Diarrhea.

[The Knife & Gun Club]

What are y’alls go to for diarrhea treatment in someone with minimal clinical concern for badness?

Yes I know I know it’s not an emergency and yes I know it’s a stupid use of ER resources. But sometimes you get people who won’t leave without a door prize and it’s quicker to just give something to make they feel better until they can see a GI or sx resolve.

My running list is:
Loperamide
Dicycloverine
Hyoscyamine
Probiotic

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[skougess]

Loperamide. And I give them a spiel that it can be dangerous to prevent diarrhea when your body is trying to expel an infection so to only use it if absolutely necessary. It has a dual effect of hopefully them just staying the course, and also them thinking they are getting something really good (the doctor used the word “dangerous” with this med WOW!!)

 

[CoolDoc1729]

What are y’alls go to for diarrhea treatment in someone with minimal clinical concern for badness?

Yes I know I know it’s not an emergency and yes I know it’s a stupid use of ER resources. But sometimes you get people who won’t leave without a door prize and it’s quicker to just give something to make they feel better until they can see a GI or sx resolve.

My running list is:
Loperamide
Dicycloverine
Hyoscyamine
Probiotic

I recommend loperamide.

If someone has used loperamide appropriately for a week and it is not helping I prescribe Lomotil. But then I’m also recommending they see GI, if there’s not an obvious cause on their workup. Thyrotoxicosis. Bad colitis. Etc

 

[Mount Asclepius]

Almost always nothing. If they can’t give a stool sample in the ED, which is usually whenever one is ordered, then I don’t give them anything in return. Most is infectious, usually viral, and self limiting.

 

[coachB]

What are y’alls go to for diarrhea treatment in someone with minimal clinical concern for badness?

Yes I know I know it’s not an emergency and yes I know it’s a stupid use of ER resources. But sometimes you get people who won’t leave without a door prize and it’s quicker to just give something to make they feel better until they can see a GI or sx resolve.

My running list is:
Loperamide
Dicycloverine
Hyoscyamine
Probiotic

Nothing. Tell them it will get better with time and while I could give them something to decrease the frequency of episodes, it will likely prolong their symptoms. Hardly anyone wants that.

 

[GassYous]

It's happening for a reason...

 

[thegenius]

Almost always nothing. If they can’t give a stool sample in the ED, which is usually whenever one is ordered, then I don’t give them anything in return. Most is infectious, usually viral, and self limiting.

I too say this...especially if the diarrhea been going on for 0-5 days. But I'd say 1/4 of my patients with diarrhea been going on for over > 5 days, and I think it's poor form to offer nothing. As the OP said it's diarrhea without badness, so loperamide and/or lomotil.

Just imagine if you were the patient and the doc said "your diarrhea will magically get better next week" when it's been going on for a week already. Patients are as a cohort are dumb, but they are not that dumb (or maybe they are)

 

[Mount Asclepius]

I too say this...especially if the diarrhea been going on for 0-5 days. But I'd say 1/4 of my patients with diarrhea been going on for over > 5 days, and I think it's poor form to offer nothing. As the OP said it's diarrhea without badness, so loperamide and/or lomotil.

Just imagine if you were the patient and the doc said "your diarrhea will magically get better next week" when it's been going on for a week already. Patients are as a cohort are dumb, but they are not that dumb (or maybe they are)

I just don’t get patients very often primarily presenting complaining of diarrhea, or, demanding treatment for diarrhea. Either way, the ones with diarrhea seem very okay with letting it ‘run’ it’s course. When you stop infectious diarrhea, there is the potential to create badness.

This also illustrates the problem with health and health care in the US. Lots of problems get better with time and waiting them out. Most things don’t need a quick fix. Just a little mental fortitude.

 

[GonnaBeADoc2222]

Discharge.

Except for the one who had a K of 1.8 and bicarb 10.

 

[gutonc]

Discharge.

Except for the one who had a K of 1.8 and bicarb 10.

I had a (chemo) patient literally s*** himself to death. Rolled into the ED (not to see me, I'm the guy who gave the chemo) in cardiac arrest. Had a K of 1.2. We had directed him to either come to clinic or the ED every day for a week prior to that, but he didn't want to leave his beach house so said he'd come in when he got back to town.

