Diarrhea

Dr. Weyrich's Naturopathic Functional Medicine Notebook

Overview

Diarrhea is disorder that presents with loose or watery stools that occur more than three times in one day. This is usually benign and self-limiting condition requiring no treatment. The combination of diarrhea and bloody stools is called dysentery.

However, severe or prolonged cases can lead to dehydration or electrolyte imbalances that are especially dangerous to young children and the elderly, and may indicate a more serious condition requiring medical attention.

Signs and Symptoms

• Loose or watery stools that occur more than three times in one day.
• Cramping abdominal pain
• Bloating
• Urgent need to use the bathroom.
• Depending on cause, possibly fever, nausea, bloody stools.

Diarrhea is characterized by bowel movements that look like types 5 to 7 on the Bristol Stool Form Scale, as shown below [Lewis1997].

Bristol Stool Form Scale
Type	Description	Example
1	Separate hard lumps
2	Sausage-like but lumpy
3	Sausage-like but with cracks in the surface
4	Smooth and soft (ideal)
5	Soft blobs with clear-cut edges
6	Fluffy pieces with ragged edges
7	Watery, no solid pieces

Etiology

• Gut dysbiosis (often due to oral antibiotic use).
• Bacterial infections (contaminated food or water):
  • Campylobacter
  • Salmonella
  • Shigella
  • Escherichia coli
  • Vibrio cholera (third world)
• Viral infections (contaminated food or water):
  • Rota virus (most common cause in children - resolves in about a week).
  • Norwalk virus
  • Cytomegalovirus
  • Herpes simplex virus
  • Viral hepatitis
• Parasites (contaminated food or water):
  • Giardia lamblia
  • Entamoebia histolytica
  • Cryptosporidium
• Food intolerances/allergies/sensitivities:
  • Inability to digest lactose, the sugar found in milk.
• Blood pressure medications [Shacket2009]
• Antacids containing magnesium
• Inflammatory bowel disease (IBS)
• Celiac disease/
• Surgery affecting gut motility: stomach or gall bladder.

Diagnosis

• CBC and CMP.
• Stool culture/sensitivity, ova, and parasites.
• Organic Acid Test (elevated markers for gut dysbiosis).
• Food elimination diet or food allergy testing.
• Colonoscopy/sigmoidoscopy (if bleeding).

Differential Diagnosis

• Dysentery
• Irritable bowel syndrome (IBS)
• Celiac disease
• Inflammatory bowel disease
• Pseudomembranous Colitis
• Cholera
• Neoplasm
• Paradoxically, fecal impaction can lead to a thin watery stool as small quantities of freshly formed watery or soft stool leak around the impaction.

Treatment

• Diarrhea in infants or the elderly lasting more that 24 hours, or signs of dehydration constitutes a medical emergency and merits an emergency referral. Signs of dehydration include:
  • Rapid, forceless, turbulent pulse [ORWJr]
  • Reduced blood pressure [ORWJr]
  • Thirst, dry mouth and tongue
  • Less frequent urination, dark colored urine
  • Infants: No wet diapers for 3 hours or more
  • Skin that does not flatten when pinched and released (tenting)
  • Dry skin, lack of perspiration
  • Sunken abdomen, eyes, or cheeks
  • Children: No tears when crying
  • Fatigue, light-headedness, listlessness or irritability
• Diarrhea accompanied by bloody or black tarry stools, stools containing mucus, severe abdominal or rectal pain, lasts more than 3 days (24 hours for children), or high temperatures requires prompt evaluation by a doctor.
• In most cases, treatment is mainly supportive: replace lost fluids and electrolytes. In mild cases, oral electrolyte solutions (e.g. Pedialyte, Ceralyte, Infalyte, etc.) suffice, but in severe cases intravenous (IV) solutions are required.
• Treat dysbiosis if present.
• Antidiarrheal agents (e.g. Imodium) are generally contraindicated in diarrhea caused by bacteria or parasites - let the body's natural reaction flush out the infectious agent.
• Antidiarrheal agents are controversial in other forms of diarrhea.
• Antibiotics may be considered in cases of bacterial infections, but beware that Herxheimer reactions (toxin release as bacteria are rapidly killed) may exacerbate symptoms.
• Antiparasitic agents may be considered in cases of parasites, but beware that some agents may annoy the parasites and cause them to burrow into the intestinal lining.

Prevention

Most cases of diarrhea arise from consuming contaminated food or water. The following precautions will avoid most cases of diarrhea:

• Never eat ground meat (hamburger) that is not cooked through to the center.
• Never allow cooking utensils that have contacted raw foods to contact cooked foods without thorough cleaning.
• Never drink from mountain brooks - they may look clean, but often harbor parasites such as Giardia.
• When traveling in third-world countries, recognize that local peoples often have developed immunity to local contaminants that can make you sick. Therefore:
  • Do not drink, brush your teeth, or use ice made from water that has not been boiled or comes from a sealed bottle that you open yourself.
  • Do not drink unpasteurized milk or dairy products.
  • Avoid all raw fruits and vegetables unless they can be peeled and you peel them yourself.
  • Do not eat raw or rare eggs, meat or fish.
  • Do not eat meat or shellfish that is not hot when served to you.
  • Do not eat food from street vendors.

Sequelae

Prolonged or severe diarrhea may deplete the body of minerals (electrolytes) and fluids. This is particularly dangerous to young children, the elderly, and patients having comorbid conditions that disturb fluid and electrolyte regulation (some drugs, compromised kidney function, etc.), or that are exacerbated by electrolyte imbalances (cardiac arrhythmias, etc.).

Pathophysiology

A number of different dysbiotic bacterial overgrowths in the gut have been associated with diarrhea, including Clostridium difficile and Vibrio cholerae [Afghani1994].

ICD-9 Codes

ICD9-Code	Description	Comments
564.5	Functional diarrhea

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References

Unless specifically noted above, references used in the construction of this web page include the following:

[FDM] Lecture notes from Functional Medicine University.

[SCNM] Lecture notes from Southwest College of Naturopathic Medicine.

[UT] Lecture notes from the University of Tennessee graduate programs in Chemistry and Biochemistry.

[Lewis1997] Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997 Sep;32(9):920-4.

[Afghani1994] Afghani B, Stutman HR. Toxin-related diarrheas. Pediatr Ann. 1994 Oct;23(10):549-50, 553-5.

[Shacket2009] www.hemorrhoid.net/diarrhea.php

[Shacket2009] www.hemorrhoid.net/constipatchild.php

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