Patient information: See related handout on chronic diarrhea , written by the authors of this article. Chronic diarrhea, defined as a decrease in stool consistency for more than four weeks, is a common but challenging clinical scenario. It can be divided into three basic categories: watery, fatty malabsorption , and inflammatory. Watery diarrhea may be subdivided into osmotic, secretory, and functional types. Watery diarrhea includes irritable bowel syndrome, which is the most common cause of functional diarrhea.
Another example of watery diarrhea is microscopic colitis, which is a secretory diarrhea affecting older persons. Laxative-induced diarrhea is often osmotic. Malabsorptive diarrhea is characterized by excess gas, steatorrhea, or weight loss; giardiasis is a classic infectious example. Celiac disease gluten-sensitive enteropathy is also malabsorptive, and typically results in weight loss and iron deficiency anemia. Inflammatory diarrhea, such as ulcerative colitis or Crohn disease, is characterized by blood and pus in the stool and an elevated fecal calprotectin level.
Invasive bacteria and parasites also produce inflammation. Infections caused by Clostridium difficile subsequent to antibiotic use have become increasingly common and virulent. Not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories overlap. Still, the most practical diagnostic approach is to attempt to categorize the diarrhea by type before testing and treating.
This narrows the list of diagnostic possibilities and reduces unnecessary testing. Empiric therapy is justified when a specific diagnosis is strongly suspected and follow-up is available. Chronic diarrhea is defined as a decrease in stool consistency continuing for more than four weeks. Enlarge Print. Chronic diarrhea should be categorized as watery secretory vs. Most persons with irritable bowel syndrome meeting Rome III criteria do not require colonoscopy if the condition responds to therapy.
Fecal calprotectin, a marker for neutrophil activity, is useful for distinguishing inflammatory bowel disease from irritable bowel syndrome and for monitoring inflammatory bowel disease activity. Testing for celiac disease should be considered in patients with irritable bowel syndrome, type 1 diabetes mellitus, thyroid disease, iron deficiency anemia, weight loss, infertility, elevated liver transaminase levels, and chronic fatigue.
Chronic diarrhea may be divided into three basic categories: watery, fatty malabsorption , and inflammatory with blood and pus. However, not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories overlap. The differential diagnosis of chronic diarrhea is described in Table 1. Bacterial enterotoxins e. Bile acid malabsorption. Brainerd diarrhea epidemic secretory diarrhea.
Congenital syndromes. Crohn disease early ileocolitis. Endocrine disorders e. Medications see Table 3. Microscopic colitis lymphocytic and collagenous subtypes. Neuroendocrine tumors e. Nonosmotic laxatives e.
Postsurgical e. Carbohydrate malabsorption syndromes e. Celiac disease. Osmotic laxatives and antacids e. Sugar alcohols e. Functional distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting. Irritable bowel syndrome. Fatty bloating and steatorrhea in many, but not all cases. Malabsorption syndrome damage to or loss of absorptive ability.
Carbohydrate malabsorption e. Celiac sprue gluten enteropathy —various clinical presentations. Gastric bypass. Lymphatic damage e. Medications e.
Mesenteric ischemia. Noninvasive small bowel parasite e. Postresection diarrhea. Short bowel syndrome. Tropical sprue. Whipple disease Tropheryma whippelii infection. Hepatobiliary disorders. Inadequate luminal bile acid. Loss of regulated gastric emptying. Pancreatic exocrine insufficiency.
Inflammatory or exudative elevated white blood cell count, occult or frank blood or pus. Inflammatory bowel disease Crohn disease ileal or early Crohn disease may be secretory. Ulcerative colitis. Ulcerative jejunoileitis. Clostridium difficile pseudomembranous colitis—antibiotic history.
Invasive bacterial infections e. Invasive parasitic infections e. Ulcerating viral infections e. Colon carcinoma. Villous adenocarcinoma. It helps differentiate secretory from osmotic diarrhea. Normal fecal osmolality is mOsm per kg mmol per kg. Although measurement of fecal electrolytes is no longer routine, knowing the fecal osmotic gap helps confirm whether watery stools represent chronic osmotic diarrhea fecal osmotic gap greater than mOsm per kg [ mmol per kg] or chronic secretory diarrhea fecal osmotic gap less than 50 mOsm per kg [50 mmol per kg].
Information from references 1 and 2. Watery diarrhea may be subdivided into osmotic water retention due to poorly absorbed substances , secretory reduced water absorption , and functional hypermotility types. Secretory diarrhea can be distinguished from osmotic and functional diarrhea by virtue of higher stool volumes greater than 1 L per day that continue despite fasting and occur at night. Stimulant laxatives fall into this secretory category because they increase motility. A history is the critical first step in diagnosis.
It is important to understand exactly what patients mean when they say they have diarrhea. A patient may not actually have diarrhea, but incontinence occasioned by fecal impaction.
A travel history is essential. Travel to the tropics vastly expands the list of diagnostic possibilities, but in no way rules out common causes.
Bloody diarrhea after a trip to Africa may still be ulcerative colitis rather than amebic dysentery. Physical examination provides additional clues to the cause of diarrhea. Recent weight loss or lymphadenopathy could result from chronic infection or malignancy.
