Brutal. Exhausting. Disgusting.
Last weekend I found myself contending with quite a nasty gastroenteritis characterized by watery diarrhea that ended up like a colonoscopy prep, but also with cramps, chills, malaise, and finally a good vomit at 1 AM. You know when your body has breached the point of no return with the urge to vomit. That unstoppable wave of nausea, the smooth muscle peristalsis kicking into reverse, the welling of spit before the acid and the retching.
Do you loathe GI bugs as much as I do?
Maybe it was the 3 day-old shrimp taco. Or the norovirus that wastewater analysis shows is “medium” right now in my neck of the woods. Or another virus. Most cases of diarrhea are viral, as indicated by the observation that stool cultures are positive in only 1.5 to 5.6% of cases in most studies. And yet, if you have 4 or more diarrheal bouts for three days or longer, up to 87% of these cases will be caused by a bacteria.
The most crucial therapy in diarrheal illness is rehydration, preferably by the oral route, with solutions that contain water, salt, and sugar. I will link to a great patient education resource about when to consider antibiotics and symptomatic treatment, but first allow me to introduce a few rehydration ideas and products. Fluids are the cornerstone of treatment. It’s a good idea to have them ready to go before illness strikes.
According to UpToDate:
Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may meet the fluid and salt needs in patients with mild illness [3]. The electrolyte concentrations of fluids used for sweat replacement (eg, Gatorade) are not equivalent to oral rehydration solutions, although they may be sufficient for the otherwise healthy patient with diarrhea who is not hypovolemic (quite dehydrated).
Oral rehydration solutions (ORS), including standard World Health Organization ORS or commercial ORS, such as Rehydralyte and Ceralyte, may be more appropriate in patients with more severe diarrheal disease. They should be used both to replete a volume depleted patient and also to maintain adequate volume status once replete…
ORSs were developed following the realization that, in many small bowel diarrheal illnesses, intestinal glucose absorption via sodium-glucose cotransport remains intact. Thus, in diarrheal disease caused by any organism that depends on small bowel secretory processes, the intestine remains able to absorb water if glucose and salt are also present to assist in the transport of water from the intestinal lumen (inside). Oral rehydration therapy is grossly underutilized in the US where health care providers tend to overuse intravenous hydration.
(But) adults with severe hypovolemia should initially receive intravenous fluid repletion. Once they are replete, they can be switched to oral rehydration solutions.
I think the accompanying graph posted below is very helpful. On Daily Kos I can’t get it to look any bigger for some reason, so you’ll have to check the original post if it looks tiny on your screen. We can see the core electrolytes that need to be added per WHO guidelines, and stack those up to compare among products:
Personally I use Pedialyte, or I’ll mix a packet of oral rehydration salts with a liter of water. Pedialyte is easy to find. The salt packets are a bit harder.
This past weekend I used an ORS packet that I purchased a while back for such an occasion, made by a company called Jianis Brothers, based in Kansas City, Missouri. You can order these for a rainy day through Amazon… but the price is 5x what I found on an emergency medical supply site called Rescue Essentials. I have no affiliations. According to the Jianis ORS product description:
Required treatment for severe diarrhea, or other illnesses where dehydration is a problem. These rehydration salts, made from the standard World Health Organization formula, should be a part of every travel kit, particularly for those traveling with children or in Third World countries.
However, The World Health Organization (WHO) has released several new formulas for oral rehydration salts since 2003, including a more dilute (lower osmolarity) low-sodium, low-glucose formula in 2014. WHO and USAID research found that this new formula is more effective than previous versions and can reduce the need for intravenous fluids by 33%. This could lead to fewer hospitalizations, secondary infections, and lower healthcare costs. The newer formula is used in a different brand I found - TRIORAL packets - also available via the same website. I’ll probably restock with these instead of the ones above:
Severe diarrhea is defined as causing:
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Hypovolemia (dehydration with symptoms like dizziness, dry skin, dry mouth, weakness, muscle cramps, dark urine, etc. Hypovolemia can progress to shock manifest by confusion, difficulty breathing, excessive sweating, and loss of consciousness)
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Passage of >6 unformed stools per 24 hours
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Severe abdominal pain
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Bloody diarrhea
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Passage of many small volume stools containing blood and mucus
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Temperature ≥38.5ºC (101.3ºF)
I felt justified mixing up a liter of the ORS because I did check the box for >6 episodes.
Over the weekend I drank Pedialyte, the liter of ORS solution over the course of a day, some free water, had some chicken rice soup , and bounced back quite well. I’ve been mostly avoiding fatty foods and limiting dairy as this can be difficult to digest after an acute diarrheal illness depletes the lactase enzymes in our digestive system.
I did not start an antibiotic like azithromycin, nor did I take Imodium. But here is that great patient education resource from UpToDate in case you are interested in when antibiotics should be considered, or when it’s OK to use symptom relievers like Imodium. As they say, talk to your doctor in these situations, but attempting oral rehydration is pretty clear cut.
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Well, that’s it. I am thankful to be feeling better than last weekend.
GI bugs are the worst. I loathe them.
Take good care, and be prepared?
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I write a medical blog/substack called Examined. This post was first published over there.
The next post will be a run down about that recently published study in JAMA about whether multivitamins are worth taking. See you there, too, I hope!