Brief Overview: According to UpToDate, “Chronic diarrhea is defined as a persistent alteration of stool consistency from the norm with loose stools (consistency between types 5 and 7 on the Bristol stool chart) and increased stool frequency of greater than three stools daily of at least four weeks' duration.”
Prevalence: The prevalence is not exactly known but is estimated to be approximately 3-7% of the population.
Etiology: There are many causes of chronic diarrhea. Sometimes chronic diarrhea will be classified as inflammatory, watery (osmotic and secretory) and fatty. Each of these classifications has a number of associated etiologies. Some of these are (but are not limited to):
- Inflammatory: parasites, IBD, ischemic colitis, diverticulitis, cancer
- Fatty: malabsorption disorders (celiac disease, pancreatic insufficiency), SIBO, mesenteric ischemia, gastric bypass surgery
- Watery: microscopic colitis, hyperthyroidism, adrenal disorders, IBS, neuroendocrine tumors, bile acid diarrhea
Risk Factors:
- Medications (ex: metformin, Olmesartan, antibiotics)
- Radiation
- Abdominal surgery
- Diabetes
- Immunocompromised patients
- Recurrent bacterial infection
- Diet that includes sugar-free foods, raw milk, food additives, FODMAPs, dairy
- Exposure to contaminated food/water
- Antibiotic use
- Travel
- Stress, anxiety
- Family history
Commonly Associated Conditions:
- IBS
- IBD – Crohn’s, Ulcerative Colitis
- Infections
- Endocrine disorders – hyperthyroidism, diabetes
- Food intolerances
- Malabsorption syndromes (ex: celiac disease)
Common Medications:
- Loperamide (available otc as Imodium)
- Anticholinergic agents – Lomotil
- Intraluminal adsorbents (clays, activated charcoal, bismuth (Kaopectate, Pepto-Bismol), fiber, and bile acid binding resins)
Common Labs, Imaging, and Tests:
- Blood tests: CBC, TSH and free T4, celiac serologies, serum electrolytes, CRP
- Stool tests
- Imaging: endoscopy, colonoscopy
- Further/additional testing may be required in specific circumstances
Common Symptoms:
- Diarrhea
- Weight loss
- Abdominal pain/discomfort
- Bloating, gas
Common Treatments:
- Medication (see above)
- IV fluids if dehydration present
- Dietary modifications
- Treatment/management of any underlying condition
Physical Findings:
- Physical exam may be normal
- Signs of dehydration may be present: dry mouth, low blood pressure
- Abdominal tenderness may be present
- Weight loss
- Fatigue
- Additional findings may be present that may point to a potential etiology (ex: muscle wasting, peripheral edema, heat murmur, lymphadenopathy, thyroid nodule, abdominal bruit, anal sphincter weakness, hepatomegaly, splenomegaly, etc.)
Potential Complications and Contraindications:
- Dehydration
- Electrolyte imbalances
- Malnutrition
- Exceeding the recommended dose of Loperamide has led to serious heart problems in some patients
- Misdiagnosis or delayed diagnosis of other conditions
General Health and Lifestyle Guidance:
- Maintain adequate hydration. Discuss your fluid recommendations with your healthcare provider.
- Avoid any known trigger foods/substances
Suggested Questions to Ask Patients:
- How long have you had diarrhea, and how often are your bowel movements?
- Do you experience pain, urgency, or bloating with symptoms?
- Have you traveled recently or used new medications?
- Are there any foods that seem to trigger your symptoms?
- Have you experienced weight loss, blood in stool, or fever?
Suggested Talking Points:
- Your PCP may be able to manage chronic diarrhea, but a referral to GI may be warranted as well
- Make sure to report any new or worsening symptoms to your healthcare provider
- Keep a symptom diary/stool log to report to your healthcare provider
- Ask your healthcare provider if a probiotic might be beneficial for you
Sources:
- UpToDate
- Cleveland Clinic