eMedicine Specialties > Emergency Medicine > Gastrointestinal

Gastroenteritis: Treatment & Medication

Author: Arthur Diskin, MD, Vice-President, Global Chief Medical Officer, Royal Caribbean Cruise Lines; Voluntary Associate Professor, University of Miami School of Medicine
Contributor Information and Disclosures

Updated: Oct 22, 2009

Treatment

Prehospital Care

  • Prehospital care is directed toward early and aggressive fluid therapy in patients who are unstable.

Emergency Department Care

  • Goals of ED therapy
    • Rehydrate orally or intravenously as needed.
    • Treat symptoms (eg, fever, pain) as indicated.
    • Identify complications.
    • Prevent the spread of infections.
    • Identify public health concerns and treat certain specific cases with specific or empiric antibiotic therapy.
  • Rehydration
    • Administration of 1-2 L dextrose 5% in 0.5 isotonic sodium chloride solution with 50 mEq NaHCO3 and 10-20 mEq KCl over 30-45 minutes may be necessary in patients who are severely dehydrated.
    • Clinical assessment and serum electrolyte concentrations should guide therapy.
    • To give fluids more rapidly, KCl may be given orally or in the second or third liter bag or as a supplemental IV of 20 mEq KCl in 100 mL of isotonic sodium chloride solution over 1 hour.
    • Rehydrate patients until mental status and signs of perfusion and pulse are normal (caution in elderly patients with congestive heart failure [CHF]).
    • For pediatric patients, administer 20 mL/kg of isotonic sodium chloride solution initially for resuscitation. Repeat as necessary and add KCl as indicated.
    • Indications for IV rehydration include severe intractable vomiting, altered consciousness, severe dehydration, ileus, excessive choleralike stools, and time or environment not conducive to oral rehydration therapy (ORT).
    • Solutions for oral rehydration
      • The World Health Organization solution is 90 mEq/L Na+, 20 mEq/L K+, 80 mEq/L Cl-, 20 g/L glucose; osmolarity is 310; CHO:Na = 1.2:1; administer 250 mL (approximately 8 oz) every 15 minutes until fluid balance is clinically restored, then 1.5 L of oral fluid per liter of stool.
      • Other products include Naturalyte, Cera Lyte, Rehydralyte, and Pedialyte.
      • Oral rehydration may not decrease the duration or volume of diarrhea.
      • Small amounts of oral fluids may be given repeatedly while the patient is still vomiting.
      • Oral rehydration has been largely responsible for the tremendous decrease in the death rate in underdeveloped countries from infectious diarrhea, including cholera.
      • The glucose/sodium transport mechanism remains intact despite enterotoxigenic illness. Coupled transport is one of several mechanisms of sodium and water absorption in the bowel. It is the direct entry of sodium and water across the cell at the intestinal brush border membrane via the linking (coupling) of 1 organic molecule, such as glucose, to 1 sodium molecule. This is the principle upon which ORT is based. Optimally, therefore, the ratio of carbohydrate to sodium should approach 1:1. Glucose is necessary to stimulate the absorption of water and electrolytes by the small intestines.
    • The solution must be iso-osmolar or hypo-osmolar to avoid an increased osmotic load in the small intestines contributing to an osmotic diarrheal effect, pulling fluid into the lumen.
    • Studies have shown oral and IV rehydration to be equivalent therapies in patients who can tolerate the oral fluid.
    • Although standard glucose-electrolyte solutions achieve and maintain rehydration, they may not reduce stool volume or duration of diarrheal illness, affecting compliance.
    • Newer solutions with complex carbohydrates and short chain polypeptides of cereals and legumes are now available to provide additional organic cotransport molecules with no increase in osmolarity. These appear to offer the advantage of decreased stool volumes and shortened duration of illness.
    • Early age-appropriate refeeding in children (and adults) is important to initiate as soon as rehydration is complete.
      • Early refeeding with complex carbohydrates provides additional cotransport molecules without osmotic penalty and stimulates mucosal repair.
      • Consider rice, wheat, bread, potatoes, and lean meats, especially chicken.
      • Milk can be safely given early. Despite the potential for lactose intolerance, clinical evidence of lactase deficiency is uncommon, and most children can tolerate nonhuman milk without difficulty during acute diarrheal illnesses.
      • What has been learned from studies of early pediatric refeeding probably can be generalized to the adult population. Initiate early feeding with the above dietary recommendations once rehydration has been accomplished and vomiting is controlled.
  • Empiric therapy for infectious diarrhea is sometimes indicated. Food-borne toxigenic diarrhea usually requires only supportive treatment, not antibiotics.
    • The duration of traveler's diarrhea (E coli, Shigella) can be shortened by half or more with trimethoprim-sulfamethoxazole (TMP/SMZ) or ciprofloxacin administered for 3 days. Single doses have been used effectively. The duration of treatment may be extended by 2-3 days for moderate-to-severe cases.
    • Generally, fluoroquinolones are the drugs of choice for acute infectious gastroenteritis when used empirically. They do not appear to increase carrier states; however, they are contraindicated in pregnant women and in children.
    • Erythromycin or azithromycin is effective in Campylobacter infections, although erythromycin is not well tolerated in the patient who is vomiting.
    • Metronidazole (oral or parenteral) is effective in mild-to-moderate cases of C difficile diarrhea (in addition to discontinuance of the causative agent). Patients who are severely ill may require orally administered vancomycin, which may require delivery via nasogastric tube or colonoscope.
    • Mild cases of suspected Yersinia infection should be treated with TMP/SMZ or a fluoroquinolone, while patients who are more ill and require admission benefit from IV ceftriaxone.
    • Intestinal salmonellosis in an immunocompetent host does not require antimicrobials because they may prolong fecal shedding of organisms.
    • Metronidazole is effective against parasitic infestations with Giardia or Entamoeba.
  • Antiemetics may be useful in the treatment of nausea and vomiting in adults. They are usually not recommended in children.
  • Antidiarrheals (antimotility agents)
    • These agents have traditionally been discouraged because of concerns with causing bacteremia; however, they appear to have a role in the symptomatic treatment of mild-to-moderate diarrhea, especially with nonbloody and traveler's diarrhea.
    • The most common agents include bismuth subsalicylate (Pepto-Bismol). For patients older than 14 years, give 2 tablets or 20 mL PO q30min as needed to a maximum of 8 doses and loperamide (Imodium), which is useful as an adjunct to rehydration for symptomatic relief. The American Academy of Pediatrics (AAP) does not recommend this for children.
    • Octreotide (Sandostatin), an analog of somatostatin, may be used subcutaneously and intravenously to control severe secretory diarrhea. It has been approved for this purpose in the treatment of carcinoid tumors and VIPomas. Octreotide is under investigation for other uses, including secretory diarrhea associated with AIDS, short bowel syndrome, dumping syndrome, radiation, and chemotherapy.

Consultations

  • A consultation to an infectious diseases specialist may be necessary for patients with chronic diarrhea, patients whose conditions have parasitic etiologies, patients infected with C difficile when vancomycin use is contemplated, patients who relapse, and patients with AIDS who have diarrhea.
  • A consultation to a gastroenterologist may also be indicated in the above circumstances and when pseudomembranous colitis, ulcerative colitis, or Crohn disease are in the differential diagnosis.

Medication

The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to possibly decrease the duration of illness.

In February 2006, the United States Food and Drug Administration (FDA) approved an oral vaccine for rotavirus (RotaTeq). It is currently the only vaccine approved in the United States for prevention of rotavirus gastroenteritis as of the date of this publication. RotaTeq is administered in a 3-dose series starting between age 6-12 weeks and completed before age 32 weeks.

In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus gastroenteritis. The current recommendation is to administer 2 separate doses of Rotarix to patients aged 6-24 weeks. Rotarix was efficacious in a large study, which reported that Rotarix protected patients with severe rotavirus gastroenteritis and decreased the rate of severe diarrhea or gastroenteritis of any cause.4

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.


Ciprofloxacin (Cipro)

Fluoroquinolones are the agents of choice for the empiric treatment of invasive and traveler's diarrhea syndromes in adult patients. They are also the agents of choice when treatment is indicated and the organism involved is known to be Campylobacter, E coli (non-O157:H7), nontyphoid Salmonella (although antibiotic treatment may prolong bacterial shedding), Shigella, or Yersinia.

