From the Guidelines
I strongly recommend continuing Lomotil 2.5 mg (2 tablets by mouth every evening) for 60 days for this 59-year-old male patient with chronic diarrhea while awaiting his GI consultation and upper endoscopy, as it has previously provided symptomatic relief. The patient's history of trying loperamide and probiotics without success, but reporting improvement with a previous short course of Lomotil, supports this decision 1. His recent colonoscopy showed only a small rectal polyp (removed), sigmoid diverticulosis, and internal hemorrhoids, which are unlikely to explain his persistent diarrhea. The CT scan revealed a small hiatal hernia and possible distal esophageal wall thickening that requires further evaluation with the scheduled upper endoscopy to rule out paraesophageal neoplasm.
Key considerations in managing this patient's chronic diarrhea include:
- Monitoring for side effects of Lomotil, such as constipation, blurred vision, urinary hesitancy, and dizziness
- Avoiding alcohol while taking Lomotil
- Scheduling a follow-up appointment in 30 days to assess medication response and monitor for side effects before completing the full course
- Considering the possibility of microscopic colitis, as suggested by the American Gastroenterological Association Institute guideline on the medical management of microscopic colitis 1, which may require further evaluation and treatment
The goal of medical therapy in this case is to relieve symptoms and improve quality of life while minimizing drug-related adverse effects, as outlined in the guideline 1. By continuing Lomotil and completing the diagnostic workup, we can provide symptomatic relief while identifying the underlying cause of his chronic diarrhea.
From the Research
Patient's Condition
The patient is a 59-year-old male with a history of diarrhea for over three months. He has tried loperamide and probiotics without improvement. However, Lomotil 5 mg provided temporary relief.
Diagnostic Findings
- Colonoscopy on 04/10/2025:
- One 6 mm polyp in the distal rectum, removed with a cold snare
- Diverticulosis in the sigmoid colon
- Internal hemorrhoids
- CT Chest/Abdomen/Pelvis with Contrast on 2.12.2025:
- No acute traumatic process in the thorax, abdomen, or pelvis
- Small hiatal hernia
- Nonspecific mild wall thickening in the distal esophagus
Treatment Plan
The patient is scheduled for an upper endoscopy to rule out paraesophageal neoplasm. He will be prescribed Lomotil 2.5 mg 2 T PO QPM for 60 days while waiting for his GI appointment.
Relevant Studies
- A study from 1998 2 found that bismuth subsalicylate was effective in treating microscopic colitis, with 11 out of 12 patients experiencing a resolution of diarrhea and a reduction in fecal weight.
- A study from 1978 3 compared the effects of codeine phosphate, Lomotil, and Isogel on ileostomy function, and found that Lomotil had a small but statistically insignificant effect on reducing the mean total weight of ileostomy output.
- A study from 2018 4 found that bismuth subsalicylate reduced the severity and incidence of flatulence and diarrhea in patients taking delayed-release dimethyl fumarate.
- A study from 2013 5 highlighted the potential for abuse of Lomotil (diphenoxylate) due to its opioid component.
- A systematic review and meta-analysis from 2021 6 found that bismuth subsalicylate was effective in preventing and treating infectious diarrhea, including traveler's diarrhea.
Potential Considerations
- The patient's response to Lomotil 5 mg suggests that it may be an effective treatment option for his diarrhea.
- The potential for abuse of Lomotil should be considered, especially given the patient's history of taking the medication for an extended period.
- Bismuth subsalicylate may be a potential alternative treatment option for the patient's diarrhea, given its efficacy in treating microscopic colitis and infectious diarrhea.