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

Management of Chronic Diarrhoea

Initial Risk Stratification

Begin by classifying chronic diarrhoea as either uncomplicated or complicated, as this determines whether outpatient management or immediate hospitalization is required. 1

Uncomplicated Chronic Diarrhoea

• Characterized by loose stools without fever, dehydration, bleeding, or severe cramping, with patients maintaining adequate oral intake and performance status 1
• Manage in the outpatient setting with loperamide and dietary modifications 2, 1

Complicated Chronic Diarrhoea

• Presence of fever, sepsis, neutropaenia, moderate to severe dehydration or orthostatic symptoms, blood in stool, severe abdominal cramping, or inability to maintain oral hydration 1
• Requires immediate hospitalization with IV fluid resuscitation, electrolyte replacement, octreotide administration, and empiric antibiotic therapy if fever or leukocytosis is present 2, 1

Management Algorithm for Uncomplicated Chronic Diarrhoea

First-Line Pharmacological Therapy

Start loperamide 4 mg initially, then 2 mg after each loose stool (maximum 16 mg daily) as the cornerstone of initial management 2, 1

• Clinical improvement should be observed within 48 hours; if not, discontinue and contact healthcare provider 3
• For chronic diarrhoea, if no improvement occurs within 10 days at maximum dosage (20 mg daily), symptoms are unlikely to be controlled by further administration 4
• Exercise caution in elderly patients, as they are at higher risk of faecal impaction and may be more susceptible to QT interval prolongation 2, 3

Essential Dietary Modifications

Implement simultaneously with loperamide 2:

• Eliminate lactose-containing products 2, 1
• Restrict fatty foods, spicy foods, caffeine, and alcohol 2, 1
• Avoid high-osmolar dietary supplements 2, 1
• Implement a bland/BRAT diet 2
• Use high-fiber diet with partially hydrolysed guar gum (soluble fiber) rather than insoluble fiber 2
• Maintain oral hydration with glucose-containing drinks or electrolyte-rich soups 2, 1

Second-Line Therapy for Refractory Cases

• Octreotide 100 μg three times daily is reserved for patients not responsive to loperamide with severe toxicity 2
• Anticholinergic antispasmodic agents can alleviate bowel cramping 2

Cause-Specific Management

Bile Acid Diarrhoea

Cholestyramine or colesevelam is first-line therapy, particularly in patients with prior cholecystectomy, terminal ileal resection, or radiation enteritis 2, 1, 5

Inflammatory Diarrhoea

• Budesonide 9 mg once daily for refractory cases 2, 1
• Infliximab 5 mg/kg once every 2 weeks until resolution for immune checkpoint inhibitor-induced diarrhoea 2

Infectious Causes

• Giardiasis and amebiasis can cause chronic infections in immunocompetent patients; use ELISA in stool for diagnosis 5
• Metronidazol or tinidazol in short cycle is effective for giardiasis 5
• Avoid empiric antimicrobials without confirmed infectious cause, as this increases drug resistance 1

Malabsorptive Diarrhoea

• Coeliac disease requires strict lifelong gluten-free diet once confirmed by positive serology (tissue transglutaminase or EMA) and duodenal biopsy 1, 5
• Small intestinal bacterial overgrowth requires empirical antibiotic cycle 5

Medication-Induced Diarrhoea

Mandatory medication review, as up to 4% of chronic diarrhoea cases are medication-induced 1, 5

Diagnostic Workup for Complicated or Refractory Cases

Initial Screening Tests

• Blood tests and stool evaluation to determine underlying cause 2, 1
• Serological testing for coeliac disease (tissue transglutaminase or EMA) 5
• Faecal calprotectin to determine presence of intestinal inflammation 5
• HIV testing in immunocompromised patients 5

When to Pursue Further Investigation

• If clinical improvement is not observed within 48 hours of loperamide therapy 3
• Presence of blood in stools, fever, or abdominal distention 3
• Any red flag symptoms requiring urgent gastroenterology referral 1

Critical Pitfalls to Avoid

• Do not miss faecal impaction, particularly in elderly patients, as it manifests as alternating constipation and diarrhoea 1
• Do not overlook microscopic colitis, which presents similarly to IBS but requires different treatment 1, 5
• Avoid relying solely on Rome IV criteria for diagnosing functional disorders, as specificity is only 52-74% 1
• Monitor for neutropaenic enterocolitis in cancer patients, as it has high mortality risk and requires broad-spectrum antibiotics and G-CSF 1
• Be aware of drug interactions: loperamide exposure increases 2-3 fold with P-glycoprotein inhibitors (quinidine, ritonavir) and up to 12.6-fold with combined CYP3A4 and CYP2C8 inhibitors (itraconazole plus gemfibrozil), increasing risk for cardiac adverse reactions 3

Special Populations

Palliative Care Patients

• Prevalence of diarrhoea is 20% in palliative care 2
• Rehydration is essential with monitoring for rapid dehydration and electrolyte imbalance 2

Elderly Patients

• Higher risk of faecal impaction requiring particular caution with loperamide 2
• Avoid loperamide in elderly patients taking Class IA or III antiarrhythmics or those with risk factors for Torsades de Pointes 3