Patrick O’Neil, PA
“Montezuma’s revenge,” the “Hershey Squirts,” “Runny Bunnies,” “Bubble Gut,” whatever you want to call it….Diarrhea is an absolutely miserable ailment. It is also an extremely common ailment that I see in the Family Practice and Urgent Care setting. I would occasionally see this in the Emergency Room, but in the vast majority of instances, this is definitely NOT an Emergency Room condition. (See the article on Emergency Room vs Urgent Care)
What Causes Diarrhea?
Diarrhea can be caused by Infection, Irritable Bowel Syndrome, and a host of other causes. Sometimes food that is not prepared, or maintained, at correct temperature can cause a bacterial diarrhea. Improper handwashing is another major cause of infection.
Signs and Symptoms
The patient suffering from diarrhea will come in with a complaint of:
1. Diarrhea (this can vary from very soft to pure watery diarrhea)
3. Loss of Appetite
4. Abdominal Cramping
5. Possible fever
6. Gastric Upset (aka, Bubble Gut, the Grumblies, etc.)
7. There will most likely be tenderness when you press on the lower abdominal areas. Caution: If you have a child and you press in the lower right abdomen and they have pain, this may be more than just simple diarrhea. It could be appendicitis.
8. If there is a lot of pain that seems to be more than a simple bout of diarrhea, seek medical attention.
9. Diarrhea can also lead to dehydration. If the gums, eyes, and mouth are dry the patient may be dehydrated. If their pulse is very rapid and their urine is dark, they are most likely very dehydrated
The vast majority of diarrhea is self-limiting, IF we adhere to some simple basics. The body is trying to tell you that it cannot handle food at the moment. I like to explain it this way: Your digestive system cannot multi-task. It can only do one thing at a time. It is either going to digest food, or try to fix whatever is ailing it. If you keep trying to introduce food to a “bad tummy,” then your digestive tract is going to let you know it is not happy with your decision. I treat diarrhea in the following manner:
1. GI rest for 24-36 hours: This means we are going to rest the gastrointestinal tract by withholding solid food. You can live for weeks without food, we just aren’t used to doing that, so we don’t like to withhold it. This is absolutely key to resolving this condition. I promise you….if you keep eating you will prolong the misery by several days.
2. Push fluids to maintain hydration: We may be able to go a couple weeks without food, but we can only go a few days without water. It is crucial that you maintain your hydration. We do this by using the “sippy diet.” You will take small sips to try and sneak the water by your stomach. You don’t want to take large gulps of water and have it land in the stomach with a lot of force. Your stomach won’t like that, and will send it right back up.
a. Fluids that are OK to drink:
(2) Pedialyte (yes, it’s even good for adults, not just kids)
(3) PowerAde or Gatorade, but it is too strong in its original form. Dilute it 50:50 with water to weaken it a bit.
(4) If you absolutely feel the need to eat something, then maybe a little Jell-O and/or a Popsicle
b. Fluids to avoid:
(1) Caffeine Products: Coffee, tea, etc.
(3) Fruit juices: Lots of acid and they can actually worsen your symptoms
(4) Milk products
3. Over-the-counter Imodium AD (aka Loperamide 2 mg) can be used to firm up the diarrhea if you do not have a fever. STOP taking this once the stool is firm or you may end up with constipation. Once your stools are firmed up and are feeling better, you may notice that your stomach will start having a very strong sensation of hunger. This is a good sign that you are ready to start advancing your diet.
Advancing your diet. Do this in the order I describe, and things should go fine. If you advance it too quickly you may have a recurrence of the diarrhea again.
1. Start with dry toast or crackers and eat a very small amount. The idea is to give the stomach something easy to digest and see if it is ready to accept food. If no diarrhea, then you can proceed to the next step
2. BRAT: Bananas, Rice, Applesauce, and Toast. Again, small amounts but can be done frequently.
3. Soups that are low sodium. A lot of sodium can cause an osmotic diarrhea, so make sure it is low on the salt.
4. Pastas: I like Spaghetti because I can limit the amount of spicy tomato sauce. Spaghetti noodles digest very easily, but you definitely want to avoid any heavy sauces like Alfredo.
6. Meats: These are the most difficult thing to digest, so save these for last
NOTE: if you notice the diarrhea is returning at any time while you are advancing your diet, simply back up a step or two and give the tummy more time to heal.
When to seek medical attention
With diarrhea, I tend to tell folks they need to seek medical attention if they have any of the following:
1. Protracted diarrhea: In other words, it just won’t stop. Children will sometimes have diarrhea so frequently they become very dehydrated and their bottoms are raw. You can lose a lot of Chloride with diarrhea and this can cause very serious metabolic issues with your acid base system. People have actually died from diarrheal epidemics. If the patient seems to be having diarrhea that is not slowing down or firming up; if they appear very weak and lethargic; if they appear to have an altered mental status….You need to take them to an Urgent Care or Emergency Room. Most Urgent Care Centers should be able to take care of this.
2. Inability to maintain hydration. Fluid replacement is important and if they absolutely cannot retain their fluids, they may need an IV to get them rehydrated. Look at their urine. If the urine is clear to straw-colored, they are hydrated very well. If their urine is yellow, that shows they are still OK. If their urine is dark, that is a sign they are dehydrated and need fluids. That means they either get obtain the liquid through the mouth in a sippy diet, or they need it through an IV. The pulse can also tell you if they are dehydrated. Typically, anything over 100 is a pretty good sign they may be dehydrated. Most Urgent Care facilities can provide IV’s if needed. I would call ahead to verify that they have that capability before driving over.
3. Severe pain in the patient’s right upper abdomen. This could be a sign of a bad gall bladder. Go to the Emergency Room if you have Right Upper Quadrant pain. They will need to do an Ultrasound and Urgent Care facilities don’t normally have one.
4. Severe pain in the patient’s right lower abdomen. This could be a sign of appendicitis. You will need to go to an Emergency Room for this as most Urgent Care facilities do not have the appropriate imaging devices to ascertain whether or not you have appendicitis.
5. Pain that you would consider out of proportion to a simple episode of nausea and vomiting. Always err on the side of caution. If you have to think for more than a few seconds about whether or not you should take somebody to an Urgent Care or ER, then you should probably take them.
The last thing I want to mention is this: The best treatment for diarrhea is through prevention! This means frequent handwashing, ensuring your food preparation areas are free from germs, and that your food is cooked to the appropriate temperatures and maintained at the appropriate temperature after preparation. Be smart when eating out and selecting your meal. However, should you tempt fate and it doesn’t work out in your favor; you can always use the tips above to help you get through it.