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Factitious diarrhea: Clinical manifestations, diagnosis, and management

Arnold Wald, MD
Section Editor
Lawrence S Friedman, MD
Deputy Editor
Shilpa Grover, MD, MPH


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 [1]. 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 [2].

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 [3].


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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Literature review current through: Sep 2016. | This topic last updated: Sep 16, 2015.
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  1. Fordtran JS, Feldman MD. Factitious Gastrointestinal Disease. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 10th ed, Feldman M, Friedman S, Brandt LJ (Eds), Saunders, Philadelphia 2015. Vol 2, p.363.
  2. Neims DM, McNeill J, Giles TR, Todd F. Incidence of laxative abuse in community and bulimic populations: a descriptive review. Int J Eat Disord 1995; 17:211.
  3. Bytzer P, Stokholm M, Andersen I, et al. Prevalence of surreptitious laxative abuse in patients with diarrhoea of uncertain origin: a cost benefit analysis of a screening procedure. Gut 1989; 30:1379.
  4. Ewe K, Karbach U. Factitious diarrhoea. Clin Gastroenterol 1986; 15:723.
  5. Oster JR, Materson BJ, Rogers AI. Laxative abuse syndrome. Am J Gastroenterol 1980; 74:451.
  6. Perez GO, Oster JR, Rogers A. Acid-base disturbances in gastrointestinal disease. Dig Dis Sci 1987; 32:1033.
  7. SCHWARTZ WB, RELMAN AS. Metabolic and renal studies in chronic potassium depletion resulting from overuse of laxatives. J Clin Invest 1953; 32:258.
  8. Fine KD, Santa Ana CA, Fordtran JS. Diagnosis of magnesium-induced diarrhea. N Engl J Med 1991; 324:1012.
  9. Castelbaum AR, Donofrio PD, Walker FO, Troost BT. Laxative abuse causing hypermagnesemia, quadriparesis, and neuromuscular junction defect. Neurology 1989; 39:746.
  10. Joo JS, Ehrenpreis ED, Gonzalez L, et al. Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited. J Clin Gastroenterol 1998; 26:283.
  11. De Ponti F, De Giorgio R. The cathartic colon? Aliment Pharmacol Ther 2002; 16:643.
  12. Thomas PD, Forbes A, Green J, et al. Guidelines for the investigation of chronic diarrhoea, 2nd edition. Gut 2003; 52 Suppl 5:v1.
  13. Topazian M, Binder HJ. Brief report: factitious diarrhea detected by measurement of stool osmolality. N Engl J Med 1994; 330:1418.
  14. Pollock RC, Banks MR, Fairclough PD, Farthing MJ. Dilutional diarrhea: underdiagnosed and over-investigated. Eur J Gastroenterol Hepatol 2006; 12:609.
  15. Fine KD, Ogunji F, Florio R, et al. Investigation and diagnosis of diarrhea caused by sodium phosphate. Dig Dis Sci 1998; 43:2708.
  16. Ryan CM, Yarmush ML, Tompkins RG. Separation and quantitation of polyethylene glycols 400 and 3350 from human urine by high-performance liquid chromatography. J Pharm Sci 1992; 81:350.
  17. Shelton JH, Santa Ana CA, Thompson DR, et al. Factitious diarrhea induced by stimulant laxatives: accuracy of diagnosis by a clinical reference laboratory using thin layer chromatography. Clin Chem 2007; 53:85.
  18. Pardi DS, Tremaine WJ, Rothenberg HJ, Batts KP. Melanosis coli in inflammatory bowel disease. J Clin Gastroenterol 1998; 26:167.
  19. Koskela E, Kulju T, Collan Y. Melanosis coli. Prevalence, distribution, and histologic features in 200 consecutive autopsies at Kuopio University Central Hospital. Dis Colon Rectum 1989; 32:235.
  20. Eisen T, Hotz J, Stolte M. [Diagnosis of factitious diarrhea (Munchausen syndrome) by colon biopsy]. Z Gastroenterol 1994; 32:351.