Recommendations

Key Recommendations

The main goals of treatment of viral gastroenteritis are to prevent and treat volume depletion, maintain nutrition, and reduce spread to other people. Pharmacologic therapy is rarely needed.[27]

Rehydration

It is important to assess hydration status because it determines the immediate management.[19]

Patients with profuse diarrhea and frequent vomiting, and patients with comorbidities or older age, are especially at risk for volume depletion.[19]

Treatment is based primarily on replacing fluids and electrolytes as directed by the estimated degree of volume depletion.[19] Oral or enteral rehydration therapy is recommended for preventing and treating early volume depletion, and continued replacement for ongoing losses.

Oral rehydration solution

Oral rehydration solution is recommended for people with acute diarrhea from any cause. It is also recommended for people with mild to moderate dehydration associated with vomiting or severe diarrhea.[19] Patients with abdominal ileus should not be rehydrated orally.

Oral rehydration solution is preferable to other clear fluids. Highly sugared fluids and fluids very low in sodium may exacerbate diarrhea.[28][29] One Cochrane review found that polymer-based oral rehydration solution (ORS) was more effective for treating acute watery diarrhea compared with glucose-based ORS.[30]

Volume depletion and hypokalemia

Shock, severe volume depletion, and decreased consciousness require hospitalization and intravenous fluid resuscitation.[19] Approximate fluid loss should be replaced in <3 hours, followed by maintenance fluid replacement for ongoing losses. Take care not to replete patients with hypernatremia or hyponatremia too quickly, as this can lead to complications, such as osmotic demyelination syndrome.[31]​ Volume depletion assessment should be repeated periodically and rate of fluid therapy modified based on signs of volume depletion.

Patients with severe volume depletion, particularly those with altered mental state, should be rehydrated with isotonic crystalloids, such as normal saline (0.9% sodium chloride), Ringer’s lactate, or Plasma-Lyte®.[19]

Evidence from two large randomized controlled trials (RCTs) suggests there is no difference between normal saline and a balanced crystalloid for critically ill patients in mortality at 90 days, although results from two meta-analyses including these RCTs point to a possible small benefit of balanced solutions compared with normal saline.[32][33][34][35]​​​

If there is severe hypokalemia, consider giving intravenous potassium to correct potassium rapidly. If intravenous hydration is not available or it is delayed (e.g., venous access problems) and the patient is not able to tolerate oral fluids, a central line can be placed. Nasogastric administration of oral rehydration solution may also be considered as an alternative.[19] Rehydration is usually achieved in 4 to 6 hours via any route. Appropriate diet should be continued as tolerated for all patients.

Other agents

The mainstay of treatment is rehydration. Routine use of antibiotics is not recommended and may even cause harm. Although not usually required, antidiarrheal agents may be used in adults for symptomatic relief of watery diarrhea. They may be considered, for example, as a specific strategy for short-term symptom management if a patient has to travel. However, avoid antidiarrheal agents in patients with bloody diarrhea (which may indicate a bacterial cause) or where an inflammatory cause is suspected, as it may prolong the infection.[25][36] Likewise, antiemetics are not recommended unless the patient has intractable vomiting.

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