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Diarrhea in Adults

By

Jonathan Gotfried

, MD, Lewis Katz School of Medicine at Temple University

Last full review/revision Mar 2020| Content last modified Mar 2020
Click here for the Professional Version
Topic Resources

The frequency of bowel movements alone is not the defining feature of diarrhea. Some people normally move their bowels 3 to 5 times a day. People who eat large amounts of vegetable fiber may produce more than a pound (1/2 kilogram) of stool a day, but the stool in such cases is well formed and not watery. Diarrhea is often accompanied by gas, cramping, an urgency to defecate, and, if the diarrhea is caused by an infectious organism or a toxic substance, nausea and vomiting.

Complications

Diarrhea can lead to dehydration Dehydration Dehydration is a deficiency of water in the body. Vomiting, diarrhea, excessive sweating, burns, kidney failure, and use of diuretics may cause dehydration. People feel thirsty, and as dehydration... read more and a loss of electrolytes, such as sodium, potassium, magnesium, chloride, and bicarbonate, from the blood. If large amounts of fluid and electrolytes are lost, the person feels weak, and blood pressure can drop enough to cause fainting (syncope), heart rhythm abnormalities (arrhythmias), and other serious disorders. At particular risk are the very young, the very old, the debilitated, and people with very severe diarrhea.

Causes of Diarrhea

The most common causes of acute diarrhea (lasting less than a week) are

The most common causes of chronic diarrhea (lasting more than 4 weeks) are

Diarrhea that has been present for more than 4 weeks may be a lingering case of acute diarrhea or the early stage of a disorder that causes chronic diarrhea.

Classification

Normally, stool is 60 to 90% water. Diarrhea occurs when not enough water is removed from the stool, making the stool loose and poorly formed. Stool may contain too much water if it

  • Passes too quickly through the digestive tract

  • Contains certain substances that prevent the large intestine from absorbing water

  • Contains excess water secreted by the intestines

Rapid passage (transit) of stool is a common cause of diarrhea. For stool to have normal consistency, it must remain in the large intestine for a certain amount of time. Stool that leaves the large intestine too quickly is watery. Many medical conditions and treatments can decrease the amount of time that stool stays in the large intestine. These conditions include an overactive thyroid (hyperthyroidism Hyperthyroidism Hyperthyroidism is overactivity of the thyroid gland that leads to high levels of thyroid hormones and speeding up of vital body functions. Graves disease is the most common cause of hyperthyroidism... read more Hyperthyroidism ); Zollinger-Ellison syndrome Gastrinoma A gastrinoma is a tumor usually in the pancreas or duodenum (the first segment of the small intestine) that produces excessive levels of the hormone gastrin, which stimulates the stomach to... read more (a condition of over-production of acid by a tumor); surgical removal of part of the stomach, small intestine, or large intestine; surgical bypass of part of the intestine; inflammatory bowel disease (such as ulcerative colitis Ulcerative Colitis Ulcerative colitis is a chronic inflammatory bowel disease in which the large intestine (colon) becomes inflamed and ulcerated (pitted or eroded), leading to flare-ups (bouts or attacks) of... read more ); surgical removal of the gallbladder (cholecystectomy Cholecystectomy Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct. Typically, people have abdominal pain, fever, and nausea. Ultrasonography can usually... read more ); and use of drugs such as antacids containing magnesium, laxatives, prostaglandins, serotonin, and even caffeine. Many foods, especially those that are acidic or have a very high amount of sugar (such as waffle or maple syrup), can increase the rate of transit. Some people are intolerant of specific foods and always develop diarrhea after eating them. Stress and anxiety are also common causes.

Osmotic diarrhea occurs when certain substances that cannot be absorbed through the colon wall remain in the intestine. These substances cause excessive amounts of water to remain in the stool, leading to diarrhea. Certain foods (such as some fruits and beans) and sugar substitutes in dietetic foods, candy, and chewing gum (for example, hexitols, sorbitol, and mannitol) can cause osmotic diarrhea. Also, lactase deficiency can lead to osmotic diarrhea. Lactase is an enzyme normally found in the small intestine that converts lactose (milk sugar) to glucose and galactose, so that it can be absorbed into the bloodstream. When people with lactase deficiency drink milk or eat dairy products, lactose is not digested. As lactose accumulates in the intestine, it causes osmotic diarrhea—a condition known as lactose intolerance Lactose Intolerance Lactose intolerance is the inability to digest the sugar lactose because of a lack of the digestive enzyme lactase, leading to diarrhea and abdominal cramping. Lactose intolerance is caused... read more . The severity of osmotic diarrhea depends on how much of the osmotic substance is consumed. Diarrhea stops soon after the person stops eating or drinking the substance. Blood in the digestive tract also acts as an osmotic agent and results in black, tarry stools (melena). Another cause of osmotic diarrhea is an overgrowth of normal intestinal bacteria or the growth of bacteria normally not found in the intestines. Antibiotics can cause osmotic diarrhea by destroying the normal intestinal bacteria.