 

[Mount Asclepius]

I had a (chemo) patient literally s*** himself to death. Rolled into the ED (not to see me, I'm the guy who gave the chemo) in cardiac arrest. Had a K of 1.2. We had directed him to either come to clinic or the ED every day for a week prior to that, but he didn't want to leave his beach house so said he'd come in when he got back to town.

He chose right (I think). If I’m cancering away, I’m going to be at the beach house when I arrest and not at the hospital. I’d give him the same advice you did as a physician, but as a patient I’d totally ignore it.

 

[turkeyjerky]

He chose right (I think). If I’m cancering away, I’m going to be at the beach house when I arrest and not at the hospital. I’d give him the same advice you did as a physician, but as a patient I’d totally ignore it.

But if he dies, we can't start him on Keytruda!?!

 

[gutonc]

He chose right (I think). If I’m cancering away, I’m going to be at the beach house when I arrest and not at the hospital. I’d give him the same advice you did as a physician, but as a patient I’d totally ignore it.

I'm not arguing that going down at the beach house was necessarily a bad idea. But that's not what he did. Instead, he went down like a *****, getting tubed in the field and 60 minutes of CPR done on him. I'm just saying, a little Lomotil might have allowed him time to hang at the beach a bit longer.

 

[JacobMcCandles]

Whatever OTC preparation they want.

 

[Apollyon]

I had a (chemo) patient literally s*** himself to death. Rolled into the ED (not to see me, I'm the guy who gave the chemo) in cardiac arrest. Had a K of 1.2. We had directed him to either come to clinic or the ED every day for a week prior to that, but he didn't want to leave his beach house so said he'd come in when he got back to town.

But if he dies, we can't start him on Keytruda!?!

OK, this reminded me to roll out this joke, again...

So, pt is in hospital for his cancer. It's time for his chemo. So, the oncologist mixes it up, and goes to the pt room. But, pt isn't there. Charge nurse says pt expired. Now, onc thinks, "We can't let this go to waste. Also, I can't bill for it". So, he goes down the morgue.

He opens the drawer, but, it's empty. There IS, though, a note - "The patient is in dialysis. They'll be back soon"!

 

[The Knife & Gun Club]

I'm not arguing that going down at the beach house was necessarily a bad idea. But that's not what he did. Instead, he went down like a *****, getting tubed in the field and 60 minutes of CPR done on him. I'm just saying, a little Lomotil might have allowed him time to hang at the beach a bit longer.

I feel like cancer is a different beast. Those people get whatever they want within reason.

I’m more talking about the “doctor it just won’t stop, I’ve had diarrhea for weeks!” Population.

Usually goes with a side of not having a single actual episode of diarrhea in the ED.

 

[wholeheartedly]

This is an intersting topic considering I’ve been up to my eyeballs in the past 5 years of statewide giardia surveillance data and also a large giardiasis outbreak.

 

[watermanMD]

Yeah I’m a little crispy rn but I’m just always amazed at the persons 60 and above that present with minor diarrhea, as if they’ve existed for 60+ years on this earth and never dealt with a GI bug. THE QUESTIONS!!! “Well, what am I supposed to eat?” “Is it ok to drink Gatorade?” “What’s causing this?” “Why won’t it go away?” “Well, I just feel a little ‘off’. I just can’t explain it. That’s why I came in.” “Everything I eat goes right through me. I think I’m dehydrated.”

Sir, you’ve had 2 episodes of diarrhea a day for 3 days. Your grandchildren just finished ****ting their brains out at home—do you think it could be related? Your labs look better than mine and so, too, do your vitals. Go on, get out of here!

It gets me every time. How TF did some of these folks make it this long?

 

[watermanMD]

And I give nothing. IV fluids to make you feel like I did something then d/c. Let the GI tract do its thing.

That being said, it is the culture at my shop to send a GI panel. I play a game with myself and try to d/c them before they’re able to produce a specimen.

 

[southerndoc]

I've found the best way to stop someone's diarrhea is to order a C diff or GI multiplex.

 

[gutonc]

I feel like cancer is a different beast. Those people get whatever they want within reason.

I’m more talking about the “doctor it just won’t stop, I’ve had diarrhea for weeks!” Population.

Usually goes with a side of not having a single actual episode of diarrhea in the ED.

Oh, I definitely agree. I wasn't commenting on your all's management of benign diarrhea. More just sharing a "funny" story of someone who literally s*** themselves to death because they wouldn't seek care.

 

[WorkNoteEmergency]

I recommend loperamide.

If someone has used loperamide appropriately for a week and it is not helping I prescribe Lomotil. But then I’m also recommending they see GI, if there’s not an obvious cause on their workup. Thyrotoxicosis. Bad colitis. Etc

My general pattern too. But, like I tell people all the time, the surest cure for diarrhea is for the ED doc to order stool studies. If it's been going on for more than 3-4 days, for old folks I order stool studies, c-diff, etc. I also give the food diary talk to the younger folks.

BTW, in residency, I never saw diarrhea, but I see people all the time for it since.

 

[Rekt]

Unless someone has foreign travel, what’s the point of stool studies? They’ve never changed my management and the nurses hate you.

Useless test.

 

[Mount Asclepius]

Unless someone has foreign travel, what’s the point of stool studies? They’ve never changed my management and the nurses hate you.

Useless test.

Antibiotics for certain bacterial infections.

 

[Rekt]

Antibiotics for certain bacterial infections.

There's no indication for antibiotics in typical diarrhea.

We're not talking about immunocomp, HIV, foreign travel, c diff, etc.

 

[RustedFox]

There's no indication for antibiotics in typical diarrhea.

We're not talking about immunocomp, HIV, foreign travel, c diff, etc.

Eh. You can get away with Flagyl for nonspecific/regional colitis.

But generally, yeah.

 

[Mount Asclepius]

There's no indication for antibiotics in typical diarrhea.

We're not talking about immunocomp, HIV, foreign travel, c diff, etc.

You have to test to diagnose C. Difficile infections. Some C. Difficile diarrhea can appear typical. Hard to diagnose or exclude without testing.

Those scenarios aren’t the only times antibiotics are indicated. Although agree usually not indicated.

A lot of diarrhea is due to a viral etiology and I also rarely test. Most can’t provide a stool sample being the primary reason.

Stool studies occasionally do change management and aren’t completely useless tests as you implied though.

Agree with your overall sentiment. Partially playing devil’s advocate.

 

[The Knife & Gun Club]

Unless someone has foreign travel, what’s the point of stool studies? They’ve never changed my management and the nurses hate you.

Useless test.

Recently did the GI PCR for a 16 year old with no risk factors who just developed horrible diarrhea out of the blue. Had the talk with kid and mom about how this is almost always viral, it’s not bloody, no travel, etc.

He actually went and did the sample almost immediately and sent it off. Got a call from the lab 2 days later that he had campylobacter.

That’s the only time I’ve had any significant management change.

 

[wholeheartedly]

It’s true most people don’t need testing or treatment.

But just a note, giardiasis does get missed quite a bit. National insurance claims data shows it takes half of patients 3 or more visits with GI symptoms to get a diagnosis and more than 20% of patients take more than 30 days after first presenting with GI symptoms to get a diagnosis of giardiasis.

That’s pretty consistent with what I found during a project reviewing and analyzing the last 5 years of state reportable diseases data for giardiasis cases. One poor guy lost almost 30 lbs over six months from diarrhea before he finally got into a GI doc and was actually tested. It’s just not really on people‘s radar a lot of the time without some obvious risk factor, but it’s more common than people think it is.

The really crappy thing 😜 is, after interviews with these folks, you can really only find risk factors such as travel or drinking untreated water in a small portion of them.

So just something to keep in mind if you have some folks who don’t seem to improve or keep coming back, even if they don’t seem to have any obvious risks.

 

[wholeheartedly]

also, humans are 🤦‍♀️

Trendy “raw water” source under bird’s nest sparks diarrheal outbreak

Health officials would like to remind you that drinking untreated water is a bad idea.

arstechnica.com

 

[RustedFox]

also, humans are 🤦‍♀️

Trendy “raw water” source under bird’s nest sparks diarrheal outbreak

Health officials would like to remind you that drinking untreated water is a bad idea.

arstechnica.com

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