What is the management approach for a patient with chronic diarrhoea?

Management of Chronic Diarrhoea

Begin with loperamide 4 mg initially, then 2 mg after each loose stool (maximum 16 mg daily) for uncomplicated chronic diarrhoea, while simultaneously implementing dietary modifications including lactose elimination, fat restriction, and avoidance of caffeine and alcohol. 1, 2

Initial Risk Stratification

Classify chronic diarrhoea as either uncomplicated or complicated to determine the appropriate management pathway 1:

Uncomplicated diarrhoea presents with:

• Loose stools without fever, dehydration, or bleeding 1
• Absence of severe abdominal cramping 1
• Maintained oral intake and performance status 1

Complicated diarrhoea presents with:

• 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 Pharmacological Management

Loperamide is the cornerstone of initial therapy 3, 1:

• Initial dose: 4 mg 3, 2
• Maintenance: 2 mg after every unformed stool 3, 2
• Maximum daily dose: 16 mg 3, 2
• Clinical improvement should be observed within 48 hours; if not, discontinue and contact healthcare provider 2

Important loperamide precautions 2:

• Avoid in patients taking Class IA or III antiarrhythmics due to QT prolongation risk 2
• Use caution with CYP3A4 inhibitors (itraconazole), CYP2C8 inhibitors (gemfibrozil), or P-glycoprotein inhibitors (quinidine, ritonavir) as these increase loperamide exposure 2-12 fold 2
• Monitor for CNS toxicity in hepatic impairment 2

Dietary Modifications (Implement Simultaneously)

Essential dietary changes 3, 1:

• Eliminate lactose-containing products 3, 1
• Restrict fatty foods, spicy foods, caffeine, and alcohol 3, 1
• Avoid high-osmolar dietary supplements 1
• Implement bland/BRAT diet 1
• Maintain oral hydration with glucose-containing drinks or electrolyte-rich soups 1

High-fiber diet considerations 3:

• Partially hydrolysed guar gum (soluble fiber) is preferable to insoluble fiber 3
• Has the largest body of evidence for diarrhoea prevention 3

Second-Line Options for Refractory Cases

If loperamide fails after 48 hours at maximum dosing 3, 2:

Octreotide 3:

• Dose: 100 μg three times daily 3
• Reserved for patients not responsive to loperamide with severe toxicity 3

Anticholinergic antispasmodic agents 3:

• Use to alleviate bowel cramping 3

Management Algorithm for Complicated Chronic Diarrhoea

Immediate hospitalization is required 1:

Acute Interventions

• IV fluid resuscitation and electrolyte replacement (particularly potassium) 3, 1
• Octreotide administration 1
• Empiric antibiotic therapy if fever or leukocytosis present 3, 1

Comprehensive Diagnostic Workup

Blood tests and stool evaluation to determine underlying cause 1:

• Fecal calprotectin for inflammatory diarrhoea 4, 5
• Celiac serology (anti-tissue transglutaminase IgA) for malabsorptive diarrhoea 4, 5
• Stool ELISA for parasites (Giardia, Entamoeba) in appropriate clinical context 4
• HIV testing in immunocompromised patients 4

Cause-Specific Management

Bile Acid Diarrhoea

Cholestyramine or colesevelam is first-line therapy 3, 1, 4:

• Particularly in patients with prior cholecystectomy, terminal ileal resection, or radiation enteritis 1
• Colesevelam is better tolerated than cholestyramine 3

Inflammatory Diarrhoea

Budesonide for refractory cases 1:

• Dose: 9 mg once daily 1

Infliximab for immune checkpoint inhibitor-induced diarrhoea 3:

• Dose: 5 mg/kg once every 2 weeks until resolution 3
• Reserved for symptoms persisting >3-5 days or recurring after improvement 3

Chronic Radiation-Induced Diarrhoea

Limited evidence for most treatments 3:

• Dietary counselling has beneficial effect on symptoms and quality of life 3
• Loperamide for symptomatic control 3
• Colesevelam for bile salt malabsorption 3
• Broad-spectrum antimicrobial therapy (often empirical) for bacterial overgrowth, requiring prolonged and cyclical courses 3

Avoid these agents as they may worsen symptoms 3:

• Aminosalicylates (mesalazine, olsalazine) 3
• Misoprostol suppositories 3
• Oral magnesium oxide 3
• Octreotide injections 3

Celiac Disease

Strict lifelong gluten-free diet 1, 4

Small Intestinal Bacterial Overgrowth

Empirical antibiotic cycle 4:

• Often requires prolonged and cyclical courses 3

Medication-Induced Diarrhoea

Mandatory medication review 1:

• Up to 4% of chronic diarrhoea cases are medication-induced 1

Critical Pitfalls to Avoid

Do not miss faecal impaction 1:

• Particularly in elderly patients 1
• Can manifest as alternating constipation and diarrhoea 1

Do not overlook microscopic colitis 1, 5:

• Presents similarly to IBS but requires different treatment 1, 5
• Requires colonoscopy with biopsy for diagnosis 5

Do not rely solely on Rome IV criteria 1:

• Specificity is only 52-74% for functional disorders 1
• Organic disease must be excluded first 1, 5

Do not use empiric antimicrobials without confirmed infectious cause 1:

• Increases drug resistance 1

Monitor for neutropaenic enterocolitis in cancer patients 1:

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

Avoid diphenoxylate in severe acute diarrhoea 3:

• Loperamide and opioids should be avoided in certain stages 3

Special Populations

Advanced Care/Palliative Patients

Prevalence of diarrhoea is 20% in palliative care 3:

• Rehydration is essential (oral or parenteral) 3
• Monitor for rapid dehydration with risk of prerenal impairment or shock 3
• Electrolyte imbalance (mainly hypokalaemia) is common 3
• Use skin barriers for incontinent patients to prevent pressure ulcers 3

Elderly Patients

Exercise particular caution 2:

• More susceptible to QT interval prolongation 2
• Avoid loperamide with drugs that prolong QT interval 2
• Higher risk of faecal impaction 1