What is the cause of persistent diarrhea and constipation in an 84-year-old male with improved abdominal pain and bloating?

From the Guidelines

For an 84-year-old male experiencing both diarrhea and constipation, I recommend starting with a bowel regimen that addresses both symptoms, prioritizing the management of constipation to prevent overflow diarrhea, as suggested by the British Society of Gastroenterology guidelines 1. To manage his symptoms, I suggest beginning with a daily osmotic laxative such as polyethylene glycol (MiraLAX) 17g mixed in 8oz of water each morning to soften stool and regulate bowel movements. Adding a bulking agent like psyllium husk (Metamucil) 1 tablespoon in water once daily can provide structure to the stool. It is essential to avoid stimulant laxatives, which may worsen diarrhea, as noted in the guidelines for the investigation of chronic diarrhoea in adults 1. Maintaining adequate hydration with at least 6-8 glasses of water daily and increasing dietary fiber gradually to 25-30g daily through fruits, vegetables, and whole grains can also help regulate bowel movements. This combination likely represents overflow diarrhea, where liquid stool passes around an impaction. If symptoms don't improve within 7 days, a digital rectal exam or abdominal imaging may be needed to rule out fecal impaction, as recommended in the guidelines for the management of irritable bowel syndrome 1. For immediate relief of any impaction, a glycerin suppository or Fleet enema could be used. The goal is to establish a regular bowel pattern by addressing the underlying constipation while managing the diarrhea symptoms, ultimately improving the patient's quality of life and reducing morbidity and mortality associated with untreated constipation and diarrhea. Considering the patient's age and symptoms, it is crucial to monitor his condition closely and adjust the treatment plan as needed to ensure the best possible outcome, as emphasized in the British Society of Gastroenterology guidelines on the management of irritable bowel syndrome 1.

From the FDA Drug Label

STOP USE AND ASK A DOCTOR IF • you have rectal bleeding or your nausea, bloating, cramping or abdominal pain gets worse. These may be signs of a serious condition. • you get diarrhea • you need to use a laxative for longer than 1 week

The patient is experiencing diarrhea, which is a condition that requires stopping the use of polyethylene glycol (PO) and consulting a doctor, as stated in the drug label 2.

• The patient should stop using the laxative.
• A doctor should be consulted to assess the patient's condition and provide further guidance.

From the Research

Patient's Condition

The patient is an 84-year-old male experiencing constipation, diarrhea, and straining with bowel movements. His abdominal pain and bloating have improved, but he still suffers from diarrhea and constipation.

Relevant Studies

• The study 3 suggests that loperamide is an effective therapy for various diarrheal syndromes and can increase anal sphincter tone, leading to improved fecal continence.
• The study 4 emphasizes the importance of evaluating constipation through a focused history, medications, diet, physical activity, and anorectal examination. It recommends lifestyle changes, such as increased physical activity, high-fiber diets, and bowel management techniques, as first-line management.
• The study 5 discusses the pathophysiology and management of chronic constipation, highlighting the use of lifestyle measures, bulking agents, osmotic laxatives, and stimulant laxatives as treatment options.
• The study 6 focuses on the treatment of diarrhea in patients with inflammatory bowel disease, emphasizing the need to control inflammatory activity and tailor therapies according to presumed etiologies.
• The study 7 compares the effectiveness of loperamide and psyllium fiber for treating fecal incontinence, finding that both treatments improve fecal incontinence, but loperamide is associated with more adverse effects, especially constipation.

Potential Treatment Options

• Loperamide may be considered to manage the patient's diarrhea, as it has been shown to be effective in various diarrheal syndromes 3.
• Lifestyle changes, such as increased physical activity, high-fiber diets, and bowel management techniques, may be recommended to manage constipation 4, 5.
• The patient's treatment plan should be tailored to address both constipation and diarrhea, taking into account potential interactions between medications and the patient's overall health status 6, 7.