Secretory diarrhea occurs when the small and large intestines secrete salts (especially sodium chloride) and water into the stool. Certain toxins—such as the toxin produced by a cholera infection or during some viral infections—can cause these secretions. Infections by certain bacteria (for example, Campylobacter) and parasites (for example, Cryptosporidium) can also stimulate secretions. The diarrhea can be massive—more than a quart (1 liter) of stool an hour in cholera. Other substances that cause salt and water secretion include certain laxatives, such as castor oil, and bile acids (which may build up after surgery to remove part of the small intestine). Certain rare tumors—such as carcinoid, gastrinoma Gastrinoma A gastrinoma is a tumor usually in the pancreas or duodenum (the first segment of the small intestine) that produces excessive levels of the hormone gastrin, which stimulates the stomach to... read more , and vipoma Vipoma A vipoma is a rare type of tumor of the pancreas that produces vasoactive intestinal peptide, a substance that causes severe watery diarrhea. These tumors arise from cells in the pancreas that... read more —also can cause secretory diarrhea, as can some polyps.

Inflammatory diarrhea occurs when the lining of the large intestine becomes inflamed, ulcerated, or engorged and releases proteins, blood, mucus, and other fluids, which increase the bulk and fluid content of the stool. This type of diarrhea can be caused by many diseases, including ulcerative colitis, Crohn disease, tuberculosis, and cancers such as lymphoma and adenocarcinoma. When the lining of the rectum is affected, people often feel an urgent need to move their bowels and have frequent bowel movements because the inflamed rectum is more sensitive to expansion (distention) by stool.

Diarrhea caused by malabsorption Overview of Malabsorption Malabsorption syndrome refers to a number of disorders in which nutrients from food are not absorbed properly in the small intestine. Certain disorders, infections, and surgical procedures can... read more is characterized by oil or grease in the stool and an oily rim around the toilet bowl after stool is flushed. Malabsorption of bile salts, which can result from certain disorders, can cause diarrhea by stimulating water and electrolyte secretion; the stools have a green or orange color.

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Evaluation of Diarrhea

Not every episode of diarrhea requires immediate evaluation by a doctor. The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.

Warning signs

Certain findings raise suspicion of a more serious cause of diarrhea.

  • Blood or pus in the stool

  • Fever

  • Signs of dehydration (such as decreased urination, lethargy or listlessness, extreme thirst, and a dry mouth)

  • Chronic diarrhea

  • Diarrhea at night

  • Weight loss

When to see a doctor

People who have warning signs of blood or pus in the stool, fever, or signs of dehydration should see a doctor right away, as should those with significant abdominal pain. Such people may need immediate testing, treatment, and sometimes admission to a hospital. If the only warning signs are chronic or nighttime diarrhea or weight loss, people should see a doctor within a week or so. People without warning signs should call a doctor if diarrhea lasts for more than 72 hours. Depending on the person's other symptoms, age, and medical history, the doctor may recommend the person have an examination or try at-home or over-the-counter treatments (see treatment of diarrhea Diarrhea is an increase in the volume, wateriness, or frequency of bowel movements. (See also Diarrhea in Children.) The frequency of bowel movements alone is not the defining feature of diarrhea... read more ).

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the diarrhea and the tests that may need to be done (see Table: Some Causes and Features of Diarrhea Some Causes and Features of Diarrhea Diarrhea is an increase in the volume, wateriness, or frequency of bowel movements. (See also Diarrhea in Children.) The frequency of bowel movements alone is not the defining feature of diarrhea... read more ).

A doctor begins by asking how long the diarrhea has been going on and how severe it has been. Simultaneous occurrence of diarrhea in friends, family members, or other personal contacts is sought. Other important questions focus on

  • Circumstances around when it started (including recent travel, food ingested, and source of water)

  • Drug use (including any antibiotics within the previous 3 months)

  • Abdominal pain or vomiting

  • Frequency and timing of bowel movements

  • Changes in stool characteristics (for example, presence of blood, pus, oil or grease, or mucus and changes in color or consistency)

  • Changes in weight or appetite

  • Feeling an urgent need to defecate or to defecate constantly

The physical examination begins with the doctor's evaluation of the person's fluid and hydration status. A full examination of the abdomen is done, as is a digital rectal examination to check for the presence of blood.

