Chronic Diarrhea : Medications/Supplements (PART-III)

Many medications can cause chronic diarrhea as a side effect. They can cause it by several different means. Whether they have that effect on you may depend on a variety of other factors, including dosage, diet and other conditions. Your healthcare provider will look at your complete medical profile to determine whether medications are a factor.

Some of the factors that can cause chronic diarrhea include:

• NSAIDs (nonsteroidal anti-inflammatory drugs), such as aspirin and ibuprofen.

• Proton pump inhibitors (PPIs).

• Antibiotics, such as amoxicillin and cephalexin.

• Certain herbal supplements and tea ingredients, such as senna.

• High doses of certain vitamin and mineral supplements, such as vitamin C and magnesium.

• Antacids containing magnesium.

• Antidepressants (selective serotonin reuptake inhibitors) such as fluoxetine (Prozac®) and sertraline (Zoloft®).

• Beta-blockers.

• Metformin.

• Chemotherapy.

• Laxatives, when overused, as in bulimia nervosa.

What are the different types of diarrhea and their causes?

Healthcare providers sometimes classify diarrhea into three or four types as a way of narrowing down the cause. These types produce diarrhea with distinct qualities that doctors can recognize in your poop. They represent broad categories of causes. The three main types are inflammatory, fatty and watery. Some divide watery diarrhea into two sub-types (secretory and osmotic) to make four main types.

Watery diarrhea

Watery diarrhea happens when your colon is unable to absorb enough water and electrolytes from your poop and/or when it’s secreting more than it’s absorbing. The osmotic type is caused by poorly absorbed nutrients that draw extra water into your colon. (This is how osmotic laxatives work.) Meanwhile, secretory diarrhea represents a wide variety of diseases that can cause watery diarrhea.

Some of these causes include:

• Bile acid diarrhea. (This happens when there’s too much bile in the gut; also known as bile acid malabsorption, or BAM.)

• Microscopic colitis.

• Diabetes-related neuropathy.

• Vagotomy.

• Hyperthyroidism.

• Adrenal disorders.

• Neuroendocrine tumors.

• Irritable bowel syndrome (IBS).

Fatty diarrhea

Sometimes, excess fat in your poop changes the consistency to diarrhea. This can happen when your body has trouble breaking down and absorbing fats, or when bacteria in your gut produce excessive fatty acids. Fatty diarrhea may be less frequent but with greater volume. It may be smellier than normal and may leave a visible oil residue in the toilet. It may come with nausea, indigestion and weight loss.

Causes include:

• Malabsorption disorders such as pancreatic insufficiency and celiac disease.

• Small intestinal bacterial overgrowth (SIBO).

• Mesenteric ischemia.

• Gastric bypass surgery.

Inflammatory diarrhea

Inflammatory diarrhea is caused by inflammation in your colon (colitis). Inflammation affects the mucous lining of your colon (mucosa). It causes swelling and impairs the colon’s ability to absorb. Inflammatory diarrhea tends to come out more frequently and in smaller amounts. It may be accompanied by stomach pain, fever or bleeding. Inflammatory conditions that can cause chronic diarrhea include:

• Persistent infections, such as parasites or C. diff (pseudomembranous colitis).

• Inflammatory bowel disease (such as ulcerative colitis or Crohn’s disease.)

• Ischemic colitis.

• Diverticulitis.

• Radiation colitis.

• Cancer.

Food and Nutrition supplements 

Foods that May Lead to or Worsen Diarrhea in Sensitive Individuals

• Milk and other dairy products

• Legumes (chickpeas, beans, peas, lentils and lupins) and cabbage family vegetables—these are all high in fiber

• Fruits and juices that contain fructose

• Caffeine-containing beverages such as coffee and tea

• Alcoholic beverages such as beer, wine, and liquor

• Fatty meats such as bacon and heavily marbled meats

• High fat foods such as fried foods, pastries, and chips

• Artificial sweeteners such as NutraSweet®, Splenda®, Equal®, sorbitol, etc.

