether associated with abdominal cramps or tenesmus] 3. Presence of thirst , fatigue, light headedness and/or postural giddiness [ these complaints indicate significant fluid loss]. Remember that a patient with moderate dehydration may have a moist tongue and a normal blood pressure! Classical teaching only tells us how to identify a severely dehydrated patient and not a patient with less severe dehydration. Give priority to patient symptoms when 4. Recent intake of motel food / water, unhygienic milk products and undercooked meat . History of similar symptoms in individuals who were along with the Diarrheal episodes more than 5 times/ day[even in the absence of fever, abdominal cramps, vomiting ] are mostly due to infective etiology in our country . I wish to clarify that “Travelers Diarrhea” is a term which is not applicable to developing nations [ we should probably call it infective diarrhea] . The Center for Disease Control (CDC) states that if a foreign traveler in[or returned from] a developing country suffers from diarrheal illness presume that it is due to infective etiology and treat with empirical The concept of considering viruses to be the most common cause of infective diarrhea in our country is probably wrong. Antibiotics are prescribed for travelers diarrhea in developed nations based on the fact that patients suffering from this disorder show favorable response [ control of diarrhea] when treated with short course quinolones compared to treatment without antibiotics. This approves the current practice of antibiotic prescription for acute diarrheal disorder by most clinicians in our country. But I would like to further discuss the type of antibiotic used and duration of therapy. When a decision is made on empirical therapy of infective diarrhea we need to know the spectrum of infective organisms and select a drug which probably covers all of them. E.coli, Salmonella, Shigella , Vibrio cholerae and Entamoeba histolytica are common causes of infective diarrhea for which antibiotic therapy may be Ciprofloxacin covers all the above mentioned organisms except the
protozoan ,Entamoeba histolytica for which metronidazole is the drug of choice. To decide on empirical therapy it is preferable to divide patients into (i) watery or mucus diarrhea sufferers
(ii) dysentery sufferers
Patients suffering from watery or mucus diarrhea may be given:
1gram of oral Ciprofloxacin along with oral or parenteral hydration based on the
In addition , the anti-secretory agent Racecadotril (100mg) thrice daily may be given if financial status of the patient permits. If the loose stool stops then no further dose of ciprofloxacin is required but continue hydrating the patient. Advice the patient to encourage curd intake and avoid milk products since lactose intolerance is a common cause of recurrence of loose stools in a patient treated with antibiotics. Alternatively Lactobacillus capsules may be prescribed.
If the stools are not controlled with the initial 1 gram dose of ciprofloxacin then
continue ciprofloxacin at a dose of 500mg twice daily for 2 more days . Add
Metronidazole at a dose of 400 mg thrice daily for 3 days [ the recommended dose of
800 mg thrice daily for 5 days is poorly tolerated by our patients]. Metallic taste , headache, irritability and high coloured [ occasionally cola coloured] urine are common adverse effects of metronidazole[ I advice my patients to chew sugar confectionaries intermittently to counter the metallic taste of metronidazole].
Both ciprofloxacin and metronidazole can produce marked gastric discomfort. Oral
Ranitidine at 150mg twice daily may be routinely added to this combination therapy. It
is preferable to avoid proton pump inhibitors[ omeprazole, pantoprazole,etc] since they increase bowel movements in some individuals. This treatment plan will succeed in 90 percent of cases. If stools persist with this therapy alternative etiologies should be considered [the discussion of which is beyond the scope of this guideline]. I wish to reiterate that secondary lactose intolerance is the most common reason for recurrence of diarrhea . Some clinicians use doxycycline additionally to cover V.cholera . But this is not required since single dose ciprofloxacin is as good as doxycycline for treating
cholera.
Patients suffering from dysentery:
May be started with oral Ciprofloxacin (500mg) twice daily and Metronidazole (400 mg, if possible 800mg) thrice daily for 5 days. The anti-secretory agent Racecadotril is not beneficial in patients with dysentery.
As far as possible avoid anti-motility agents like loperamide in all patients. An exception is a patient with watery diarrhea (without fever or abdominal cramps ) who needs to ambulate for important reasons . But caution the risk if multiple doses are taken. Routine stool examination and culture is not required for patients with acute diarrhea since they are not cost-effective . Hanging drop examination for V.cholera may be done if clinical features are suspicious. Refer patients:
1. Who are suspected to have HIV
2. Who have features of abdominal distension or
persistent abdominal pain
3. Who have persistent diarrhea beyond five days
Dr.M.Emmanuel Bhaskar
Specialist in Internal Medicine
Chennai , India

Source: http://dmri.in/clinicalpracticeguideline_diarrhea.pdf