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Testing

The need for testing depends on what the doctor finds during the history and physical examination (see Table: Some Causes and Features of Diarrhea Some Causes and Features of Diarrhea Diarrhea is an increase in the volume, wateriness, or frequency of bowel movements. (See also Diarrhea in Children.) The frequency of bowel movements alone is not the defining feature of diarrhea... read more ). Acute watery diarrhea (lasting less than about 4 days) without warning signs is usually caused by a viral infection, and people who otherwise appear well do not require testing. People with warning signs of dehydration, bloody stool, fever, or severe abdominal pain typically need testing—particularly those who are very young or very old. In these people, doctors do blood tests to detect blood and electrolyte abnormalities and stool tests to detect blood Stool Occult Blood Tests Bleeding in the digestive system can be caused by something as insignificant as a little irritation or as serious as cancer. Chemicals can be used to detect small amounts of blood in the stool... read more , markers of inflammation, and the presence of infectious organisms (such as Campylobacter, Yersinia, amebas, Giardia, and Cryptosporidium). Some causes of infection are detected by looking under the microscope, whereas others require a culture (growing the organism in the laboratory) or special enzyme tests (for example, Shigella or Giardia). If the person has taken antibiotics within the past 2 to 3 months, the doctor may test the stool for Clostridioides difficile (formerly Clostridium difficile) toxin. A colonoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... read more is usually not necessary.

For diarrhea lasting more than 4 weeks (more than 1 to 3 weeks for people who have a weakened immune system or who appear seriously ill), similar tests are done. In addition, the doctor may test the stool, including tests for fat (indicating malabsorption) , do blood tests, and do a colonoscopy to examine the lining of the rectum and colon and to gather samples to test for infection. People whose symptoms seem related to diet may have a breath test to look for hydrogen, which suggests they are not absorbing carbohydrates. Sometimes a biopsy (removal of a tissue specimen for examination under a microscope) of the rectal lining is done to look for inflammatory bowel disease Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more . Sometimes the volume of stool over a 24-hour period is determined. Imaging tests, such as computed tomography (CT) enterography CT enterography and MR enterography Computed tomography (CT—see also Computed Tomography (CT)) and magnetic resonance imaging (MRI—see also Magnetic Resonance Imaging (MRI)) scans are good tools for assessing the size and location... read more , may be needed if the doctor suspects certain tumors. If doctors are still uncertain about the diagnosis, they may need to assess the function of the pancreas. Depending on the person's symptoms, doctors may also do tests for thyroid or adrenal gland disease.

Treatment of Diarrhea

Treatment is directed at the cause of diarrhea, when possible. For example, dietary and drug causes are avoided, tumors are removed, and drugs are given to eradicate a parasitic infection. However, in many cases, the body heals itself. A viral cause usually resolves by itself in 24 to 48 hours.

Dehydration

Extra fluids containing a balance of water, sugars, and salts are needed for people who are dehydrated. As long as the person is not vomiting excessively, these fluids can be given by mouth (see Treatment Treatment Dehydration is a deficiency of water in the body. Vomiting, diarrhea, excessive sweating, burns, kidney failure, and use of diuretics may cause dehydration. People feel thirsty, and as dehydration... read more ). Seriously ill people and those with significant electrolyte abnormalities require intravenous fluids and sometimes hospitalization.

Drugs

Drugs that relax intestinal muscles and slow intestinal transit (antidiarrheal drugs) can help slow diarrhea. Loperamide is available over the counter. Opioid drugs, such as codeine, diphenoxylate, and paregoric (tincture of opium), are available by prescription and also can help. However, certain bacterial causes of gastroenteritis, particularly Salmonella, Shigella, and Clostridioides difficile, can be worsened by antidiarrheal drugs. Doctors typically recommend antidiarrheal drugs only for people with watery diarrhea and no warning signs because such people are unlikely to have such bacterial infections. Eluxadoline is another drug that may be given to some people who have diarrhea caused by IBS.

Over-the-counter drugs include adsorbents (for example, kaolin-pectin), which adhere to chemicals, toxins, and infectious organisms. Some adsorbents also help firm up the stool. Bismuth helps many people with diarrhea. It has a normal side effect of turning the stool black. Bulking agents used for chronic constipation Constipation is difficult or infrequent bowel movements, hard stool, or a feeling that the rectum is not totally empty after a bowel movement (incomplete evacuation). (See also Constipation... read more , such as psyllium or methylcellulose, can sometimes help relieve chronic diarrhea as well.

Key Points about Diarrhea

  • In people with acute diarrhea, doctors examine the stool only if they suspect people have certain acute infections or if people have prolonged symptoms (that is, more than about 4 to 7 days) or warning signs.

  • Doctors avoid using antidiarrheal drugs if there is a possibility that the person has Clostridioides difficile, Salmonella, or Shigella.

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