Patient information: Chronic diarrhea in adults

CHRONIC DIARRHEA OVERVIEW

Chronic diarrhea is defined as loose stools that last for at least four weeks. You may have one or more loose stools per day. At any given time, up to 5 percent of people in the United States have chronic diarrhea.

There are many possible causes of chronic diarrhea; identifying the underlying cause ensures that the appropriate treatment is used. Treatment is aimed at correcting the cause of diarrhea (whenever possible), alleviating loose stools, and addressing any complications of long-standing or severe diarrhea.

Chronic diarrhea can have a substantial impact on your quality of life and overall health. At its mildest, the condition may be an inconvenience; at its worst, it may be disabling and even life-threatening. More detailed information about chronic diarrhea is available by subscription. (See "Approach to the adult with chronic diarrhea in developed countries".)

CHRONIC DIARRHEA CAUSES

This article will focus on causes of chronic diarrhea in developed countries such as the United States. A wide range of conditions can cause chronic diarrhea; some of the most common causes include irritable bowel syndrome, inflammatory bowel disease (Crohn's disease and ulcerative colitis), malabsorption syndromes, and chronic infections. There are also many other less common causes of chronic diarrhea.

Irritable bowel syndrome — Irritable bowel syndrome (IBS) causes abdominal pain and changes in bowel habits (diarrhea and/or constipation). IBS is one of the most common causes of chronic diarrhea. Abdominal pain is typically crampy, may be mild to severe, and is often located in the lower left abdomen. (See "Patient information: Irritable bowel syndrome".)

IBS can cause diarrhea, constipation, or alternating diarrhea and constipation. Diarrhea is often preceded by a sense of extreme urgency and followed by a feeling of not being able to empty completely.

Inflammatory bowel disease — There are several types of inflammatory bowel disease, with two of the most common being Crohn's disease and ulcerative colitis. These conditions may develop when the body's immune system inappropriately attacks parts of the digestive tract.

Crohn's disease — Common features of Crohn's disease include mouth sores, diarrhea, abdominal pain, weight loss, and fever. There may also be problems outside of the digestive tract. (See "Patient information: Crohn's disease".)

Ulcerative colitis — Symptoms of ulcerative colitis depend upon the severity of the disease, but can include frequent, loose bloody stools, anemia, abdominal pain or cramps, and fever. (See "Patient information: Ulcerative colitis".)

Infections — Intestinal infections are an uncommon cause of chronic diarrhea in people who live in developed countries such as the United States. Infections that cause chronic diarrhea can be seen in people who travel or live in tropical or developing countries, especially older adults and those affected by HIV. Other risk factors for infection include recent use of antibiotics and drinking contaminated water or unpasteurized ("raw") milk.

Medications — A number of medications, herbs, and dietary supplements can cause diarrhea as a side effect. To determine if a medication could be the cause of chronic diarrhea, review your medications with your healthcare provider or pharmacist. This information may also be available on the medication bottle or paperwork that accompanies most prescriptions.

CHRONIC DIARRHEA EVALUATION

You should see a healthcare provider if you have loose or watery stools that last more than four weeks. You may need to be seen sooner than this, especially you develop complications of diarrhea (eg, dehydration or weight loss).

During this visit, it is important to mention when your diarrhea began, any recent changes in medicines or medical problems, and if you have had accidents (leaking or smearing stool in the underwear).

Diagnostic tests — Tests can help to diagnose the underlying cause of diarrhea. In most cases, tests of the blood, stool, or urine are recommended first. If these tests are not conclusive, other tests may be needed, including x-ray tests or procedures such as colonoscopy or sigmoidoscopy. Your primary care provider may order these tests or refer you to a specialist (a gastroenterologist).

In some cases, your provider will recommend a trial of treatment before more invasive tests.

CHRONIC DIARRHEA TREATMENT

Treatment of chronic diarrhea aims to eliminate the underlying cause (if the cause is known), relieve the diarrhea, and treat any diarrhea-related complications.

Treatment of the underlying cause — The underlying cause of chronic diarrhea should be identified and treated, whenever possible. As examples, infections may be treated with antibiotics while inflammatory bowel diseases (such as ulcerative colitis and Crohn's disease) require treatment with specific medications. (See "Patient information: Ulcerative colitis".)

In some cases, treatment may be as simple as eliminating a food. For people with lactose intolerance, this may include foods/drinks that contain lactose (table 1). Other ingredients that are known to cause diarrhea include sugar-free products made with sorbitol and foods made with fat replacements (eg, Olestra®). Certain medications can also cause diarrhea (such as laxatives and antacids).

Treatment of diarrhea — In some people, the goal of treatment is to simply reduce the frequency of diarrhea. This approach is often used before testing, when the results of tests are normal or inconclusive, or if diarrhea is caused by a chronic medical problem.

Treatments include:

• Bismuth (Kaopectate®, Pepto-Bismol®)
• Measures that bulk the stools, such as a high fiber diet or fiber supplement (see "Patient information: High fiber diet")

• Antidiarrheal medicines such as loperamide (Imodium®, available without a prescription) or prescription medication such as diphenoxylate (Lomotil®).
• Octreotide; this is a prescription medicine that may be given to people with severe diarrhea

Treatment trial — If your healthcare provider strongly suspects a specific cause of chronic diarrhea, but the results of your tests are normal or inconclusive, he or she may recommend trying a treatment before further testing.

Examples include:

• A trial of antibiotics for a presumed infection
• Stopping a specific medicine for presumed drug-induced diarrhea
• Changes in your diet for presumed food allergies or malabsorption (eg, related to lactose intolerance or celiac disease)

Treatment of complications — Chronic or severe diarrhea can lead to potentially serious complications, including dehydration and malnutrition. While you are being evaluated, you should be sure to drink plenty of fluids. You are drinking enough fluids if your urine is a light yellow color.

If you are not able to drink enough fluids and you become dehydrated, you may be given fluids into a vein to replace the fluids and electrolytes (salts) lost in diarrhea. This will not cure your diarrhea, but it can prevent more serious complications.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Irritable bowel syndrome
Patient information: Crohn's disease
Patient information: Ulcerative colitis
Patient information: High fiber diet

Professional Level Information:
Approach to the adult with chronic diarrhea in developed countries
Clinical features and diagnosis of malabsorption
Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults
Cryptosporidiosis
Cyclospora infections
Definition of and risk factors for inflammatory bowel disease
Differential diagnosis of microbial foodborne disease
Eosinophilic gastroenteritis
Epidemiology, clinical manifestations, and diagnosis of giardiasis
Evaluation of the HIV-infected patient with diarrhea
Isospora infections
Lactose intolerance
Lymphocytic and collagenous colitis (microscopic colitis)
Medical management of Crohn's disease in adults
Medical management of ulcerative colitis
Overview of the management of Crohn's disease in children and adolescents
Pathogenesis, clinical manifestations, and diagnosis of bacterial overgrowth
Treatment and prevention of giardiasis in adults
Treatment of irritable bowel syndrome

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/diarrhea.html)

• The Centers for Disease Control and Prevention

      (www.cdc.gov/ncidod/dpd/parasites/diarrhea/factsht_chronic_diarrhea.htm)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/diarrhea/)

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