Diarrhoea

Overview of Diarrhoea

Diarrhoea is the passage of more than 200 g of stool daily, and measurement of stool volume is helpful in confirming this.

This is extremely common and is usually due to Faecal– oral transmission of bacteria or their toxins, viruses or parasites. [4]

Epidemiology of Diarrhoea

Causes of Diarrhoea

1.Causes of Acute Diarrhoea:

Infections

• Viruses – e.g. Adenovirus, Herpes simplex virus
• Bacteria- e.g. Campylobacter, E. coli, Salmonella enteritis, Shigella
• Parasites- e.g. E. histolytica, Giardia

Food poisoning/toxins

• Bacillus cereus
• Salmonella
• Staphylococcus
• Vibrio

Drugs

• Antibiotics- e.g. Amoxicillin
• Anti hypertensives- e.g. Angiotensin converting enzyme inhibitors
• Antineoplastic drugs- e.g. Digoxin
• Antidepressants- e.g. Fluoxetine, Lithium
• Cholesterol lowering drugs
• GI drugs- e.g. Magnesium containing antacids, Prostaglandin analogues, H2- antagonists, Sulphasalazine
• Others: e.g. Theophylline, Diuretics, Oral hypoglycemic drugs, Thyroxine, Colchicine

Poorly absorbed sugars:

• Fructose, Mannitol, Sorbitol [1]

2.Causes of Chronic Diarrhea:

Dietary factors

• Excess ingestion of fructose, sorbitol, also caffeine

Infections

• Giardia lamblia
• histolytica
• Campylobacter enteritis
• Various organisms in immunocompromised (in other words; AIDS)

Drugs

• Antacids- e.g. Magnesium trisilicate
• Anti hypertensives- e.g. Methyldopa, Propranolol
• Theophylline
• Frusemide
• Methotrexate
• Antibiotics- such as Amoxicillin
• Digoxin
• Iron preparations
• NSAIDs

Lactose intolerance

Malabsorption

• Chronic pancreatitis
• Bacterial overgrowth
• Short bowel syndrome

Inflammatory bowel disease

Neoplasms

• Pancreatic cancer
• Neuroendocrine tumors
• Idiopathic secretory diarrhoea
• Microscopic colitis
• Collagenous colitis
• Idiopathic bile salt diarrhoea
• Post-cholecystectomy
• Large – volume nonspecific secretory diarrhoea

Endocrine disorders

• Diabetes mellitus
• Hyperthyroidism
• Hypoadrenalism

Functional bowel disorder

• Purgative use and abuse

Faecal incontinence

• Autonomic neuropathy (in other words; diabetes)
• Anorectal surgery [1]

Types of Diarrhoea

1. Acute Diarrhoea
2. Chronic and Recurrent Diarrhoea [1]

Risk factors of Diarrhea

Getting in contact with infected surfaces, bacteria, viruses and parasites causes Diarrhea and stomach flu. This is known as the fecal-oral route in medicine.

Wash your hands thoroughly after using the restroom and change your child’s diapers to lower hygiene risk. It is always recommended to use alcohol-based hand gel for a clean hand wash.

Only drink bottled water or purified water when travelling to locations where there is a greater danger of contaminated water and food.

Here are some of the risk factors that can cause Diarrhea:

• Poor hygiene practices
• Poor sanitation
• Poor access to clean
• Food insecurity
• Poor nutritional status (8)

Pathogenesis of Diarrhoea:

Diarrhea results from defective absorption of fluid and electrolytes, excessive secretion, or both. These defects can occur in the small or large intestine.

• Osmotic Diarrhea: Occurs when poorly absorbed, osmotically active solutes remain in the intestinal lumen, drawing water into the bowel. This can result from malabsorption of carbohydrates (e.g., lactose intolerance), ingestion of certain laxatives (e.g., magnesium salts), or malabsorption syndromes.

• Secretory Diarrhea: Occurs when there is an increase in the active secretion or inhibition of absorption of electrolytes, leading to water being drawn into the lumen. This can be caused by bacterial enterotoxins (e.g., cholera, E. coli), certain hormones (e.g., vasoactive intestinal peptide), or congenital disorders of ion transport.

• Inflammatory Diarrhea: Occurs due to mucosal inflammation and damage, leading to impaired absorption and increased secretion. Causes include inflammatory bowel diseases (e.g., Crohn’s disease, ulcerative colitis), infections, and radiation enteritis.

• Motility Disorders: Altered intestinal motility can lead to diarrhea due to rapid transit of luminal contents, preventing adequate absorption. This can be caused by irritable bowel syndrome, post-surgical states, or autonomic neuropathy. [12]

Pathophysiology of Diarrhoea

Clinical Features of Diarrrhoea

The clinical presentation of diarrhea is variable and depends on its etiology, severity, and duration.

Symptoms:

Increased stool frequency: Defined as more than three bowel movements per day.

Increased stool volume: Usually exceeding 200 g/day.

Altered stool consistency: Loose or watery stools.

Abdominal pain or cramping: May be associated with urgency and tenesmus (feeling of incomplete evacuation).

Nausea and vomiting: May be present, particularly in infectious diarrhea.

Fever: Suggests an infectious or inflammatory etiology.

Blood or mucus in stool: Indicates mucosal inflammation or damage.

Dehydration: Can occur due to fluid and electrolyte losses, especially in severe or prolonged diarrhea. Signs of dehydration include thirst, dry mouth, decreased urine output, lethargy, and dizziness.

Additional Considerations:

Duration:

• Acute diarrhea: Lasts less than 14 days.
• Persistent diarrhea: Lasts 14-29 days.
• Chronic diarrhea: Lasts more than 30 days.

