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To be used:
To be used:
 for those with acute diarrhea (STRICTLY DEFINED as ≥3 loose stools in 24 hours) with or without vomiting.Â
NOT TO BE USED:
NOT TO BE USED:
for adult patients who areÂ
terminally ill,Â
HIV positive,Â
have chronic diarrhea (> 2 weeks),Â
bedbound,
have ONLY vomiting.
FOCUSED HISTORY TAKING
FOCUSED HISTORY TAKING
Symptom Prioritization
Symptom Prioritization
Which symptom is predominant? (e.g., pain or vomiting > diarrhea → look beyond gastroenteritis)
What was the first symptom? (Pain before vomiting → consider appendicitis)
Diarrhea Assessment
Diarrhea Assessment
Stool count and consistency (≤2 or solid = not diarrhea)
Presence of blood (think bacteria, parasites, IBD, or C. diff)
Fever (suggests bacterial, parasitic, or inflammatory cause)
Vomiting Assessment
Vomiting Assessment
Number of episodes (frequent → may need IV hydration)
Pain Features
Pain Features
Location and migration (migratory or localized → evaluate for appendicitis)
Red Flags & Supporting Features
Red Flags & Supporting Features
Similar past episodes → favors acute gastroenteritis
Thirst → helps assess dehydration
Antibiotic use in the last 3 months → suspect C. diff
Sick household contacts → suggests gastroenteritis
Pain relief after vomiting/diarrhea → reassures
Outside food history → common in gastroenteritis (but not required)
At-risk populations: elderly, pregnant, immunosuppressed
Social History & Risk Factors
Social History & Risk Factors
Opioid use → consider withdrawal
High-risk sexual behavior → consider proctitis/STIs
Food or drug allergies
Medication history (immunosuppressants, lithium, colchicine, etc.)
EXAMINATION
EXAMINATION
General Goals
General Goals
Assess hydration
Look for signs of alternative diagnoses
Abdominal Exam
Abdominal Exam
Epigastric pain → consider peptic ulcer, pancreatitis, or vomiting-related gastritis
RLQ pain → appendicitis
LLQ pain → diverticulitis
Stool Inspection
Stool Inspection
Fresh blood → bacteria, amoeba, IBD
Mucoid and foul → Giardia
Rice-water → Cholera
Melena → upper GI bleed
Dehydration Assessment
Dehydration Assessment
Severe Dehydration (≥2 of):
Severe Dehydration (≥2 of):
Lethargy or unconsciousness
Sunken eyes (confirmed by caregiver)
Inability to drink or poor drinking
Skin pinch returns very slowly (>2 seconds)
Moderate Dehydration (≥2 of):
Moderate Dehydration (≥2 of):
Sunken eyes
Drinks eagerly/thirsty
Skin pinch returns slowly
LABORATORY EVALUATION
LABORATORY EVALUATION
When to Send Labs:
When to Send Labs:
Age > 65
Immunocompromised
Fever
Moderate to severe dehydration
Blood in stool
Suspected sepsis
Consider Labs If:
Consider Labs If:
On diuretics
Orthostatic hypotension or dizziness
Dark urine
Poor oral intake
Dry axilla
Which Labs:
Which Labs:
Always: CBC, UCE, RBS
As Needed: Lactate, Blood cultures, Stool DR/culture, C. diff assay
Note: Low platelets may suggest hemolytic uremic syndrome
If Diarrhea Persists >3 Days:
If Diarrhea Persists >3 Days:
Or with fever, bloody/mucoid stool, or severe cramps → send stool DR & culture
Treatment
Treatment
IV vs Oral Rehydration
IV vs Oral Rehydration
IV Fluids if:
Severe dehydration
Shock
Failed oral trial
Oral Fluids otherwise
Options: ORS, coconut water (good), diluted sports drinks or apple juice (less ideal), homemade ORS (last resort)
IV Fluid Protocol (if needed):
IV Fluid Protocol (if needed):
30 ml/kg bolus over 30 mins (repeat if in shock)
Then 70 ml/kg over 2.5 hours
ORS: 5 ml/kg/hr as tolerated
Use Ringer’s lactate if available
Monitor for fluid overload
Nausea Management
Nausea Management
First line: Ondansetron
Adjuncts:
Alcohol swab vapors (2.5 cm from nostrils, every 2 mins)
Ginger (250 mg tablet, QID)
Antimotility Agents (LOPERAMIDE)
Antimotility Agents (LOPERAMIDE)
Loading: 4 mg → then 2 mg after each stool
Max: 16 mg/day (hospital), 8 mg/day (home)
Avoid if:
Age <3
Bloody diarrhea, fever, moderate-severe disease
OK with antibiotics in adults
Probiotics
Probiotics
Can be used
Avoid in immunocompromised
Antibiotics
Antibiotics
Use only if:
Moderate-severe disease
Fever
Blood in stool
Diarrhea >72 hrs
Recent antibiotics
Suspected cholera:
Doxycycline 300 mg PO x1
Azithromycin 1 g PO x1 (if pregnant)
C. diff suspected:
Vancomycin 125 mg QID x10 days
OR Metronidazole 500 mg TID x10 days
If moderate-severe + elderly (age >65):
Azithromycin 500 mg OD x3 days
Add metronidazole if severe (500 mg TID x10 days)
Giardia (mucoid, smelly, floating stool):
Metronidazole 500 mg BID x7 days
Disposition & Discharge
Disposition & Discharge
When to Discharge
When to Discharge
Euvolemic
Tolerating oral intake
Normal vitals
Moist mucous membranes
Symptom improvement
Discharge Instructions
Discharge Instructions
Prescribe:
Paracetamol (+/- Drotaverine)
ORS instructions
Diet guidance
Smecta (Diosmectite)
Return precautions
Work leave advice
Hygiene instructions
Anal soreness: Apply zinc oxide 15–20% ointment or petroleum jelly
Diet Advice
Diet Advice
No food is strictly prohibited
Encourage hygienically prepared, preferred foods
Hydration is key
Medications to Avoid
Medications to Avoid
Proton pump inhibitors (PPIs)
H2 blockers
Preventing Spread
Preventing Spread
Strict handwashing, especially after toilet use and before contact with others
Reference
Reference
WHO Integrated Management of Adult and Adolescent Illnesses
EB Medicine: Diarrhea in Adults
AUTHOR: Faysal Subhani
EDITED BY: Ayesha Saeed
Page updated
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