Initial treatment of any patient begins with the ABCs. Patients with diarrhea are no different. Diarrhea of any type can cause circulatory collapse. Rehydration of severely dehydrated patients should begin immediately after large-bore intravenous access is achieved. Thereafter, treatment is dictated by the differential diagnosis. The emergency medicine approach to a patient with diarrhea, therefore, hinges on treating or excluding the life-threatening causes of diarrhea. Because infectious diarrhea is the most common cause of acute diarrhea, after the differential diagnosis is considered, physicians most commonly are left considering that diagnosis.

NONINFECTIOUS DIARRHEA Almost all true diarrheal emergencies (e.g., gastrointestinal bleed, adrenal insufficiency, thyroid storm, toxicologic exposures, acute radiation syndrome, and mesenteric ischemia, all discussed elsewhere in this textbook) are of noninfectious origin. The emergency physician must be ever mindful of them because patients with those conditions require intensive treatment and hospitalization. The less emergent, noninfectious causes of diarrhea are listed in Ta.ble..„l 79-1. They, too, are covered elsewhere in this textbook.

INFECTIOUS DIARRHEA Viruses cause the vast majority of infectious diarrheas, followed by bacterial and parasitic organisms. Treatment of infectious diarrhea involves antibiotic therapy, antimotility agents, restoration of fluid balance, and avoidance of agents that worsen diarrhea. For the past 30 years, two pervasive myths involving the use of antibiotics and antimotility agents in the treatment of infectious diarrhea have dictated the management of large numbers of patients with diarrhea. These myths are discussed in detail below, and a discussion of the modern medical approach to infectious diarrhea follows.

Antibiotics MYTH For years, physicians avoided antibiotic use in the treatment of infectious diarrhea because of a fear of prolonging the Salmonella carrier state. This fear arose from an article published in 1969 in which the duration of Salmonellaexcretion following a salmonellosis epidemic was studied.14 The study compared the length of excretion in patients who received antibiotics (ampicillin or chloramphenicol) with that of patients who were not treated and found that Salmonellaexcretion was longer in the cohort that received antibiotics. The authors concluded that, because of a prolonged carrier state, antibiotics should not be given to patients suspected of having a diarrheal illness due to Salmonella.

MODERN MEDICINE For adults with domestically acquired diarrhea in whom the origin is felt to be infectious, antibiotics [ciprofloxacin 500 mg by mouth (PO) bid for 5 days] shorten the duration of illness by approximately 24 h. Regardless of the causative agent, all patients—even those who had a negative Wright's stain, negative stool culture, and a low diarrheal illness score, suggesting less clinically significant disease and/or a viral cause—improved on ciprofloxacin. 15 Even though most infectious diarrheas are self-limited, because of the inconveniencing and occasionally life-threatening nature of the disease, we recommend ciprofloxacin treatment for all patients believed to have an infectious diarrhea who do not have a contraindication to antimicrobial treatment (e.g., pediatric age group, allergy, pregnancy, or drug interaction). Single-dose and 3-day ciprofloxacin regimens have been proposed but deserve further investigation. Trimethoprim-sulfamethoxazole (Bactrim DS on tablet PO bid for 5 days) also shortens the duration of infectious diarrhea in adults but was proven to be inferior to a 5-day course of ciprofloxacin in the above-mentioned study.

Antimotility Agents MYTH Since the early 1960s, the use of antimotility agents in the treatment of diarrhea has been denounced by most of the medical community. This dictum emerged out of a 1963 study published by Formal and colleagues.16 In this study, guinea pigs were starved and poisoned to make them susceptible to Shigellainfection (an organism to which guinea pigs are not usually susceptible). They were then innoculated with Shigella, and a subset of the study was then given opium. The authors discovered an association between opium administration and fatal Shigella infection. From these data, the authors concluded that a major defense mechanism of the guinea pig is its peristaltic activity and that antimotility agents (opium) might increase susceptibility to enteric infection.

A study in 1973 on human volunteers perpetuated the myth. In this study, DuPont and Hornick examined, among other things, the effect of diphenoxylate and atropine (Lomotil) on shigellosis.17 The authors found that Lomotil seemed to diminish the number of unformed stools but in so doing may have increased patients' susceptibility to invasive infection, since fever was prolonged only in the patients receiving Lomotil. However, the sample size in this study was 25, and there were four treatment arms, making the number of patients in each treatment arm approximately six. The authors admitted that the study was inconclusive due to its small sample size and suggested that further investigation occur before conclusions could be made regarding the use of Lomotil in infectious diarrhea. Nevertheless, the two studies led to a nearly universal avoidance of the use of antimotility agents in patients with infectious diarrhea.

MODERN MEDICINE In 1990, Ericsson, DuPont, Mathewson, and colleagues18 published a paper that addressed the use of loperamide (Imodium) in the treatment of traveler's diarrhea. In a study of 227 adults with acute diarrhea, combination treatment with Bactrim and loperamide was proven to be both safe and effective in treating traveler's diarrhea. In 1993, a randomized, placebo-controlled, double-blind study was performed in Thailand comparing the use of ciprofloxacin and loperamide with ciprofloxacin and placebo in the treatment of adults with bacillary dysentery. 19 The study showed that loperamide combined with ciprofloxacin decreased the number of diarrheal stools and shortened the duration of illness in adult patients with dysentery due to Shigella or enteroinvasive Escherichia coli. No complications were seen in the group treated with loperamide. Although the study size was small ( n = 88), it was much larger than DuPont's 1973 study,17 and it was the first of its kind to suggest the safety of antimotility agents in the treatment of adult invasive diarrheas. We therefore recommend the prescription of loperamide 4 mg PO initially, then 2 mg PO after each diarrheal stool to a maximum of 16 mg/d, since it has clearly been proven to shorten duration of symptoms when combined with an antibiotic regimen. Diphenoxylate and atropine (Lomotil) is a more potent antidiarrheal whose modern-day safety is less well studied. For patients with severely inconveniencing diarrhea refractory to loperamide, diphenoxylate and atropine (Lomotil two tablets PO qid) may be helpful. It should be used with caution, however, in patients with a history of constipation or cardiac disease.

Rehydration For patients presenting to the emergency department with significant dehydration, intravenous fluid therapy is indicated. For a mildly dehydrated patient who is not vomiting, oral rehydration therapy is recommended. Glucose-containing, caffeine-free beverages are the fluids of choice. For patients who can afford to buy it, Gatorade is a good rehydration choice. Otherwise, the World Health Organization recipe for oral rehydration solution can be followed easily and inexpensively (I§ble..79:;2.). Mildly dehydrated patients should aim to drink 30 to 50 mL/kg over the next 4 h. For moderate dehydration, patients should drink 100 mL/kg over the next 4 h.10


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