Eye findings, such as episcleritis or exophthalmia, suggest that the diarrhea is attributable to inflammatory bowel disease IBD and hyperthyroidism, respectively. Dermatitis herpetiformis, an itchy blistering rash, is found in 15 to 25 percent of patients with celiac disease.
Anal fistulae suggest Crohn disease. A quick office anoscopy may detect ulcerations or impacted stool. Such impactions are a common cause of pseudodiarrhea or paradoxical diarrhea, which is actually seepage around impacted stools. Basic blood work may include a complete blood count, albumin level, erythrocyte sedimentation rate, liver function testing, thyroid-stimulating hormone level, and electrolyte levels.
Iron deficiency anemia may be an indicator of celiac disease and warrants screening. Fecal calprotectin, a neutrophil activity marker, is extremely useful in identifying IBD.
Clostridium difficile stool toxin should be obtained for diarrhea after hospitalization or antibiotic use. A stool laxative screen e. A fecal pH test is quick and can be performed in the office if the patient is not taking antibiotics. At least 0. A pH of less than 5. Fecal electrolyte levels can be used to distinguish secretory from osmotic diarrhea. Although fecal pH tests and fecal electrolyte levels are helpful, they are often omitted from the initial workup.
Abnormal laboratory results help distinguish organic from functional disease. Travel risk factors might warrant a stool culture and sensitivity test, stool ova and parasite examination, and Giardia and Cryptosporidium stool antigen tests. Giardia and Cryptosporidium infections are easily missed on routine ova and parasite examination, although stool acid-fast staining identifies Cryptosporidium.
Finally, sigmoidoscopy or colonoscopy is often required to establish a specific diagnosis. Microscopic colitis can be diagnosed only by colon biopsy. It is usually impractical to test and treat the many possible causes of chronic diarrhea. In most cases, it is more reasonable to categorize by type of diarrhea before testing and treating to narrow the list of diagnostic possibilities and reduce unnecessary testing. Information from references 1 and Empiric therapy may be justified if a specific diagnosis is strongly suspected or resources are limited.
Your doctor may perform stool tests for bacteria and parasites if your diarrhea is severe or bloody or if you traveled to an area where infections are common. If you have severe diarrhea, blood tests will be helpful to guide replacement of fluid and electrolytes and minerals such as magnesium, potassium and zinc that can become depleted.
If you have chronic diarrhea, your doctor will want to further assess etiologic factors or complications of diarrhea by obtaining several tests. These can include a blood count to look for anemia and infections, an electrolyte and kidney function panel to assess for electrolyte abnormalities and renal insufficiency, and albumin to assess your nutritional status. A stool sample may help define the type of diarrhea. The presence of fat, microscopic amounts of blood, and white blood cells will help determine if a fatty, inflammatory, or watery diarrhea is present.
Endoscopic examination of the colon with flexible sigmoidoscopy or colonoscopy and upper endoscopy are helpful in detecting the etiology of chronic diarrhea, as this allows direct examination of the bowel mucosa and the ability to obtain biopsies for microscopic evaluation.
Double-balloon enteroscopy and capsule endoscopy are sometimes used to examine the mucosa of the small intestine that lies beyond the reach of conventional endoscopes. Radiographic studies such as an upper GI series or barium enema are not routinely performed in the evaluation of chronic diarrhea, and have largely been replaced by cross-sectional imaging.
Ultrasound and CT scan of the abdomen can be helpful to evaluate the bowel, pancreas and other intra-abdominal organs. It is important to take plenty of fluid with sugar and salt to avoid dehydration. Salt and sugar together in a beverage help your intestine absorb fluids. Milk and dairy products should be avoided for 24 to 48 hours as they can make diarrhea worse.
Initial dietary choices when refeeding should begin with soups and broth. Anti-diarrheal drug therapy can be helpful to control severe symptoms, and includes bismuth subsalicylate and antimotility agents such as loperamide.
These, however, should be avoided in people with high fever or bloody diarrhea as they can worsen severe colon infections and in children because the use of anti-diarrheals can lead to complications of hemolytic uremic syndrome in cases of Shiga-toxin E.
Your doctor may prescribe antibiotics if you have high fever, dysentery, or moderate to severe traveler's diarrhea.
Some infections such as Shigella always require antibiotic therapy. Treatment of chronic diarrhea depends on the etiology of the chronic diarrhea. Often, empiric treatment can be provided for symptomatic relief, when a specific diagnosis is not reached, or when a diagnosis that is not specifically treatable is reached. Antimotility agents such as loperamide are the most effective agents for the treatment of chronic diarrhea. They reduce symptoms as well as stool weight.
Attention should be paid to replacing any mineral and vitamin deficiencies, especially calcium, potassium, magnesium and zinc. Updated April Updated December Digestive Health Topics A-Z.
Children should see a doctor as soon as possible if they have had more than five bouts of diarrhea or vomited more than twice within 24 hours. There is evidence to suggest that interventions from public health bodies to promote hand-washing can reduce diarrhea rates by about one-third. In developing countries, however, the prevention of diarrhea may be more challenging due to dirty water and poor sanitation.
In most cases, a range of home remedies and medical treatments can help. However, a person should see their doctor if they are concerned about diarrhea or other symptoms.
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