Factitious diarrhea: Clinical manifestations, diagnosis, and management
- Arnold Wald, MD
Arnold Wald, MD
- Professor of Medicine
- University of Wisconsin School of Medicine and Public Health, Madison
Factitious diarrhea may be due to a self-induced true increase in stool volume or the creation of an apparent increase in stool volume by the addition of various substances to the stool. Early diagnosis of factitious diarrhea can prevent patient self-harm as well as iatrogenic complications arising from unnecessary tests and treatments. This topic will review the clinical manifestations, diagnosis, and management of factitious diarrhea. Other causes of chronic diarrhea and the clinical features, diagnosis, and management of factitious disorder are discussed separately. (See "Approach to the adult with chronic diarrhea in resource-rich settings" and "Factitious disorder imposed on self (Munchausen syndrome)".)
More than 90 percent of patients with factitious diarrhea are women and have a history of work in the healthcare field . These patients often seek care from many clinicians and have multiple hospital admissions in an effort to establish the cause of the diarrhea. They also have a higher incidence of anorexia nervosa, suggesting a common underlying psychiatric basis .
Surreptitious laxative abuse is the most frequent cause of factitious diarrhea and often presents as chronic watery diarrhea of unknown etiology. In one study in which 47 patients at a tertiary referral center for evaluation of diarrhea of unclear etiology were screened for laxative use, seven patients (15 percent) tested positive for laxatives .
Clinical presentation — Patients with factitious diarrhea often present with a history of frequent, large-volume, watery diarrhea [4,5]. Patients report between 10 and 20 bowel movements a day, with 24-hour stool volumes ranging from 300 to 3000 mL. More than 50 percent of patients complain of nocturnal bowel movements. Patients may also report associated blood in the stool.
In patients with factious diarrhea due to laxatives, diarrhea is often associated with cramping abdominal pain due to an increase in the fluid content of the stool and enhanced gastrointestinal motility. Lethargy, generalized weakness, and dizziness or lightheadedness may result from orthostatic hypotension due to dehydration. Weight loss is common, and in severe cases, patients may have malnutrition and cachexia due to diarrhea, concurrent nausea or vomiting, or diminished nutrient absorption. As an example, rhein (an anthraquinone) and bisacodyl (a diphenolic laxative) impair glucose absorption and may also cause mild steatorrhea and gastrointestinal protein loss. (See "Mechanisms, causes, and evaluation of orthostatic hypotension", section on 'Symptoms' and "Management of chronic constipation in adults", section on 'Stimulant laxatives'.)
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