What is Chronic Diarrhea?

Diarrhea is commonly used to refer to loose or watery bowel movements that happen three or more times in a single day. These symptoms need to persist for four or more weeks to be classified as chronic diarrhea. Almost everyone will experience diarrhea at some point, and what is considered diarrhea can differ from person to person. Therefore, doctors need to gather specific details about the person’s symptoms to correctly diagnose diarrhea. Many people will use the term diarrhea to describe any type of loose or watery stool, no matter how often it occurs.

What Causes Chronic Diarrhea?

Long-term diarrhea can have many causes, and it usually happens when more water ends up in the stool than usual. These causes mainly fall into two groups – inflammatory and secretory. Depending on the individual’s economic status, the causes may differ. Those from lower-income backgrounds are more likely to have bacterial, mycobacterial, and parasitic infections causing diarrhea. Meanwhile, individuals from mid to high-income backgrounds are more likely to have conditions like irritable bowel syndrome, inflammatory bowel disease, and malabsorption syndromes.

Irritable bowel syndrome is a condition that causes abnormal bowel habits, like diarrhea or constipation, along with stomach pain. It has nothing to do with any disease. Women are more likely to have it than men, and stress tends to make it worse. Symptoms include lower abdominal pain and diarrhea, constipation, or alternating between the two. These symptoms often improve after a bowel movement.

Certain medications can cause diarrhea. There are more than 700 drugs known to do this. Medical practitioners need to be aware of any new medication that might be causing diarrhea in their patients.

Crohn’s disease is a kind of inflammatory bowel disease causing diarrhea, abdominal pain, and signs of bowel obstruction. There might even be abnormal connections, called fistulas, in the anus, which can provide a clue towards the diagnosis.

Ulcerative colitis is another major type of inflammatory bowel disease whose cause is unknown. Symptoms include abdominal pain, diarrhea, and bloody stools. Weight loss and pale skin due to anaemia might also provide hints towards the diagnosis.

Microscopic colitis is a common cause of long-term watery diarrhea. It has two subtypes: collagenous and lymphocytic colitis. This can be diagnosed with an endoscopic biopsy, a procedure where a small amount of tissue is taken for examination.

Celiac disease is an autoimmune condition where eating gluten triggers a harmful immune response. It leads to symptoms like abdominal cramping, diarrhea, and weight loss. To confirm the diagnosis, a biopsy of the intestine is needed, showing damage to the intestinal lining. Most patients will also have antibodies against a certain enzyme in their blood.

Chronic pancreatitis, a disease of the pancreas, leads to reduced production of digestive enzymes. This in turn leads to nutrient malabsorption, resulting in fat-rich stools and weight loss.

Lactose intolerance happens when the enzyme that breaks down lactose sugars in the intestine is missing. This leads to an increased amount of water in the stools, causing diarrhea after consuming lactose-containing foods.

Malabsorption syndromes refer to any condition where the intestine isn’t able to absorb nutrients properly.

Post-cholecystectomy diarrhea occurs in up to 12% of patients who have had their gallbladders removed. In these cases, bile goes straight from the liver to the colon, which can cause diarrhea. Chronic infections can also cause long-term diarrhea. A healthcare provider should always consider an infectious cause of diarrhea, especially if the patient has traveled recently or has a weakened immune system.

Risk Factors and Frequency for Chronic Diarrhea

Chronic diarrhea is a condition that impacts around 5% of people at any given time. However, its exact prevalence isn’t defined. Interestingly, symptoms like stomach pain and bloating are more frequently reported by women. That said, the occurrence of diarrhea itself is about the same in both men and women. It’s worth noting that people over the age of 60 tend to experience diarrhea less often.

Signs and Symptoms of Chronic Diarrhea

Chronic diarrhea is a condition that has a variety of causes and symptoms, which can differ greatly from one patient to another. The severity and cause of the disease greatly influence the symptoms. Often, patients with chronic diarrhea show no significant signs during a physical exam, but if weight loss occurs without trying, it might suggest a more serious issue. Even though looking at the patient’s medical history and doing a physical exam usually doesn’t lead to a specific cause, it’s still a crucial step in any medical evaluation. It’s also beneficial for patients to describe their diarrhea, like if there’s blood or mucus in the stool, or it appears fatty, as these descriptions can be helpful in making a diagnosis.

