gastrointestinal disorders
Diarrhea
Treatment of Diarrhea
Fluid and electrolytes for dehydration Possibly antidiarrheals for nonbloody diarrhea in patients without systemic toxicity 15 mEq/L (< 15 mmol/L). An oral glucose-electrolyte solution can be given if diarrhea is not severe and nausea and vomiting are minimal ( see Solutions ). Oral and parenteral fluids are sometimes given simultaneously when water and electrolytes must be replaced in massive amounts (eg, in cholera). Diarrhea is a symptom. When possible, the underlying disorder should be treated, but symptomatic treatment is often necessary. Diarrhea may be decreased by oralloperamide2 to 4 mg 3 or 4 times a day (preferably given 30 minutes before meals), diphenoxylate 2.5 to 5 mg (tablets or liquid) 3 or 4 times a day, oralcodeinephosphate 15 to 30 mg 2 or 3 times a day, or paregoric (camphorated opium tincture) oral liquid 5 to 10 mL once a day to 4 times a day. Because antidiarrheals may exacerbateC. difficilecolitis or increase the likelihood of hemolytic-uremic syndrome inShigatoxin–producingEscherichia coliinfection, they should not be used in bloody diarrhea of unknown cause. Their use should be restricted to patients with watery diarrhea and no signs of systemic toxicity. However, there is little evidence to justify previous concerns about prolonging excretion of possible bacterial pathogens with antidiarrheals. Psylliumormethylcellulosecompounds provide bulk. Although usually prescribed for constipation, bulking agents given in small doses decrease the fluidity of liquid stools. Kaolin, pectin, and activated attapulgite adsorb fluid. Osmotically active dietary substances (see table) and stimulatory drugs should be avoided. Eluxadoline, which has mu-opioid receptor agonist and delta-opioid receptor antagonist effects, can be used to treat diarrhea-predominant IBS. The dose is 100 mg orally 2 times a day (75 mg 2 times a day if the 100-mg dose cannot be tolerated). It should not be used in patients who have had a cholecystectomy or a history of pancreatitis. Patients with diarrhea-predominant IBS may also be given the antibioticrifaximin550 mg orally 3 times a day for 14 days. 