What is the best way to bulk loose stools?

Best Methods to Bulk Loose Stools

Psyllium (soluble fiber) is the most effective first-line treatment for bulking loose stools due to its superior water-holding capacity and ability to normalize stool consistency without changing water content. 1

Mechanism of Loose Stools

• Loose stools occur when the intestine fails to complete absorption of electrolytes and water from luminal contents, often resulting in secretory diarrhea 2
• Stool looseness is determined by the ratio of fecal water to water-holding capacity of insoluble solids 1
• Normal intestine delivers stools that differ widely in quantity but maintains percent fecal water within a narrow range 1

First-Line Treatment: Soluble Fiber

Psyllium

• Most effective for bulking loose stools by increasing water-holding capacity of insoluble solids without changing percent water content 1
• Standard dosing: 1 packet mixed with at least 8 ounces of water, up to 3 times daily 3
• For new users: Start with 1 dose per day and gradually increase to 3 doses daily as necessary 3
• Ensure adequate hydration as fiber intake increases to prevent constipation 4

Second-Line Treatments

Polyethylene Glycol (PEG)

• Though primarily used for constipation, PEG can help normalize stool consistency in some cases of alternating bowel patterns 4
• Standard initial dose: 17g daily 5
• Can be titrated based on symptom response with no clear maximum dose established 5
• Monthly cost: $10-$45, making it cost-effective compared to prescription medications 4

Loperamide

• Acts by slowing intestinal motility and affecting water and electrolyte movement through the bowel 6
• Reduces daily fecal volume, increases viscosity and bulk density, and diminishes fluid and electrolyte loss 6
• Initial dose: 4 mg (two capsules) followed by 2 mg (one capsule) after each unformed stool 6
• Maximum daily dose: 16 mg (eight capsules) 6
• Clinical improvement usually observed within 48 hours 6

Dietary Modifications

• Increase dietary fiber intake to approximately 30 g/day through fruits, vegetables, whole grains, and legumes 4
• Consume adequate fluids, particularly water, to help normalize stool consistency 4
• For patients with an ileostomy, foods that can thicken output include bananas, pasta, rice, white bread, mashed potato, and marshmallows 4
• Avoid hypotonic drinks (tea, coffee, juices) and hypertonic solutions containing sorbitol or glucose which can cause sodium and water loss 4

Special Considerations

For Elderly Patients

• Ensure access to toilets, especially in cases of decreased mobility 4
• Provide dietetic support and manage decreased food intake which can negatively influence stool volume and consistency 4
• Optimize toileting by educating patients to attempt defecation at least twice a day, usually 30 minutes after meals 4

For Patients with Inflammatory Bowel Disease

• Avoid non-evidence-based self-directed exclusion diets which can lead to limited diet quality and nutrient deficiency 4
• For patients with functional bowel symptoms in remission/mildly active disease, consider dietary advice as for irritable bowel syndrome 4

Common Pitfalls to Avoid

• Avoid bulk laxatives such as psyllium for opioid-induced constipation 4
• Avoid liquid paraffin for bed-bound patients and those with swallowing disorders due to risk of aspiration lipoid pneumonia 4
• Be cautious with saline laxatives (e.g., magnesium hydroxide) in older adults due to risk of hypermagnesemia 4
• Avoid non-absorbable, soluble dietary fiber or bulk agents in non-ambulatory patients with low fluid intake due to increased risk of mechanical obstruction 4
• Avoid uncritical use of antibiotics and intestinal antiseptics in the therapy of bacterial diarrhea 7