Different conditions can produce specific symptoms and these include:

  • Irritable Bowel Syndrome (IBS): Patients typically experience bloating and abdominal pain which might be eased by having a bowel movement. Stress is often linked with these symptoms.
  • Medications: Chronic diarrhea may be linked to a new medication, so it’s crucial to check all medications the patient is taking.
  • Crohn’s Disease: There may not be any significant signs during a physical exam in early stages, but patients may report mucus or blood in their stool. The presence of fistulas near the rectum could indicate an advanced stage of the sickness.
  • Ulcerative Colitis: Often, physical exams might not help in diagnosing the disease in its early stages. Patients might see blood in their stool, and due to this blood loss, fatigue, and pallor, which are signs of anemia, could be experienced.
  • Microscopic Colitis: A physical exam is typically normal, but very watery diarrhea could point to this diagnosis.
  • Celiac Disease: This autoimmune disease usually comes with symptoms of chronic diarrhea and abdominal cramping. An antibody against tissue transglutaminase found in a blood test could suggest this condition.
  • Chronic Pancreatitis: This condition often causes repeated bouts of abdominal pain, with diarrhea appearing fatty. Patients with this condition often need hospital treatment.
  • Lactose Intolerance: Typically, patients will have a normal physical exam. Symptoms such as bloating, gas, cramps, and diarrhea usually occur shortly after eating lactose-based foods.
  • Post-cholecystectomy Diarrhea: These patients have a history of recent gallbladder removal, which can be seen through an incision site in the abdomen during the physical examination.
  • Chronic Infections: Symptoms are generally non-specific but may include a history of recent travel, HIV infection, or long-term steroid use.

Testing for Chronic Diarrhea

If you’re experiencing long-term diarrhea, a thorough evaluation of your health history and a physical exam are essential. Your doctor may order several tests, such as a complete blood count, to look for signs of infection and anemia, tests for inflammation or infection, thyroid function tests to check for an overactive thyroid, a metabolic profile to check your kidney function and electrolyte levels, tests for protein malnutrition, and a stool test to see if you have gastrointestinal bleeding.

If you have certain concerning symptoms, your doctor may send you for a special examination called an endoscopy. These concerning symptoms could include starting to experience these symptoms after age 50, rectal bleeding, pain or diarrhea at night, worsening abdominal pain, unexplained weight loss or other systemic symptoms, findings from tests that suggest problems like iron deficiency anemia or inflammation, or having a close relative with inflammatory bowel disease or colorectal cancer.

If you don’t have these concerning symptoms, your doctor may still suggest stool tests. For example, if you’ve used antibiotics recently or have specific symptoms (like watery diarrhea happening 3 or more times per day), the doctor might test your stool for a toxin produced by a harmful bacterium called C. difficile.

When testing the stool, your doctor will check for certain things, like electrolytes, signs of inflammation, pancreatic enzymes, hidden blood, and fat level. The tests will help the doctor understand more about the type of diarrhea you’re experiencing, leading to a clearer diagnosis.

Some examples: If you have certain markers in your stool, it could be a sign of inflammation and point to conditions like Crohn’s disease or ulcerative colitis. The presence of certain pancreatic enzymes could suggest pancreatic insufficiency, while the presence of fat could point to problems with absorbing fats. These details are critical for your doctor in diagnosing and treating your condition effectively.

For watery diarrhea, stool electrolytes will further classify the diarrhea into either osmotic diarrhea or secretory diarrhea based on the result of a specific calculation.

Your doctor will use all this information to create a step-by-step plan for diagnosing and managing your condition.

Treatment Options for Chronic Diarrhea

The treatment for chronic diarrhea often depends on the specific diagnosis that is made after initial tests. If no clear diagnosis is made, or if there isn’t a specific treatment for the diagnosis, a type of general treatment may be needed. This often includes drugs that activate the opioid receptors mainly found in the gut to reduce its activity – Loperamide is a safe drug that’s commonly used for this.

