What is the treatment for chronic diarrhea?

Treatment for Chronic Diarrhea

The treatment of chronic diarrhea should be directed at the underlying cause, with specific therapies based on diagnostic findings, while symptomatic management can include loperamide for inflammatory bowel disease-associated diarrhea or cholestyramine for bile acid diarrhea. 1, 2

Diagnostic Approach

• Chronic diarrhea is defined as abnormal passage of ≥3 loose stools per day for more than 4 weeks 3
• Initial assessment should include:
  • Detailed history to distinguish organic from functional causes 1
  • Blood tests (complete blood count, electrolytes, liver function, vitamin B12, folate, calcium, ferritin, inflammatory markers, thyroid function) 1
  • Stool tests for inflammation (fecal calprotectin) 1
  • Serological testing for celiac disease 1

Categorization of Chronic Diarrhea

Chronic diarrhea can be categorized into three main types to guide treatment:

• Watery diarrhea 1, 4

  • Functional (IBS-D)
  • Secretory (hormone-secreting tumors)
  • Osmotic (lactose intolerance, medication side effects)

• Fatty diarrhea (malabsorption) 1, 4

  • Pancreatic insufficiency
  • Celiac disease
  • Small bowel disease

• Inflammatory diarrhea 1, 4

  • Inflammatory bowel disease
  • Microscopic colitis
  • Infectious colitis

Treatment Based on Specific Causes

1. Bile Acid Diarrhea

• Common but frequently underdiagnosed cause of chronic diarrhea 1
• Risk factors include terminal ileal resection, cholecystectomy, abdominal radiotherapy 1
• Treatment: Cholestyramine is recommended as initial therapy, with alternate bile acid sequestrants when tolerability is an issue 1
• Maintenance therapy should be given at the lowest effective dose 1

2. Inflammatory Bowel Disease

• Treatment: Loperamide is indicated for chronic diarrhea associated with inflammatory bowel disease 2
• Specific disease-modifying therapies should be used based on disease type and severity 1

3. Microscopic Colitis

• Diagnosis requires colonoscopy with biopsies of right and left colon 1
• Treatment: Budesonide is the treatment of choice 1

4. Celiac Disease

• Confirmed by serological testing and duodenal biopsies 1
• Treatment: Strict gluten-free diet 1

5. Small Bowel Bacterial Overgrowth

• Treatment: Empirical trial of antibiotics is recommended rather than routine hydrogen or methane breath testing 1

6. Medication-Induced Diarrhea

• Up to 4% of chronic diarrhea cases may be due to medications 1
• Common culprits: magnesium supplements, antihypertensives, NSAIDs, antibiotics, antiarrhythmics 1
• Treatment: Medication review and discontinuation of offending agents when possible 1

7. Functional Diarrhea/IBS-D

• Diagnosis of exclusion after organic causes ruled out 1
• Treatment options:
  • Dietary modifications (low-FODMAP diet) 5
  • Loperamide for symptom control 2, 5
  • Eluxadolin for abdominal pain and diarrhea 5
  • 5-HT3 receptor antagonists in refractory cases 5
  • Low-dose tricyclic antidepressants 5

8. Lactose Intolerance

• Treatment: Dietary lactose restriction or lactase enzyme supplements 1
• Hydrogen breath testing can confirm diagnosis if available 1

Symptomatic Management

When specific cause cannot be immediately identified or while awaiting diagnostic results:

• Loperamide for control and symptomatic relief of chronic diarrhea 2, 5
• Cholestyramine for bile acid diarrhea 1
• Dietary modifications to eliminate potential triggers (caffeine, alcohol, sorbitol, fructose) 1
• Probiotics may help in some cases 6, 5

Common Pitfalls to Avoid

• Failing to distinguish between functional disorders and organic disease 3
• Overlooking microscopic colitis, which can present similar to IBS but requires different treatment 3
• Missing bile acid malabsorption, which is common but often underdiagnosed 3
• Neglecting to review medications as potential causes of chronic diarrhea 1