3-19
Inflammatory bowel disease - chronic, abdominal pain, urgency and diarrhea; may be associated with anxiety.
GI Bleeding - bright red blood per rectum (lower GI bleed); black (Hemocult positive), tarry stool (upper GI
bleed); may be accompanied by vomiting blood if perforated peptic ulcer, ruptured esophageal veins; anemia.
Giardiasis - chronic diarrhea, cramping, weight loss, pale and greasy stools.
Viral Gastroenteritis (stomach flu) - various viruses can cause diarrhea, which may be associated with
outbreaks in daycare or other institutional facilities (Rotavirus), epidemics in military personnel (e.g., Norwalk
virus), and food-borne and waterborne outbreaks.
Food poisoning - usually with vomiting; (see GI: Acute Bacterial Food Poisoning); includes toxic E. coli; some
viruses can also be spread by food (e.g., hepatitis A)
Traveler’s diarrhea - non-specific term; diarrhea of bacterial or viral origin originating in conjunction with
foreign travel
A multitude of other infectious agents including parasitic worms, malaria, and many other tropical illnesses.
Other chronic diseases including malabsorption syndromes.
Plan:
Treatment
- Fluid Resuscitation: Either intravenous or oral rehydration solution (ORS).
World Health Organization ORS: 1 liter of purified water + 20 gm glucose + 3.5 gm salt + 5 gm sodium
bicarbonate + 1.5 gm potassium chloride - Food: Continue nutrition intake, but avoid lactose and caffeine.
- Antibiotics (see GI: Acute Bacterial Food Poisoning also)
Primary/Empiric: Ciprofloxacin 500 mg po
Alternate: Norfloxacin 400 mg q 12 hr for 5 days
Specific Organism:
Shigella - Ampicillin 500 mg po qid or Bactrim 1 po bid x 5 days
Clostridium difficile - Metronidazole 250-500 mg po tid x 10 days
Salmonella, hemorrhagic E. coli - Ampicillin 50-100 mg/kg/day in four doses x 10-14 days
Amebiasis - Metronidazole 750 mg tid x 10 days then iodoquinol 650 po tid x 20 days
Giardia lamblia - Metronidazole 250 mg tid X 5 days
E. coli - Bactrim 1 po bid x 5 days - Antimotility drugs: Codeine, paregoric, tincture of opium, loperamide. Use only in cases of simple or
minimal diarrhea, or if necessary to enable operator to complete the mission. There is a significant risk
of toxic megacolon, sepsis and perforation. - Blood. Consider transfusion for excessive GI bleeding, depending on stability of patient.
- Treat other chronic illnesses if possible.
Patient Education
General: Most patients recover from acute diarrhea without sequelae. Fluid resuscitation with a glucose,
bicarbonate and potassium containing liquid is the essential method to avoid dehydration. Gatorade is an
excellent commercial drink.
Diet: Liquids rst, then bland solids as tolerated. Bananas can improve consistency of stool.
Prevention and Hygiene: Wash hands. Consume only approved water and food (see Preventive Medicine
chapter).
Follow-up Actions
Return evaluation: Review history and consider alternate treatment or evacuation.
Evacuation/Consultation Criteria: Evacuate all with severe diarrhea, especially if associated with change in
mental status, sepsis. Most cases of simple or minimal diarrhea do not require evacuation. Consult infectious
disease specialist for severe or chronic diarrhea.