Other drugs used for chronic diarrhea include substances that bind to and eliminate bile acids in the gut, like cholestyramine. Clonidine, a drug that decreases the activity of the gut, can also be used, particularly for diarrhea caused by withdrawal from opioids or loss of nerve activity seen in patients with diabetes. However, it should be used carefully due to its blood pressure-lowering effect. This can, on the other hand, be beneficial for patients with both high blood pressure and chronic diarrhea.

Medications that inhibit the activity of a specific type of nerve cell (anticholinergics) can also be helpful. Certain antidepressants, known as tricyclic antidepressants, which are often used to treat depression or pain, can also help with diarrhea.

Chronic diarrhea can have many possible causes. Sorting the type of diarrhea can help identify which condition is to blame.

There are three main types:

Watery Diarrhea:

  • Osmotic diarrhea, which can stem from consuming too much osmotic laxatives, malabsorption of carbohydrates like lactose and fructose, celiac disease, or an intake of sugar alcohols
  • Secretory diarrhea, which might relate to alcohol consumption, bacterial infections like cholera, bile acid malabsorption, early stage Crohn’s disease in the small intestine, hyperthyroidism, use of certain medications, microscopic colitis, or intestinal tumors
  • Functional issues like irritable bowel syndrome

Fatty Diarrhea can be symptomatic of:

  • Malabsorption syndromes that impair the absorption of food nutrients, possibly caused by certain medications, gastric bypass surgery, malabsorption disorders like celiac sprue, poor circulation to the intestines, parasitic infections like giardia, syndrome of the small intestine, bacterial overgrowth, gluten-sensitive disease, and Whipple’s disease
  • Maldigestion, which is due to the inability to break down food properly, often results from liver or gallbladder disorders, inadequate bile acid in the intestine, and pancreatic insufficiency

Inflammatory Diarrhea can be due to:

  • Inflammatory bowel disease, including Crohn’s disease, ulcerative colitis, diverticulitis, and inflammation of the upper small intestine
  • Invasive infections like Clostridium difficile colitis
  • Significant bacterial infections, parasites, or ulcer-causing viral infections
  • Cancerous growths such as colon cancer, lymphomas, and villous adenocarcinoma
  • Radiation-induced colitis

What to expect with Chronic Diarrhea

The outlook for chronic diarrhea can greatly change depending on what is causing it. For those who are told they have chronic diarrhea but the exact cause isn’t found, the outlook is generally quite positive. The standard treatments, like medications that mimic the effects of opioids, are very effective for general cases of chronic diarrhea.

Possible Complications When Diagnosed with Chronic Diarrhea

Chronic diarrhea can lead to different complications depending on its cause. However, one common problem for all patients with chronic diarrhea is malabsorption. This happens when the body can’t absorb enough nutrients and fluids because things are passing through the intestines too quickly. As a result, it may cause symptoms of malnutrition like anemia and unintentional weight loss. Chronic diarrhea can also cause dehydration, which can even lead to acute kidney injury if the body can’t absorb enough fluids. Furthermore, it can also lead to abnormal levels of electrolytes in the body, which may require monitoring and adjustment.

Common complications:

  • Malabsorption
  • Signs of malnutrition (anemia, unintentional weight loss)
  • Dehydration
  • Acute kidney injury due to dehydration
  • Electrolyte abnormalities

Preventing Chronic Diarrhea

If you find yourself going to the bathroom with loose, watery stools three times a day or even more, and this continues for over four weeks, it’s essential to discuss this with your family doctor. This could be a sign that you have an underlying health issue that needs to be diagnosed and treated.

Frequently asked questions

Chronic diarrhea is classified as loose or watery bowel movements that persist for four or more weeks.

Chronic diarrhea impacts around 5% of people at any given time.

The signs and symptoms of chronic diarrhea can vary depending on the severity and underlying cause of the condition. However, some common signs and symptoms include: - Chronic or persistent diarrhea: Diarrhea that lasts for an extended period of time, typically more than four weeks. - Weight loss: Unintentional weight loss can be a sign of a more serious underlying issue. - Bloating and abdominal pain: These symptoms are often associated with conditions like irritable bowel syndrome (IBS). - Blood or mucus in the stool: The presence of blood or mucus in the stool can indicate conditions like Crohn's disease or ulcerative colitis. - Fatigue and pallor: These symptoms may be experienced due to blood loss from conditions like ulcerative colitis. - Watery diarrhea: Microscopic colitis can cause very watery diarrhea. - Abdominal pain: Chronic pancreatitis can cause repeated bouts of abdominal pain. - Symptoms after eating lactose-based foods: Lactose intolerance can cause symptoms such as bloating, gas, cramps, and diarrhea shortly after consuming lactose. - History of recent gallbladder removal: Post-cholecystectomy diarrhea is characterized by a history of recent gallbladder removal, which can be observed during a physical examination. - Non-specific symptoms: Chronic infections may present with non-specific symptoms, such as a history of recent travel, HIV infection, or long-term steroid use. It is important for patients to describe their diarrhea in detail, including any additional symptoms or characteristics like the presence of blood, mucus, or fatty appearance, as this information can be helpful in making a diagnosis.

Chronic diarrhea can be caused by various factors such as inflammatory bowel disease, irritable bowel syndrome, malabsorption syndromes, chronic infections, medications, celiac disease, lactose intolerance, chronic pancreatitis, and post-cholecystectomy diarrhea.

The doctor needs to rule out the following conditions when diagnosing Chronic Diarrhea: - Inflammatory bowel disease, including Crohn's disease, ulcerative colitis, diverticulitis, and inflammation of the upper small intestine - Invasive infections like Clostridium difficile colitis - Significant bacterial infections, parasites, or ulcer-causing viral infections - Cancerous growths such as colon cancer, lymphomas, and villous adenocarcinoma - Radiation-induced colitis

The types of tests that a doctor may order to properly diagnose chronic diarrhea include: - Complete blood count (CBC) to look for signs of infection and anemia - Tests for inflammation or infection - Thyroid function tests to check for an overactive thyroid - Metabolic profile to check kidney function and electrolyte levels - Tests for protein malnutrition - Stool test to check for gastrointestinal bleeding - Stool tests to check for electrolytes, signs of inflammation, pancreatic enzymes, hidden blood, and fat levels - Special examination called an endoscopy for certain concerning symptoms - Stool test for C. difficile toxin if specific symptoms or recent antibiotic use are present These tests will help the doctor understand the underlying cause of the chronic diarrhea and guide the appropriate treatment plan.

The treatment for chronic diarrhea often depends on the specific diagnosis that is made after initial tests. If no clear diagnosis is made, or if there isn't a specific treatment for the diagnosis, a type of general treatment may be needed. This often includes drugs that activate the opioid receptors mainly found in the gut to reduce its activity - Loperamide is a safe drug that's commonly used for this. Other drugs used for chronic diarrhea include substances that bind to and eliminate bile acids in the gut, like cholestyramine. Clonidine, a drug that decreases the activity of the gut, can also be used, particularly for diarrhea caused by withdrawal from opioids or loss of nerve activity seen in patients with diabetes. However, it should be used carefully due to its blood pressure-lowering effect. This can, on the other hand, be beneficial for patients with both high blood pressure and chronic diarrhea. Medications that inhibit the activity of a specific type of nerve cell (anticholinergics) can also be helpful. Certain antidepressants, known as tricyclic antidepressants, which are often used to treat depression or pain, can also help with diarrhea.

The side effects when treating chronic diarrhea can include malabsorption, signs of malnutrition (such as anemia and unintentional weight loss), dehydration, acute kidney injury due to dehydration, and electrolyte abnormalities.

The prognosis for chronic diarrhea depends on the underlying cause. If the exact cause is not found, the outlook is generally positive and standard treatments are effective.

You should see a gastroenterologist for chronic diarrhea.

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