What are the management options for chronic diarrhea?

From the Guidelines

Chronic diarrhea management options are primarily focused on treating the underlying cause, with antidiarrheals, dietary changes, and bile acid sequestrants being common treatments.

Management Options

• Antidiarrheals: such as loperamide, can be used to manage symptoms of chronic diarrhea 1.
• Dietary changes: including a low-fat diet, reduced lactose intake, and increased fluid consumption, can help alleviate symptoms 1.
• Bile acid sequestrants: such as cholestyramine, can be used to treat bile acid diarrhea, a common cause of chronic diarrhea 1.
• Probiotics: may be considered for treatment of functional symptoms in inflammatory bowel disease (IBD) patients with chronic diarrhea 1.
• Hypomotility agents: may be used for chronic diarrhea in quiescent IBD patients 1.

Investigation and Referral

• Initial assessment: should include blood, stool, and serological tests to rule out underlying causes such as infectious etiologies, inflammatory component, coeliac disease, hyperthyroidism, and anaemia 1.
• Referral: to secondary care should be considered if symptoms are severe, interfere with normal activities, or compromise quality of life, and if initial investigations are normal 1.

Specific Patient Populations

• Bariatric surgery patients: may require specific nutritional recommendations, such as increased water intake, reduced dietary intake of lactose, fat, and fiber, and supplementation with probiotics or bile chelators to manage chronic diarrhea 1.
• IBD patients: may require treatment with hypomotility agents, bile acid sequestrants, or probiotics to manage chronic diarrhea 1.

From the Research

Management Options for Chronic Diarrhea

The management of chronic diarrhea can be categorized into several approaches, including:

• Supportive management
• Pharmacological management, which can be further divided into symptomatic and causal treatment 2
• Dietary alterations, such as avoiding high FODMAP foods and identifying individual sensitivities 3
• Treatment of underlying causes, such as inflammatory bowel disease, colorectal neoplasia, coeliac disease, microscopic colitis, and bile acid diarrhoea 3

Pharmacological Treatment

Pharmacological treatment options for chronic diarrhea include:

• Antispasmodics and anti-diarrheal agents, which are used as first-line therapy 4
• Serotonin-3 receptor antagonists, eluxadoline, and rifaximin, which are used for patients with first-line refractory irritable bowel syndrome with diarrhea and functional diarrhea 4
• Opiate antidiarrheal drugs, such as loperamide, diphenoxylate, codeine, opium, and morphine 5, 6
• Clonidine, which has proabsorptive and motility effects, but its antihypertensive action limits its utility 5, 6
• Octreotide, which is of great value in treating diarrhea due to endocrine tumors and dumping syndrome, but its efficacy in other conditions is less well established 6
• Bile acid binders, such as cholestyramine or colestipol, which have limited utility in nonspecific chronic diarrhea 6

Alternative Therapeutic Approaches

Alternative therapeutic approaches for chronic diarrhea include:

• Fecal microbiota transplantation 4
• Enterobacterial "crapsules" 4
• Dietary fiber supplementation to improve stool consistency 6
• Oral rehydration solutions to prevent volume depletion 6
• Enteral or parenteral nutrition if nutritional status is compromised 6