• Sugar-free gums and mints that contain sorbitol, mannitol, or xylitol

• Real black licorice (not the candy)

• Large quantities of nuts or nut butters

• Concentrated sweets
  o Dried fruits such as figs, dates, raisins, and prunes
  o Prune juice

Foods/Fluids that may Improve Diarrhea

• Increase fluids to prevent dehydration. Try to drink these fluids between your meals. Liquids with a meal may speed up stomach emptying and
  possibly worsen diarrhea.

• Eat and/or drink foods and beverages with sodium and potassium. Diarrhea can lead to low levels of both sodium and potassium, so it is important to replace these electrolytes through your diet

• Broth (sodium)

• Sports drinks (sodium and potassium); however, avoid sugar-free drinks which have artificial sweeteners (see list above)

• Equalyte®, Pedialyte® (sodium and potassium)

• Bananas (potassium)

• Nectars (potassium)

• Boiled or mashed potatoes (potassium)

• Eat lower fiber foods:

• Yogurt (if you are lactose intolerant, may want to avoid)

• Rice

• Noodles

• White bread

• Cream of wheat

• Smooth peanut butter, a small amount at a time

• Lean meats

• Drink beverages at room temperature, not too cold or hot

Supplements that May Help to Control Diarrhea

Probiotics may help prevent antibiotic-associated diarrhea. They are found in yogurts that contain Live Active Cultures (LAC) such as lactobacillus acidophilus. Look for the term LAC on the label of yogurts in the dairy aisle (note: frozen yogurt does not contain LAC). 

Pectin is a form of fiber found in fruits and some vegetables that may slow the movement of stool in your intestines. It is also sold as a powder in grocery stores. You can find this in the aisle with pudding and gelatin. To help with diarrhea, mix 1 tablespoon of pectin powder with ¼ cup of lemon water and drink it 20–30 minutes before a meal.

The Bottom Line

To prevent complications that can result from frequent bowel movements, do try to do the following:

• Keep a food and symptom diary to help identify which foods, drinks, and supplements may be leading to or worsening your diarrhea

• Eat smaller, more frequent meals during the day

• Sit and relax for 20-30 minutes after you eat

• Drink plenty of fluids in between your meals

• Eat and drink foods and beverages that contain sodium and potassium 

Remember, generalized dietary advice does not work for everyone. The influence of diet is unique to each individual. If you have questions about your symptoms and circumstances, talk to your healthcare provider. They will be able to identify dietary and other changes that may decrease your symptoms and improve your quality of life.

Chronic Diarrhea : Pathophysiology and Diagnosis (PART-II)

 Diarrhea is an increase in the volume of stool or frequency of defecation. It is one of the most common clinical signs of gastrointestinal disease, but also can reflect primary disorders outside of the digestive system. Certainly, disorders affecting either the small or large bowel can lead to diarrhea.

For many people, diarrhea represents an occasional inconvenience or annoyance, yet at least 2 million people in the world, mostly children, die from the consequences of diarrhea each year.

There are numerous causes of diarrhea, but in almost all cases, this disorder is a manifestation of one of the four basic mechanisms described below. It is also common for more than one of the four mechanisms to be involved in the pathogenesis of a given case.

Osmotic Diarrhea

Absorption of water in the intestines is dependent on adequate absorption of solutes. If excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhea will result. Osmotic diarrhea typically results from one of two situations:

• Ingestion of a poorly absorbed substrate: The offending molecule is usually a carbohydrate or divalent ion. Common examples include mannitol or sorbitol, epson salt (MgSO4) and some antacids (MgOH2).

