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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]
2. Presence of fever
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
assessing hydration status .
4. Recent intake of motel food / water, unhygienic milk products and undercooked
meat . History of similar symptoms in individuals who were along with the
patient.
5. Recent antibiotic use.
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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
antibiotics.

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
helpful.

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
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Patients suffering from watery or mucus diarrhea may be given:
1gram of oral Ciprofloxacin along with oral or parenteral hydration based on the
clinical assessment.
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.
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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
with treatment

Dr.M.Emmanuel Bhaskar
Specialist in Internal Medicine
Chennai , India