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Overview |
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Definition |
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Diarrhea is characterized by unformed, watery stools (200 to 250 g/day) and
increased bowel movement frequency, often accompanied by fever, chills, malaise.
The symptom of an underlying condition or conditions, diarrhea is considered to
be acute at onset, and chronic after two to three weeks. Although diarrhea is a
common condition and usually self-limiting (two to three days), complications
can be serious, even fatal, in infants and elderly patients, consequently it is
important to attempt to determine the cause(s).
Diarrhea has four primary classifications.
- Osmotic: reduced solute absorption
- Secretory: increased electrolyte and water secretion
- Exudative: loss of fluid and protein from intestinal
mucosa
- Motility disorder: intestinal transit
alterations
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Etiology |
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Common causes include viral, bacterial, and parasitic infection (often spread
person-to-person), inflammation, drugs, and psychogenic causes. In
particular:
Acute:
- Infection (primary)
- Inflammatory bowel disease (primary)
- Iatrogenic causes
- Poisoning
Chronic:
- Malabsorption (notably lactose intolerance)
- Inflammatory bowel disease
- Colitis
- Irritable bowel syndrome
- Food allergies
- Giardia
- Chronic constipation
- AIDS and other immune disorders
Chronic subdivisions (multiple types of diarrhea may be present):
Osmotic diarrhea:
- Malabsorption
- Low sugar absorption (lactose intolerance)
- Antacids
Secretory diarrhea:
- Bacterial infections (e.g., cholera)
- Collagenous colitis
- Crohn's disease
- Celiac sprue
- Laxative abuse (common with chronic diarrhea)
- Tumors
- Hyperthyroidism
Exudative diarrhea:
- Bacterial infections (e.g., Shigella, Salmonella)
- Ulcerative colitis
- Inflammatory bowel disease
Motility disorder diarrhea:
- Irritable bowel syndrome
- Scleroderma
- Diabetes
- Surgical procedures
- Laxatives
- Hyperthyroidism
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Risk Factors |
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- Dairy products, some fruits and legumes
- Sugar substitutes (hexitols, sorbitol, mannitol)
- Hospitalization/surgery (iatrogenic)
- Foreign travel
- Hiking, camping, fishing trips
- Exposure to infected persons
- Medications (e.g., antibiotics, antacids, diuretics,
antihypertensives, anti-inflammatories, and cardiovascular
medications)
- Stress
- Recent antibiotic therapy
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Signs and Symptoms |
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- Loose stools, with or without blood and mucus
- Frequent need to defecate
- Abdominal pain, cramping
- Fever, chills, malaise
- Weight loss
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Differential
Diagnosis |
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- Crohn's disease
- Colitis, ulcerative colitis
- Whipple's disease
- Inflammatory bowel disease
- Irritable bowel syndrome
- Reiter's syndrome
- Zollinger-Ellison syndrome
- Over-the-counter medications
- Various rare intestinal tumors (ganglioneuroblastoma, mucinous
cystadenoma, and intestinal lipoblastoma)
- Congenital microvillous atrophy
- Congenital chloride diarrhea
- Magnesium or vitamin C
supplementation
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Diagnosis |
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Physical Examination |
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For most patients, diarrhea is relatively benign and self-limiting. A few
patients, however, have an underlying illness that should be diagnosed and
treated—in particular, patients with diarrhea that has
persisted for longer than three days or with blood in the feces (suggesting
exudative diarrhea). Determining the mechanism (osmotic, secretory, exudative,
or motility) helps direct treatment.
Because patients will not be capable of reporting stool weight/day, patient
history plays a major role in diagnosing diarrhea.
- Confirm that the condition is diarrhea, not fecal
incontinence.
- Determine the volume type of diarrhea.
- Determine if diarrhea is acute (generally related to infection) or
chronic.
- Note signs and symptoms.
- Ask patient about risk factors, lactose intolerance, antibiotics use,
sexual orientation, and surgery.
- Explore the effect of diet. (Osmotic diarrhea generally ends when
fasting. Secretory diarrhea generally does not end when fasting. Lactase
deficiency generally is an accurate diagnosis if symptoms improve with the
elimination of milk and dairy products).
Assess:
- Hydration
- Abdominal tenderness
- Bowel sounds
- Rectum (carcinoma, fecal
impactions)
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Laboratory Tests |
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- Stool sample
- CBC
- Serum electrolytes
- BUN
- d-xylose
- Pancreatic function
- Urinalysis
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Pathology/Pathophysiology |
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Blood:
- Leukocytosis
- Pathogens
- Anemia
- Biochemical deficiencies
Endoscopy:
- Mucosal abnormalities
- Bleeding
- Ulcers
Stool:
- Blood (generally exudative diarrhea)
- Weight/volume
- Fecal fat
- Electrolytes
- Osmolality
- Parasites
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Imaging |
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- Small-bowel radiography
- Barium enema
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Other Diagnostic
Procedures |
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In addition to patient history and physical assessment, endoscopy, laboratory
tests (including stool analysis), and rectal biopsy (occasionally) can help
determine the cause—and thus the
treatment—of diarrhea. |

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Treatment Options |
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Treatment Strategy |
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Because diarrhea is a symptom, treatment should be dictated by the cause (or
causes). For acute, uncomplicated diarrhea, it may be sufficient to reassure
patients that the diarrhea is benign and will resolve in a couple of days and
simply treat the symptoms.
For some chronic diarrhea, dietary change can be sufficient without
additional evaluation.
Serious acute bloody diarrhea and chronic diarrhea will require evaluation
and treatment of underlying cause(s). Hospitalization should be considered with
dehydration; in any case, replacement of fluids (clear fluids without caffeine
and rehydration fluids) and electrolytes—particularly
with very young and very old patients—is
critical. |