Adult

500 mg PO bid for 3-5 d; studies have shown that a single dose of 500 mg or 1000 mg may be equally effective

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Trimethoprim-sulfamethoxazole (Bactrim)

Excellent second choice for empiric therapy, although it is not effective against Campylobacter organisms. Increasing resistance. First drug of choice for patients younger than 18 years. Specifically recommended for 5 d for shigellosis.

Adult

1 DS tab (or 4 tsp of the pediatric susp) PO bid for 3-5 d

Pediatric

Dose is adjusted based on the trimethoprim component; 8-10 mg/kg/d PO in divided doses or 40 mg of trimethoprim per tsp (5 mL) PO

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation; refer to PDR and product information


Rifaximin (Xifaxan, RedActiv, Flonorm)

Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie, gram-positive, gram-negative, aerobic, and anaerobic). Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea.

Adult

200 mg PO tid

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Induces CYP450 3A4 in vitro; limited data exist; no significant interactions shown in single-dose studies with midazolam and oral contraceptives

Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May promote intestinal bacterial overgrowth and cause superinfection; discontinue if diarrhea persists more than 24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge (tabs not effective); not effective for travelers' diarrhea due to suspected pathogens other than E coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and pruritus

Antiemetics

All these drugs are indicated in the control of nausea and vomiting. All have been associated with extrapyramidal adverse effects, especially in patients who are acutely ill, dehydrated, or children. They should be used with caution and only in the lowest effective dose. A weak association with Reye syndrome exists, and all may mask the vomiting associated with underlying CNS lesions.


Prochlorperazine (Compazine)

Antidopaminergic drug that blocks the postsynaptic mesolimbic dopamine receptors. Has an anticholinergic effect and can depress the reticular activating system, possibly responsible for relieving nausea and vomiting.

Adult

5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid

Pediatric

2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
IV dosing is not recommended for children
0.1-0.15 mg/kg/dose IM and change to PO as soon as possible

Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension

Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently; akathisia is the most common extrapyramidal reaction in elderly patients; lowers seizure threshold; caution with history of seizures; refer to PDR and product information


Promethazine (Phenergan)

Antidopaminergic agent effective in the treatment of emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.

Adult

12.5-25 mg PO/IV/IM/PR q4h prn

Pediatric

<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d prn

May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension

Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; not for use in children <2 years as it may cause respiratory depression; refer to PDR and product information


Trimethobenzamide (Tigan)

Has central effects in which it inhibits the medullary receptor trigger zone.

Adult

250 mg PO tid/qid
Alternatively, 200 mg IM tid/qid

Pediatric

<14 kg: 100 mg PO tid/qid
14-40 kg: 100-200 mg PO tid/qid
>40 kg: Administer as in adults

May inhibit effects of anticoagulants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not for use in patients with acute vomiting; refer to PDR and product information


Ondansetron (Zofran)

Selective 5-HT3 receptor antagonist that blocks serotonin both peripherally and centrally. Indicated for nausea and vomiting due to radiation and/or chemotherapy and for postoperative nausea and vomiting. Cost considerations.

Adult

Nausea and vomiting secondary to gastroenteritis: 4-8 mg PO q8h; 4 mg IV

Pediatric

Nausea and vomiting secondary to gastroenteritis: 4 mg PO q8h; 0.1-0.15 mg/kg IV

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose and use caution if liver function significantly impaired

Antidiarrheal agents

These agents are used to decrease the frequency of diarrheal stools and possibly the duration. They should be used with caution in children and in patients with dysentery, as some reports of prolonged illness and development of toxic megacolon exist.


Loperamide (Imodium)

Antimotility DOC. Generally safe and indicated in the early treatment of travelers' diarrhea.

Adult

4 mg PO once, followed by 2 mg after each loose stool; do not exceed 16 mg/d

Pediatric

Initial doses:
2-6 years: 1 mg PO tid
6-8 years: 2 mg PO bid
8-12 years: 2 mg PO tid
Maintenance: 0.1 mg/kg PO after each loose stool; not to exceed initial dose
Chronic diarrhea: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose

Phenothiazines, tricyclic antidepressants, and CNS depressants may increase loperamide toxicity

Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue use if no clinical improvement in 48 h; because loperamide is primarily metabolized in the liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use medication if high fever or blood in stool coincides with diarrhea; refer to PDR and product information


Diphenoxylate HCl 2.5 mg/atropine sulfate 0.025 mg (Lomotil)

Antidiarrheal agent chemically related to narcotic analgesic meperidine. A subtherapeutic dose of anticholinergic atropine sulfate is added to discourage overdosage, in which case diphenoxylate may clinically mimic the effects of codeine.
Each tab of Lomotil or 5 cc of elixir contains 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate.
Almost always the preferred antimotility agent.

Adult

2 tab PO qid until the diarrhea is controlled

Pediatric

<2 years: Not recommended
2-5 years: 2 mg of diphenoxylate PO tid
5-8 years: 2 mg of diphenoxylate PO qid
8-12 years: 2 mg of diphenoxylate PO 5 times/d

May delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase the toxicity of this drug combination

Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In young children, dehydration may influence variability of response and predispose patient to delayed diphenoxylate intoxication; exercise caution in patients with ulcerative colitis
A decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella, Salmonella, and toxigenic strains of E coli; refer to PDR and product information

Vaccines

Elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.


Rotavirus vaccine (RotaTeq, Rotarix)

Currently, 2 orally administered live-virus vaccines are marketed in the United States. Each is indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.
RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a 3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A serotypes. It also contains attachment protein P1A (genotype P[8]).
Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is administered as a 2-dose series in infants aged 6-24 wk.
Clinical trials found that the vaccines prevented 74-78% of all rotavirus gastroenteritis cases, nearly all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.

Adult

Not indicated

Pediatric

<6 weeks: Not established
RotaTeq
6-12 weeks: 2 mL PO as a single dose, followed by 2 additional doses at 4- to 10-wk intervals; do not administer after age 32 wk
Rotarix
6 weeks: 1 mL PO as a single dose; administer a second dose after an interval of at least 4 wk and before age 24 wk

Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-dose corticosteroids) may decrease immune response

Documented hypersensitivity; uncorrected congenital GI malformation that would predispose to intussusception

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include diarrhea, vomiting, otitis media, inflamed nasal passages, and bronchospasm; refrigerate and protect from light; handle and discard empty tube according to biological waste procedures; previously marketed rotavirus vaccine (RotaShield) was associated with intussusception; however, RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage), and Rotarix did not show an increase in intussusception in 31,673 infants compared with 31,552 infants who received placebo; do not mix in same syringe with other vaccines or solutions

More on Gastroenteritis

Overview: Gastroenteritis
Differential Diagnoses & Workup: Gastroenteritis
Treatment & Medication: Gastroenteritis
Follow-up: Gastroenteritis
Multimedia: Gastroenteritis
References
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References

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  2. Centers for Disease Control and Prevention. Vessel Sanitation Program: Cruise Ship Inspection. Available at http://wwwn.cdc.gov/InspectionQueryTool/Forms/InspectionSearch.aspx.

  3. Centers for Disease Control and Prevention. Investigation Update: Outbreak of Salmonella Typhimurium Infections, 2008–2009. Available at http://www.cdc.gov/salmonella/typhimurium/update.html.

  4. [Best Evidence] Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [Medline].

  5. DuPont HL, Jiang ZD, Okhuysen PC, Ericsson CD, de la Cabada FJ, Ke S, et al. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med. May 17 2005;142(10):805-12. [Medline].

  6. Caeiro JP, DuPont HL. Management of travellers' diarrhoea. Drugs. Jul 1998;56(1):73-81. [Medline].

  7. CDC. Outbreaks of gastroenteritis associated with noroviruses on cruise ships--United States, 2002. MMWR Morb Mortal Wkly Rep. Dec 13 2002;51(49):1112-5. [Medline]. [Full Text].

  8. Dolin R. Noroviruses--challenges to control. N Engl J Med. Sep 13 2007;357(11):1072-3. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Arthur Diskin, MD, Vice-President, Global Chief Medical Officer, Royal Caribbean Cruise Lines; Voluntary Associate Professor, University of Miami School of Medicine
Arthur Diskin, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Royal Caribbean Cruise Lines Salary Employment

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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