What is the best approach to manage a patient with chronic diarrhoea?

Management of Chronic Diarrhoea

The best approach to managing chronic diarrhoea is to first classify it as uncomplicated versus complicated, then initiate loperamide 4 mg initially followed by 2 mg after every loose stool (maximum 16 mg/day) for uncomplicated cases, while complicated cases require hospitalization with IV fluids, octreotide, antibiotics, and comprehensive stool workup. 1

Initial Classification and Risk Stratification

The critical first step is determining whether the patient has uncomplicated or complicated diarrhoea, as this dictates the entire management pathway 1:

Uncomplicated diarrhoea (Grade 1-2 with no alarming features):

• Loose stools without fever, dehydration, bleeding, or severe cramping 1
• Patient maintains adequate oral intake and performance status 1
• No nocturnal symptoms or unintentional weight loss 1

Complicated diarrhoea (requires immediate escalation):

• Presence of fever, sepsis, or neutropaenia 1
• Moderate to severe dehydration or orthostatic symptoms 1
• Blood in stool or severe abdominal cramping 1
• Diminished performance status or inability to maintain oral hydration 1

Management Algorithm for Uncomplicated Chronic Diarrhoea

First-Line Treatment

Loperamide is the cornerstone of initial management 2, 3:

• Initial dose: 4 mg, then 2 mg after every unformed stool 1, 2
• Maximum daily dose: 16 mg 1, 2, 3
• Continue until diarrhoea is controlled 1

Critical caveat: Loperamide can cause serious cardiac adverse reactions including QT prolongation, Torsades de Pointes, and cardiac arrest, particularly when combined with CYP3A4 inhibitors (itraconazole), CYP2C8 inhibitors (gemfibrozil), or P-glycoprotein inhibitors (quinidine, ritonavir) 3. Avoid in patients taking Class IA or III antiarrhythmics 3.

Concurrent Supportive Measures

Dietary modifications 1, 2:

• Eliminate all lactose-containing products 1
• Avoid high-osmolar dietary supplements 1
• Restrict fatty foods, spicy foods, caffeine, and alcohol 2
• Implement bland/BRAT diet (bread, rice, applesauce, toast) 2

Oral hydration 1, 2:

• Glucose-containing drinks or electrolyte-rich soups 2
• Essential to prevent dehydration 1

Skin protection 1:

• Use skin barriers to prevent pressure ulcer formation in incontinent patients 1
• Prevent skin irritation from faecal material 1

Patient Monitoring Instructions

Instruct patients to 1:

• Record number of stools daily 1
• Report fever or dizziness on standing immediately 1
• Seek medical attention if no improvement within 48 hours 2

Management Algorithm for Complicated Chronic Diarrhoea

Hospitalization is mandatory for complicated cases 1:

Immediate Interventions

IV fluid resuscitation and electrolyte replacement 1:

• Aggressive IV hydration for dehydration 1
• Monitor and correct electrolyte abnormalities, particularly hypokalemia 2

Octreotide administration 1, 2:

• Starting dose: 100-150 μg subcutaneously three times daily 1
• Alternative: 25-50 μg/hour IV if severely dehydrated 1
• Escalate up to 500 μg subcutaneously three times daily until diarrhoea controlled 1

Empiric antibiotic therapy 1:

• Fluoroquinolones as first-line 1
• Add metronidazole if Clostridium difficile suspected 1

Comprehensive Diagnostic Workup

Blood tests 1, 2:

• Complete blood count 1
• Comprehensive electrolyte profile 1
• Consider tissue transglutaminase/EMA for coeliac disease 1, 2
• Thyroid function tests 1, 2

Stool evaluation 1, 2:

• Test for blood 1
• Clostridium difficile toxin 1
• Salmonella, Escherichia coli, Campylobacter 1
• Infectious colitis markers 1
• Fecal calprotectin to screen for inflammatory bowel disease 1, 2

Cause-Specific Management Considerations

Bile Acid Diarrhoea

Cholestyramine is the initial therapy of choice 2, 4:

• Particularly effective in patients with prior cholecystectomy, terminal ileal resection, or radiation enteritis 2
• Consider intermittent on-demand dosing rather than continuous therapy to minimize adverse events 2

Inflammatory Diarrhoea

Budesonide for refractory cases 2:

• Dose: 9 mg once daily 2
• Indicated when fecal calprotectin is elevated 2

Medication-Induced Diarrhoea

Medication review is mandatory 2:

• Up to 4% of chronic diarrhoea cases are medication-induced 2
• Common culprits: magnesium products, NSAIDs, antibiotics, antihypertensives, theophyllines 2
• Discontinue or substitute offending agents 2

Coeliac Disease

Strict lifelong gluten-free diet 2, 4:

• Mandatory once confirmed by positive serology and duodenal biopsy 2

Critical Pitfalls to Avoid

Do not rely solely on Rome IV criteria 2:

• Specificity only 52-74% for functional disorders 1, 2
• Cannot reliably exclude IBD, microscopic colitis, or bile acid diarrhoea 1, 2

Do not miss faecal impaction 1:

• Can manifest as alternating constipation and diarrhoea in elderly patients 1
• Particularly common in palliative care settings 1

Avoid empiric antimicrobials without confirmed infectious cause 2:

• Increases drug resistance 2
• Reserve for confirmed infections or traveler's diarrhoea with dysentery 2

Do not overlook microscopic colitis 2:

• Presents similarly to IBS but requires different treatment 2
• More common in elderly patients 1

Monitor for neutropaenic enterocolitis in cancer patients 1:

• High mortality risk 1
• Requires broad-spectrum antibiotics and G-CSF 1

Special Populations

Elderly patients 1:

• Laxative abuse, malabsorption, or previous surgery commonly responsible 1
• More susceptible to QT prolongation with loperamide 3
• Diarrhoea less common than constipation in palliative care (<10% prevalence) 1

Paediatric patients 3:

• Loperamide contraindicated in children under 2 years due to respiratory depression and cardiac risks 3
• Greater variability of response requires special caution 3
• Dehydration particularly influences response in children under 6 years 3