From the Guidelines
For chronic diarrhea, a patient should initially consult a primary care physician, who can provide an initial evaluation and treatment, and refer to a gastroenterologist if symptoms persist or worsen, or if alarm features are present. According to the British Society of Gastroenterology guidelines 1, primary care physicians are often the first point of contact for patients with chronic diarrhea, and they can perform initial investigations such as blood, stool, and serological tests.
Initial Evaluation
The primary care physician will assess the patient's symptoms, including duration, frequency, and consistency of stools, as well as associated symptoms like pain or weight loss 1. They will also consider recent travel, antibiotic use, and dietary changes. If the patient's symptoms are severe enough to impair quality of life and do not respond to treatment, or if alarm features such as unexplained change in bowel habit, persistent blood in the stool, and unintentional weight loss are detected, referral to a gastroenterologist should be initiated 1.
Specialist Referral
A gastroenterologist can provide further evaluation and treatment, including specialized tests such as colonoscopy or endoscopy, if necessary 1. Chronic diarrhea can result from various conditions, including irritable bowel syndrome, inflammatory bowel disease, celiac disease, microscopic colitis, or medication side effects. Proper diagnosis by a specialist is essential for effective treatment of the underlying condition.
Key Considerations
- Patients with chronic diarrhea should not delay seeking medical attention, especially if they experience severe symptoms like blood in stool, significant weight loss, or dehydration 1.
- A patient with recent change in bowel habit to include diarrhea over 6 weeks is likely to need a different approach compared with another patient who has suffered from intermittent watery diarrhea which has been present for over 5 years 1.
- The presence of normal first-line investigations with symptoms severe enough to impair quality of life and not responding to treatment constitutes a rationale for referral to a specialist 1.
From the FDA Drug Label
For those patients being treated for travelers’ diarrhea, discontinue XIFAXAN if diarrhea persists more than 24-48 hours or worsens. Advise the patient to seek medical care for fever and/or blood in the stool [see Warnings and Precautions (5. 1)]. If diarrhea occurs after therapy or does not improve or worsens during therapy, advise patients to contact a physician as soon as possible [see Warnings and Precautions (5. 2)].
A patient with chronic diarrhea should consult a physician as soon as possible if their diarrhea:
- Persists more than 24-48 hours
- Worsens
- Is accompanied by fever and/or blood in the stool
- Occurs after therapy or does not improve during therapy 2
From the Research
Diagnosis and Treatment of Chronic Diarrhea
To diagnose and treat chronic diarrhea, patients should consult:
- A primary care physician for an initial evaluation, including a complete history and physical examination 3, 4, 5
- A gastroenterologist for further evaluation and management, especially if the diagnosis is unclear or if the patient has a complex medical history 5, 6
- Other specialists, such as a surgeon or an oncologist, if the underlying cause of the chronic diarrhea is suspected to be a structural problem, such as inflammatory bowel disease or colorectal cancer 5, 6
Evaluation and Management
The evaluation and management of chronic diarrhea include:
- A thorough medical history and physical examination 3, 4, 5
- Laboratory tests, such as a complete blood count, C-reactive protein, and stool studies 5
- Imaging studies, such as endoscopy or colonoscopy, if necessary 5
- Pharmacological treatment, including symptomatic and causal treatment, depending on the underlying cause of the chronic diarrhea 4, 7
Pharmacological Treatment
Pharmacological agents for chronic diarrhea include:
- Loperamide, a synthetic opiate agonist, to decrease peristaltic activity and inhibit secretion 7
- Cholestyramine, a bile acid sequestrant, to treat bile acid diarrhea 7
- 5-HT3 receptor antagonists, such as ramosetron, to improve stool consistency and global IBS symptoms 7
- Probiotics, to prevent antibiotic-associated diarrhea, although data on their role in treating chronic diarrhea are lacking 7
- Antispasmodics, such as alverine citrate, mebeverine, otilonium bromide, and pinaverium bromide, to relieve diarrheal symptoms and abdominal pain 7
- Rifaximin, to treat chronic diarrhea associated with IBS and small intestinal bacterial overgrowth 7