• Malabsorption: Inability to absorb certain carbohydrates is the most common deficit in this category of diarrhea, but it can result virtually any type of malabsorption. A common example of malabsorption, afflicting many adults humans and pets is lactose intolerance resulting from a deficiency in the brush border enzyme lactase. In such cases, a moderate quantity of lactose is consumed (usually as milk), but the intestinal epithelium is deficient in lactase, and lactose cannot be effectively hydrolyzed into glucose and galactose for absorption. The osmotically-active lactose is retained in the intestinal lumen, where it "holds" water. To add insult to injury, the unabsorbed lactose passes into the large intestine where it is fermented by colonic bacteria, resulting in production of excessive gas.

A distinguishing feature of osmotic diarrhea is that it stops after the patient is fasted or stops consuming the poorly absorbed solute.

Secretory Diarrhea

Large volumes of water are normally secreted into the small intestinal lumen, but a large majority of this water is efficiently absorbed before reaching the large intestine. Diarrhea occurs when secretion of water into the intestinal lumen exceeds absorption.

Many millions of people have died of the secretory diarrhea associated with cholera. The responsible organism, Vibrio cholerae, produces cholera toxin, which strongly activates adenylyl cyclase, causing a prolonged increase in intracellular concentration of cyclic AMP within crypt enterocytes. This change results in prolonged opening of the chloride channels that are instrumental in secretion of water from the crypts, allowing uncontrolled secretion of water. Additionally, cholera toxin affects the enteric nervous system, resulting in an independent stimulus of secretion.

Exposure to toxins from several other types of bacteria (e.g. E. coli heat-labile toxin) induce the same series of steps and massive secretory diarrhea that is often lethal unless the person or animal is aggressively treated to maintain hydration.

In addition to bacterial toxins, a large number of other agents can induce secretory diarrhea by turning on the intestinal secretory machinery, including:

• some laxatives

• hormones secreted by certain types of tumors (e.g. vasoactive intestinal peptide)

• a broad range of drugs (e.g. some types of asthma medications, antidepressants, cardiac drugs)

• certain metals, organic toxins, and plant products (e.g. arsenic, insecticides, mushroom toxins, caffeine)

In most cases, secretory diarrheas will not resolve during a 2-3 day fast.

Inflammatory and Infectious Diarrhea

The epithelium of the digestive tube is protected from insult by a number of mechanisms constituting the gastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results. Examples of pathogens frequently associated with infectious diarrhea include:

• Bacteria: Salmonella, E. coli, Campylobacter

• Viruses: rotaviruses, coronaviruses, parvoviruses (canine and feline), norovirus

• Protozoa: coccidia species, Cryptosporium, Giardia

The immune response to inflammatory conditions in the bowel contributes substantively to development of diarrhea. Activation of white blood cells leads them to secrete inflammatory mediators and cytokines which can stimulate secretion, in effect imposing a secretory component on top of an inflammatory diarrhea.

Reactive oxygen species from leukocytes can damage or kill intestinal epithelial cells, which are replaced with immature cells that typically are deficient in the brush border enyzmes and transporters necessary for absorption of nutrients and water. In this way, components of an osmotic (malabsorption) diarrhea are added to the problem.

Diarrhea Associated with Deranged Motility

In order for nutrients and water to be efficiently absorbed, the intestinal contents must be adequately exposed to the mucosal epithelium and retained long enough to allow absorption. Disorders in motility than accelerate transit time could decrease absorption, resulting in diarrhea even if the absorptive process per se was proceeding properly.

Alterations in intestinal motility (usually increased propulsion) are observed in many types of diarrhea. What is not usally clear, and very difficult to demonstrate, is whether primary alterations in motility are actually the cause of diarrhea or simply an effect.

Chronic Diarrhea : Symptoms and Causes (PART-I)

 What is chronic diarrhea?

Diarrhea is loose, runny poop. We’ve all probably had it at one time or another. It tends to come out fast, suddenly and urgently, and you may have cramping or spasms in your colon when you go.

If you have food poisoning or the flu, you might have diarrhea for a day or so. It goes away when the original infection does. Chronic diarrhea is persistent diarrhea that continues for more than four weeks.

How common is this condition?