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Drug Therapies |
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Because some medications prescribed for diarrhea can delay resolution of
certain infectious diarrhea conditions (as well as other contraindications),
diarrhea should be diagnosed before drug therapy is undertaken. Common drug
therapies (many OTC) include the following.
- Opioid derivatives: diphenoxylate-atropine (Lomotil) and loperamide
(Imodium). May have CNS effect.
- Adsorbents: bismuth salts (Pepto-Bismol), kolin, and pectin
(Kaopectate), aluminum hydroxide (Amphojel), cholestyramine
(Questran)
- Bulk-forming medications: psyllium (Metamucil,
Konsyl)
Specific guidelines include:
- Bismuth salts for traveler's diarrhea
- Cholestyramine for bile-acid-induced
diarrhea
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Complementary and Alternative
Therapies |
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Severe diarrhea can be life-threatening, and it is imperative that the
underlying etiology be assessed before initiating any treatment other than fluid
replacement. Nutrition suggestions should be followed for all types of
diarrhea. |

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Nutrition |
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- Avoid coffee, chocolate, dairy products, strong spices, and solid
foods. Introduce clear soup, crackers and white bread, rice, potatoes,
applesauce, and bananas as diarrhea begins to resolve. Sips of black tea may
help settle the stomach when nausea is present.
- To restore and maintain fluid and electrolyte balance, consider rice
and/or barley water, fresh vegetable juices (especially carrot and celery), miso
broth, or other clear broths. Rice and barley water are made using 1 cup of
grain to 1 quart of boiling water. Let steep for 20 minutes. Strain and drink
throughout the day.
- Lactobacillus species taken as powder or in capsules helps to
normalize bowel flora and may help resolve diarrhea. Take as directed, or one
dose with each meal. Saccharomyces bolardii and brewer's yeast are
specific for treating antibiotic-induced diarrhea that has caused Clostridium
difficile overgrowth.
- Vitamin C (1,000 mg tid to qid) and vitamin A (10,000 to 20,000
IU/day) support immune function. High doses of vitamin C may cause diarrhea.
High doses of vitamin A should not be taken long-term without physician
supervision.
- Glutamine (3,000 mg tid) is helpful to treat diarrhea that is caused
by mucosal irritation rather than infection, such as chemotherapy-induced
diarrhea.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Do not initiate antidiarrheal therapy if the diarrhea is secondary to an
infectious agent. Herbs can be used as anti-inflammatories, antimicrobials, or
antidiarrheals. Choose one or two from each category as needed. They are best
used as teas unless otherwise noted.
Anti-inflammatory herbs:
- Quercetin (250 to 500 mg bid to qid)
- Chamomile (Matricaria recutita) is a soothing
antispasmodic.
- Marshmallow root (Althea officinalis) is best prepared as
cold-water tea. Soak 2 tbsp. root in one quart of water overnight. Strain and
drink throughout the day.
Antimicrobial herbs:
- Barberry (Berberis vulgaris), 250 to 500 mg tid
- Goldenseal (Hydrastis canadensis), 250 to 500 mg
tid
- Licorice root (Glycyrrhiza glabra) (contraindicated in
hypertension)
Antidiarrheal herbs:
- Blackberry leaf (Rubus fruticosus) or raspberry leaf (Rubus
idaeus)—use 1 heaping tsp./cup. Drink 1/2 cup per
hour.
- Carob powder—use 4 tsp. per 4 oz. of water
or mix in applesauce. Take 1/2 to 1 tsp. every 30 to 60 minutes.
- Slippery elm powder (Ulmus fulva) or marshmallow root
powder—use 1 oz. powder to 1 quart of water. Make a
paste with the powder and a small amount of water. Gradually add in the rest of
the water and then simmer down to one pint. Take 1 tsp. every 30 to 60
minutes.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Arsenicum album when patient is weak, chilly, anxious, and
restless with diarrhea.
- Podophyllum for yellow, explosive, gushing, gurgling, painless
diarrhea
- Chamomilla for greenish, frothy stool with severe colicky
pains; stool smells like rotten eggs.
- Mercurius vivus for strong urging with offensive, bloody
diarrhea.
- Aloe for colicky, cramping pains before and during stool. Weak
and sweaty after diarrhea.
- Veratrum album for diarrhea and vomiting, collapsed
states.
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Patient Monitoring |
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Dehydrated patients and infant and elderly patients with serious signs and
symptoms should be monitored carefully. Patients with acute diarrhea should
report conditions that do not resolve in three to five days. Follow up with
chronic patients as required. |

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Other
Considerations |
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Prevention |
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Avoid risk factors as possible. |

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Complications/Sequelae |
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- Dehydration
- Syncope, arrhythmias (from loss of electrolytes)
- Anemia
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Prognosis |
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- Acute: generally resolves in two to three days
- Chronic, idiopathic diarrhea: generally self-limiting, although it
may continue indefinitely
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Pregnancy |
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Dehydration can cause preterm labor. Gastrointestinal spasm may have
reflexive action on uterine muscle and induce contractions. Goldenseal
(Hydrastis canadensis) and barberry (Berberis vulgaris) should be
avoided in pregnancy as they may stimulate contractions. High doses of vitamin A
may be teratogenic and should be avoided. |

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References |
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Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine.
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Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |