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DiarrhoeaWhat is diarrhea? Diarrhoea is an increase in the frequency of bowel movements or a decrease in the form of stool (greater looseness of stool). Although changes in frequency of bowel movements and looseness of stools can vary independently of each other, changes usually occur in both. Diarrhoea needs to be distinguished from four other conditions that can be confused with diarrhoea. Although these conditions may accompany diarrhoea, they often have different causes and different treatments than diarrhoea. These other conditions are: Incontinence of stool, which is the inability to control (delay) bowel movements until an appropriate time, i.e., until one can get to the toilet Rectal urgency, which is a sudden urge to have a bowel movement that is so strong that if a toilet is not immediately available there will be incontinence incomplete evacuation, which is a sensation that another bowel movement is necessary soon after a bowel movement, yet there is difficulty passing further stool the second time Bowel movements immediately after eating a meal. How is diarrhoea defined? Diarrhoea can be defined in absolute or relative terms based on either the frequency of bowel movements or the consistency (looseness) of stools. Frequency of bowel movements: Absolute diarrhoea is having more bobowel wel movements than normal. Thus, since among healthy individuals the maximum number of daily bowel movements is approximately five, diarrhoea can be defined as any number of stools greater than five. Relative diarrhoea is having more bowel movements than usual. Thus, if an individual who usually has one bowel movement each day begins to have three bowel movements each day, then diarrhoea is present-even though there are not more than five bowel movements a day, that is, there is not absolute diarrhoea. Consistency of stools: Absolute diarrhoea is more difficult to define on the basis of the consistency of stool because the consistency of stool can vary considerably in healthy individuals depending on their diets. Thus, individuals who eat large amounts of vegetables will have looser stools than individuals who eat few vegetables. Stools that are liquid or watery are always abnormal and considered diarrheal. Relative diarrhoea is easier to define based on the consistency of stool. Thus, an individual who develops looser stools than usual has diarrhoea--even though the stools may be within the range of normal with respect to consistency. Why does diarrhoea develop? With diarrhoea, stools usually are looser whether or not the frequency of bowel movements is increased. This looseness of stool--which can vary all the way from slightly soft to watery--is caused by increased water in the stool. During normal digestion, food is kept liquid by the secretion of large amounts of water by the stomach, upper small intestine, pancreas, and gallbladder. Food that is not digested reaches the lower small intestine and colon in liquid form. The lower small intestine and particularly the colon absorb the water, turning the undigested food into a more-or-less solid stool with form. Increased amounts of water in stool can occur if the stomach and/or small intestine secretes too much fluid, the distal small intestine and colon do not absorb enough water, or the undigested, liquid food passes too quickly through the small intestine and colon for them to remove enough water. Of course, more than one of these abnormal processes may occur at the same time. For example, some viruses, bacteria and parasites cause increased secretion of fluid, either by invading and inflaming the lining of the small intestine (inflammation stimulates the lining to secrete fluid) or by producing toxins (chemicals) that also stimulate the lining to secrete fluid but without causing inflammation. Inflammation of the small intestine and/or colon from bacteria or from ileitis/colitis can increase the rapidity with which food passes through the intestines, reducing the time that is available for absorbing water. Conditions of the colon such as collagenous colitis can block the ability of the colon to absorb water. Diarrhoea generally is divided into two types, acute and chronic. Acute diarrhoea lasts a few days or up to a week. Chronic diarrhoea can be defined in several ways but almost always lasts more than three weeks. It is important to distinguish between acute and chronic diarrhoea because they usually have different causes, require different diagnostic tests, and require different treatment. What are common causes of acute diarrhoea? The most common cause of acute diarrhoea is infection--viral, bacterial, and parasitic. Bacteria also can cause acute food poisoning. A third important cause of acute diarrhoea is medications. Viral gastroenteritis Viral gastroenteritis (viral infection of the stomach and the small intestine) is the most common cause of acute diarrhoea worldwide. Symptoms of viral gastroenteritis (nausea, vomiting, abdominal cramps, and diarrhoea) typically last only 48-72 hrs. Unlike bacterial enterocolitis (bacterial infection of the small intestine and colon), patients with viral gastroenteritis usually do not have blood or pus in their stools and have little if any fever. Viral gastroenteritis can occur in a sporadic form (in a single individual) or in an epidemic form (among groups of individuals). Sporadic diarrhoea probably is caused by several different viruses and is believed to be spread by person-to-person contact. The most common cause of epidemic diarrhoea(e.g., on cruise ships) is calciviruses. The calciviruses are transmitted by food that is contaminated by sick food-handlers or by person-to-person contact. Food poisoning Food poisoning is a brief illness that is caused by toxins produced by bacteria. The toxins cause abdominal pain (cramps) and vomiting and also cause the small intestine to secrete large amounts of water that leads to diarrhoea. The symptoms of food poisoning usually last less than 24 hours. With some bacteria, the toxins are produced in the food before it is eaten, while with other bacteria, the toxins are produced in the intestine after the food is eaten. Symptoms usually appear within several hours when food poisoning is caused by toxins that are formed in the food before it is eaten. It takes longer for symptoms to develop when the toxins are formed in the intestine (because it takes time for the bacteria to produce the toxins). Therefore, in the latter case, symptoms usually appear after 7-15 hours. For more, please see the Food Poisoning article. Staphylococcus aureus is an example of a bacterium that produces toxins in food before it is eaten. Typically, food contaminated with Staphylococcus (such as salad, meat or sandwiches with mayonnaise) is left un-refrigerated at room temperature overnight. The Staphylococcal bacteria multiply in the food and produce toxins. Clostridium perfringens is an example of a bacterium that multiplies in food (usually canned food), and produces toxins in the small intestine after the contaminated food is eaten. Traveler's diarrhoea There are many strains of E. coli bacteria. Most of the E. coli bacteria are normal inhabitants of the small intestine and colon and are non-pathogenic, meaning they do not cause disease in the intestines. Nevertheless, these non-pathogenic E. coli can cause diseases, however, if they spread outside of the intestines, for example, into the urinary tract (where they cause bladder or kidney infections) or into the blood stream (sepsis). Certain strains of E. coli, however, are pathogenic (meaning they can cause disease in the small intestine and colon). These pathogenic strains of E. coli cause diarrhea either by producing toxins (called enterotoxigenic E. coli or ETEC) or by invading and inflaming the lining of the small intestine and the colon and causing enterocolitis (called enteropathogenic E. coli or EPEC). Traveller's diarrhoea usually is caused by an ETEC strain of E. coli that produces a diarrhoea-inducing toxin. Tourists visiting foreign countries with warm climates and poor sanitation (Mexico, parts of Africa, etc.) can acquire ETEC by eating contaminated foods such as fruits, vegetables, seafood, raw meat, water, and ice cubes. Toxins produced by ETEC cause the sudden onset of diarrhoea, abdominal cramps, nausea, and sometimes vomiting. These symptoms usually occur 3-7 days after arrival in the foreign country and generally subside within 3 days. Occasionally, other bacteria or parasites can cause diarrhoea in travellers (for example, Shigella, Giardia, Campylobacter). Diarrhoea caused by these other organisms usually lasts longer than 3 days. For more, please see the Traveller's Diarrhoea article. Bacterial enterocolitis Disease-causing bacteria usually invade the small intestines and colon and cause enterocolitis (inflammation of the small intestine and colon). Bacterial enterocolitis is characterized by signs of inflammation (blood or pus in the stool, fever) and abdominal pain and diarrhea. Campylobacter jejuni is the most common bacterium that causes acute enterocolitis in the U.S. Other bacteria that cause enterocolitis include Shigella, Salmonella, and EPEC. These bacteria usually are acquired by drinking contaminated water or eating contaminated foods such as vegetables, poultry, and dairy products. Enterocolitis caused by the bacterium Clostridium difficile is unusual because it often is caused by antibiotic treatment. Clostridium difficile is also the most common nosocomial infection (infection acquired while in the hospital) to cause diarrhoea. E. coli O157:H7 is a strain of E. coli that produces a toxin that causes hemorrhagic enterocolitis (enterocolitis with bleeding). There was a famous outbreak of hemorrhagic enterocolitis in the U. S. traced to contaminated ground beef in hamburgers (hence it is also called hamburger colitis). Approximately 5 % of patients infected with E. coli O157:H7 can develop hemolytic uremic syndrome (HUS), a syndrome that can lead to kidney failure, usually in children. Some evidence suggests that prolonged use of anti-diarrhea agents or use of antibiotics may increase the chance of developing HUS. For more information, please see the E. coli O157:H7 article. Parasites Parasitic infections are not common causes of diarrhoea in the U. S. Infection with Giardia lamblia occurs among individuals who hike in the mountains or travel abroad and is transmitted by contaminated drinking water. Infection with Giardia usually is not associated with inflammation; there is no blood or pus in the stool and little fever. Infection with amoeba (amoebic dysentery) usually occurs during travel abroad to undeveloped countries and is associated with signs of inflammation--blood or pus in the stool and fever. Cryptosporidium is a diarrhea-producing parasite that is spread by contaminated water because it can survive chlorination. Cyclospora is a diarrhea-producing parasite that has been associated with contaminated raspberries from Guatemala. For more, please read the article on Cryptosporidium. Drugs Drug-induced diarrhea is very common because many drugs cause diarrhea. The clue to drug-induced diarrhea is that the diarrhea begins soon after treatment with the drug is begun. The medications that most frequently cause diarrhea are antacids and nutritional supplements that contain magnesium. Other classes of medication that cause diarrhea include nonsteroidal anti-inflammatory drugs NSAIDs, chemotherapy medications, antibiotics, medications to control irregular heartbeats (antiarrhythmics), and medications for high blood pressure. A few examples of specific medications that commonly cause diarrhea are misoprostol (Cytotec), quinidine (Quinaglute, Quinidex), olsalazine (Dipentum), colchicine (Colchicine), metoclopramide (Reglan), and cisapride (Propulsid). What are common causes of acute diarrhea? The most common cause of acute diarrheais infection--viral, bacterial, and parasitic. Bacteria also can cause acute food poisoning. A third important cause of acute diarrhea is medications. Viral gastroenteritis Viral gastroenteritis (viral infection of the stomach and the small intestine) is the most common cause of acute diarrhea worldwide. Symptoms of viral gastroenteritis (nausea, vomiting, abdominal cramps, and diarrhea) typically last only 48-72 hrs. Unlike bacterial enterocolitis (bacterial infection of the small intestine and colon), patients with viral gastroenteritis usually do not have blood or pus in their stools and have little if any fever. Viral gastroenteritis can occur in a sporadic form (in a single individual) or in an epidemic form (among groups of individuals). Sporadic diarrhea probably is caused by several different viruses and is believed to be spread by person-to-person contact. The most common cause of epidemic diarrhea(e.g., on cruise ships) is calciviruses. The calciviruses are transmitted by food that is contaminated by sick food-handlers or by person-to-person contact. Food poisoning Food poisoning is a brief illness that is caused by toxins produced by bacteria. The toxins cause abdominal pain (cramps) and vomiting and also cause the small intestine to secrete large amounts of water that leads to diarrhea. The symptoms of food poisoning usually last less than 24 hours. With some bacteria, the toxins are produced in the food before it is eaten, while with other bacteria, the toxins are produced in the intestine after the food is eaten. Symptoms usually appear within several hours when food poisoning is caused by toxins that are formed in the food before it is eaten. It takes longer for symptoms to develop when the toxins are formed in the intestine (because it takes time for the bacteria to produce the toxins). Therefore, in the latter case, symptoms usually appear after 7-15 hours. For more, please see the Food Poisoning article. Staphylococcus aureus is an example of a bacterium that produces toxins in food before it is eaten. Typically, food contaminated with Staphylococcus (such as salad, meat or sandwiches with mayonnaise) is left un-refrigerated at room temperature overnight. The Staphylococcal bacteria multiply in the food and produce toxins. Clostridium perfringens is an example of a bacterium that multiplies in food (usually canned food), and produces toxins in the small intestine after the contaminated food is eaten. Traveler's diarrhoea There are many strains of E. coli bacteria. Most of the E. coli bacteria are normal inhabitants of the small intestine and colon and are non-pathogenic, meaning they do not cause disease in the intestines. Nevertheless, these non-pathogenic E. coli can cause diseases, however, if they spread outside of the intestines, for example, into the urinary tract (where they cause bladder or kidney infections) or into the blood stream (sepsis). Certain strains of E. coli, however, are pathogenic (meaning they can cause disease in the small intestine and colon). These pathogenic strains of E. coli cause diarrhoea either by producing toxins (called enterotoxigenic E. coli or ETEC) or by invading and inflaming the lining of the small intestine and the colon and causing enterocolitis (called enteropathogenic E. coli or EPEC). Traveler's diarrhea usually is caused by an ETEC strain of E. coli that produces a diarrhea-inducing toxin. Tourists visiting foreign countries with warm climates and poor sanitation (Mexico, parts of Africa, etc.) can acquire ETEC by eating contaminated foods such as fruits, vegetables, seafood, raw meat, water, and ice cubes. Toxins produced by ETEC cause the sudden onset of diarrhoea, abdominal cramps, nausea, and sometimes vomiting. These symptoms usually occur 3-7 days after arrival in the foreign country and generally subside within 3 days. Occasionally, other bacteria or parasites can cause diarrhea in travelers (for example, Shigella, Giardia, Campylobacter). Diarrhoea caused by these other organisms usually lasts longer than 3 days. Bacterial enterocolitis Disease-causing bacteria usually invade the small intestines and colon and cause enterocolitis (inflammation of the small intestine and colon). Bacterial enterocolitis is characterized by signs of inflammation (blood or pus in the stool, fever) and abdominal pain and diarrhea. Campylobacter jejuni is the most common bacterium that causes acute enterocolitis in the U.S. Other bacteria that cause enterocolitis include Shigella, Salmonella, and EPEC. These bacteria usually are acquired by drinking contaminated water or eating contaminated foods such as vegetables, poultry, and dairy products. Enterocolitis caused by the bacterium Clostridium difficile is unusual because it often is caused by antibiotic treatment. Clostridium difficile is also the most common nosocomial infection (infection acquired while in the hospital) to cause diarrhea. E. coli O157:H7 is a strain of E. coli that produces a toxin that causes hemorrhagic enterocolitis (enterocolitis with bleeding). There was a famous outbreak of hemorrhagic enterocolitis in the U. S. traced to contaminated ground beef in hamburgers (hence it is also called hamburger colitis). Approximately 5 % of patients infected with E. coli O157:H7 can develop hemolytic uremic syndrome (HUS), a syndrome that can lead to kidney failure, usually in children. Some evidence suggests that prolonged use of anti-diarrhea agents or use of antibiotics may increase the chance of developing HUS. Parasites Parasitic infections are not common causes of diarrhoea in the U. S. Infection with Giardia lamblia occurs among individuals who hike in the mountains or travel abroad and is transmitted by contaminated drinking water. Infection with Giardia usually is not associated with inflammation; there is no blood or pus in the stool and little fever. Infection with amoeba (amoebic dysentery) usually occurs during travel abroad to undeveloped countries and is associated with signs of inflammation--blood or pus in the stool and fever. Cryptosporidium is a diarrhoea-producing parasite that is spread by contaminated water because it can survive chlorination. Cyclospora is a diarrhoea-producing parasite that has been associated with contaminated raspberries from Guatemala. For more, please read the article on Cryptosporidium. Drugs Drug-induced diarrhoea is very common because many drugs cause diarrhoea. The clue to drug-induced diarrhoea is that the diarrhoea begins soon after treatment with the drug is begun. The medications that most frequently cause diarrhoea are antacids and nutritional supplements that contain magnesium. Other classes of medication that cause diarrhoea include nonsteroidal anti-inflammatory drugs NSAIDs, chemotherapy medications, antibiotics, medications to control irregular heartbeats (antiarrhythmics), and medications for high blood pressure. A few examples of specific medications that commonly cause diarrhoea are misoprostol (Cytotec), quinidine (Quinaglute, Quinidex), olsalazine (Dipentum), colchicine (Colchicine), metoclopramide (Reglan), and cisapride (Propulsid). What are the complications of diarrhea? Dehydration occurs when there is excessive loss of fluids and minerals (electrolytes) from the body due to diarrhea, with or without vomiting. Dehydration is common among adult patients with acute diarrhea who have large amounts of stool, particularly when the intake of fluids is limited by lethargy or is associated with nausea and vomiting. It also is common in infants and young children who develop viral gastroenteritis or bacterial infection. Patients with mild dehydration may experience only thirst and dry mouth. Moderate to severe dehydration may cause orthostatic hypotension with syncope (fainting upon standing due to a reduced volume of blood, which causes a drop in blood pressure upon standing), a diminished urine output, severe weakness, shock, kidney failure, confusion, acidosis (too much acid in the blood), and coma. Electrolytes (minerals) also are lost with water when diarrhea is prolonged or severe, and electrolyte deficiencies may occur. The most common mineral deficiencies occur with sodium and potassium. Abnormalities of chloride and bicarbonate also may develop. Finally, there may be irritation of the anus due to the frequent passage of watery stool containing irritating substances. When should the doctor be called for diarrhoea? Most episodes of diarrhoea are mild and of short duration and do not need to be brought to the attention of a doctor. The doctor should be consulted when there is: High fever (temperature greater than 101 F) Moderate or severe abdominal pain or tenderness Bloody diarrhoea that suggests severe intestinal inflammation Diarrhoea in persons with serious underlying illness for whom dehydration may have more serious consequences, for example, diabetes, heart disease, and AIDS Severe diarrhoea that shows no improvement after 48 hours. Moderate or severe dehydration Prolonged vomiting that prevents intake of fluids orally Acute diarrhoea in pregnant women because of concern for the health of the foetus Diarrhoea that occurs during or immediately after completing a course of antibiotics because the diarrhoea may represent antibiotic-associated infection with C. difficile that requires treatment Diarrhoea after returning from developing countries or from camping in the mountains because there may be infection with Giardia (for which there is treatment) Diarrhoea that develops in patients with chronic intestinal diseases such as colitis or Crohn's disease because the diarrhoea may represent worsening of the underlying disease or a complication of the disease, both requiring treatment Acute diarrhoea in an infant or young child in order to ensure the appropriate use of oral liquids (type, amount, and rate), to prevent or treat dehydration, and to prevent complications of inappropriate use of liquids such as seizures and abnormal blood minerals How is diarrhoea treated? Absorbents: Absorbents are compounds that absorb water. Absorbents that are taken orally bind water in the small intestine and colon and make diarrhoea stools less watery. They also may bind toxic chemicals produced by bacteria that cause the small intestine to secrete fluid; however, the importance of toxin binding in reducing diarrhoea is unclear. The two main absorbents are attapulgite and polycarbophil, and they are both available without prescriptions. They may occasionally cause constipation and bloating. One concern is that absorbents also can bind medications and interfere with their absorption into the body. For this reason, it often is recommended that medications and absorbents be taken several hours apart so that they are physically separated within the intestine. Anti-motility medications: Anti-motility medications are drugs that relax the muscles of the small intestine and/or the colon. Relaxation results in slower flow of intestinal contents. Slower flow allows more time for water to be absorbed from the intestine and colon and reduces the water content of stool. Cramps, due to spasm of the intestinal muscles, also are relieved by the muscular relaxation. The two main anti-motility medications are loperamide (Imodium), which is available without a prescription, and diphenoxylate (Lomotil), which requires a prescription. Both medications are related to opiates (e.g., codeine ) but neither has the pain-relieving effects of opiates. Loperamide, though related to opiates, does not cause addiction. Diphenoxylate is a man-made medication that at high doses can be addictive because of its opiate-like, euphoric (mood-elevating) effects. In order to prevent abuse of diphenoxylate and addiction, a second medication, atropine, is added to loperamide in Lomotil. If too much Lomotil is ingested, unpleasant side effects from too much atropine will occur. Anti-motility medications should not be used without a doctor's guidance to treat diarrhoea caused by moderate or severe ulcerative colitis, C. difficile colitis, and intestinal infections by bacteria that invade the intestine (e.g., Shigella). Their use can lead to more serious inflammation and prolong the infections. Diphenoxylate can cause drowsiness or dizziness, and caution should be used if driving or performing tasks that require alertness and coordination are required. Anti-motility medications should not be used in children younger than two years of age. Most unimportant, acute diarrhoea should improve within 72 hours. If symptoms do not improve or if they worsen, a doctor should be consulted before continuing treatment with anti-motility medications. Self care at Home: It is essential to drink plenty of fluids to prevent dehydration. During mild cases of diarrhoea diluted fruit juices, soft drinks containing sugar, sports drinks and water can be used to prevent dehydration. Caffeine and lactose containing dairy products should be temporarily avoided since they can aggravate diarrhoea. If there is no nausea and vomiting, solid foods should be continued. Foods that usually are well tolerated during a diarrheal illness include rice, cereal, bananas, potatoes, and lactose free products. If the diarrhoea is stress or anxiety related then relaxation treatments are often helpful. Sometimes diarrhoea can become persistent in people who are anxious, fearful and tense can suffer from on-going diarrhoea . The essential oils of Chamomile Roman, Lavender and Neroli can be very helpful and both massaging the abdomen and also bathing in these oils can provide relaxation which in turn can relieve the tension and help to calm. Antispasmodic essential oils are Chamomile Roman, Cypress, Eucalyptus, Lavender, Neroli and Peppermint and again massage of the abdomen and bathing will benefit the sufferer. Eucalyptus essential oil is recommended if a viral infection is the cause and Chamomile Roman would be the choice if a food allergy was the cause. In certain cases warming oils such as Benzoin essential oil, Black Pepper essential oil, Fennel essential oil and Ginger essential oil can be massaged gently into the abdomen. |
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