An estimated 1% to 3% of the population has chronic diarrhea. But these estimates may be low, as many people don’t seek treatment unless they have other symptoms, such as pain or bleeding.

Is it normal to have diarrhea all day every day?

Chronic and frequent diarrhea is an everyday experience for some people, but under normal circumstances, it shouldn’t be. Your colon, where poop is formed, is reacting to something abnormal.

Some people have chronic bowel diseases that cause chronic diarrhea. These diseases may not be curable, but you can treat the symptoms. Other causes are often curable with the right treatment.

What does persistent diarrhea indicate?

Normally, your colon receives liquefied food waste from your small intestine and gradually condenses it into solid poop. But with diarrhea, something impairs this process, leaving you with liquefied poop.

Something is making it hard for your colon to absorb water as it normally would, or making it excrete extra water, or both. It may be a problem with your colon itself or something abnormal inside it.

Symptoms and Causes

What are some common causes of chronic diarrhea?

Many diseases can cause chronic diarrhea. But before looking for diseases, a healthcare provider will ask you about your diet and medications. These are some of the most common causes of self-induced chronic diarrhea, and also some of the easiest causes to fix. Possible causes include:

Diet

Certain foods and drinks can cause diarrhea. If you eat or drink excessive amounts of them on a regular basis, or if you’re particularly sensitive to any of them, they might cause chronic diarrhea. Isolating the offending food or drink and reducing it or eliminating it from your diet may solve the problem. Consider:

• Coffee/Tea : Coffee affects your motility, speeding up your colonic transit time. Too much can make the food waste in your colon hastily exit before it has time to solidify. It’s unclear whether this is due to the caffeine or other chemicals in coffee. Some people experience similar effects from caffeinated tea or decaffeinated coffee. Different people may be more or less sensitive to different chemicals in these products. (You may also be sensitive to the milk or sweeteners added to them.) If you drink them often enough, you might have chronic side effects.

• Alcohol : Alcohol also speeds up your gut motility and your colonic transit time, especially on an empty stomach. It might be more likely to occur with moderate amounts than with excessive amounts. Too much alcohol may slow your digestion and dehydrate you, causing constipation. But regular, heavy drinking can cause diarrhea for a different reason — inflammation. If your colon is irritated and inflamed by alcohol, it can’t absorb water and minerals as it normally would. If the mucous lining of your colon has been damaged, it might even leak fluids.

• Specific sugars : Some sugars are harder to digest, and too much may cause diarrhea. Your intestines may lack the necessary enzymes to break them down, or there may be no such enzyme. Artificial sweeteners, such as sorbitol, mannitol and lactulose, are among the sugars that can’t be digested by human intestines. That’s why they don’t add calories. When your intestines can’t break the molecules down, they draw in extra water to help usher the oversized molecules out of your body. Fructose can have this effect in certain quantities and proportions, which is why products made with high fructose corn syrup may cause diarrhea. Some people also have specific intolerances to specific sugars. Lactose intolerance is the most common.

• Food intolerances : You might have a food intolerance if you have difficulties digesting a particular type of food. This often means that you lack an enzyme necessary to break the food down in your digestive system. Gluten intolerance, histamine intolerance and certain sugar (carbohydrate) intolerances are common examples of this. Unabsorbed foods cause diarrhea. 

Complications : 

Diarrhea can cause dehydration, which can be life-threatening if untreated. Dehydration is particularly dangerous in children, older adults and those with weakened immune systems. 

If you have signs of serious dehydration, seek medical help.

Indications of dehydration in adults

These include:

• Excessive thirst.

• Dry mouth or skin.

• Little or no urination.

• Weakness, dizziness or lightheadedness.

• Fatigue.

• Dark-colored urine.

Indications of dehydration in infants and young children

These include:

• Not having a wet diaper in three or more hours.

• Dry mouth and tongue.

• Fever above 102 F (39 C).

• Crying without tears.

• Drowsiness, unresponsiveness or irritability.

• Sunken appearance to the belly, eyes or cheeks.