Travel history: Suggests the possibility of traveler’s diarrhea.

Medication history: Certain medications can cause diarrhea as a side effect.

Dietary history: Recent dietary changes or intolerance may contribute to diarrhea.

Concomitant symptoms: Weight loss, malabsorption, or systemic symptoms may indicate underlying chronic conditions. [12]

Sign & Symptoms of Diarrhoea

Colonic i.e.:

• Blood and mucus in stool
• Cramping lower abdominal pain

Malabsorption i.e.:

• Steatorrhea
• Undigested food in the stool
• Weight loss and nutritional disturbances

Small bowel i.e.:

• Large-volume, watery stool
• Abdominal bloating
• Cramping mid-abdominal pain [2]

Clinical examination of Diarrhea

Physical examination of patients with acute diarrhea shows signs of dehydration (dry mouth and tongue, sunken eyes, sunken anterior fontanelle, poor skin turgor, hypotension, altered consciousness, absent tears), abdominal tenderness and distension, increased peristaltic activity, perineal erythema and signs of malnutrition.

Appearance of the patient

• Patients with acute diarrhea may appear ill, dehydrated, or lethargic depending upon the severity of diarrhea.

Vital signs

• Hypotension
• Fever
• Orthostasis
• Tachycardia or bradycardia
• Tachypnea

Skin

• Skin examination of patients with diarrhea can be done by pinch test.
• If the skin on the thigh, calf, or forearm is pinched, it will immediately return to its normal flat state when the pinch is released in normal patients.
  • Mild dehydration (0-5%): Pinch retracts immediately
  • Moderate dehydration (5-10%): Pinch retracts slowly
  • Severe dehydration (>10%): Pinch remain folded
• Delayed capillary refill

Heart

• Hypotension
• Tachycardia/ Bradycardia
• Decreased jugular venous pressure

Abdomen

• Abdominal distention
• Diffuse abdominal tenderness
• Borborygmi
• Rigidity and rebound abdominal tenderness
• Hepatosplenomegaly is associated with certain infections (Mycobacterium Avium complex, Salmonellosis)

Perineal erythema

• In children mostly, frequent passage of stools cause perineal skin breakdown.
• Carbohydrate malabsorption secondary to diarrhea may be responsible for more acidic stools, that results in erythema.
• Bile acid malabsorption leads to diaper dermatitis that is severe, appears as burnt perianal skin.

Failure to thrive and malnutrition

• Reductions in muscle and fat mass or peripheral edema may be present in presence of underlying carbohydrate, fat, and/or protein malabsorption.
• Giardia can cause intermittent diarrhea and fat malabsorption.

Lungs

• Examination is usually normal.
• Tachypnea caused by metabolic acidosis as a result of severe volume depletion.

HEENT

• Sunken anterior fontanelle
• Oral mucosal lesions and angular stomatitis in tropical sprue
• Dry mucous membranes and tongue

Neuromuscular

• Muscle weakness and convulsions because of moderate to severe electrolyte imbalance (9)

Diagnosis of Diarrhoea

Generally, Your doctor will ask about your medical history, review the medications you take, conduct a physical exam and may order tests to determine what’s causing your diarrhea. Possible tests i.e.:

• Blood test- In detail, A complete blood count test, measurement of electrolytes and kidney function tests can help indicate the severity of your diarrhea.
• Stool test- Your doctor might recommend a stool test to see if either a bacterium or parasite is causing your diarrhea.
• Hydrogen breath test- This type of test can help your doctor determine if you have a lactose intolerance. Moreover;  After you drink a liquid that contains high levels of lactose, your doctor measures the amount of hydrogen in your breath at regular intervals. Lastly, Breathing out too much hydrogen indicates that you aren’t fully digesting and absorbing lactose.
• Flexible sigmoidoscopy or colonoscopy- Using a thin, lighted tube that’s inserted in your rectum, your doctor can see inside your colon. Additionally, The device is also equipped with a tool that allows your doctor to take a small sample of tissue (in other words, biopsy) from your colon. All in all, Flexible sigmoidoscopy provides a view of the lower colon, while colonoscopy allows the doctor to see the entire colon.
• Upper endoscopy- In brief, Doctors use a long, thin tube with a camera on the end to examine your stomach and upper small intestine. They may remove a tissue sample (biopsy) for analysis in the laboratory.[7]

Differential diagnosis of Diarrhea

• Ischemic colitis
• Lactose intolerance
• Tropical sprue
• Pseudomembranous enterocolitis
• Escherichia coli enteritis
• Vibrio cholera
• Food poisoning
• Organophosphate poisoning
• Short bowel syndrome (9)

Complications of Diarrhea

Diarrhea can cause dehydration, which can be life-threatening if untreated.

Dehydration is particularly dangerous in children, older adults and those with weakened immune systems.[7]

Investigation of Diarrhoea

• Faecal calprotectin
• Ileocolonoscopy with biopsies
• Ultrasound
• CT
• MRCP
• Small-bowel biopsy
• Barium
• Small-bowel MRI
• Stool volume
• Gut hormone profile [2]

Treatment of Diarrhoea

• Symptomatic therapy includes:
• Vigorous rehydration (IV or with oral glucose-electrolyte solutions),
• Electrolyte replacement
• Binders of osmotically active substances kaolin-pectin
• Opiates to decrease bowel motility (e.g. Loperamide, Diphenoxylate) opiates may be contraindicated in infectious or inflammatory causes of diarrhea. [4]

Prevention of Diarrhoea

Preventing infectious diarrhoea

Wash your hands to prevent the spread of infectious diarrhea. To ensure adequate hand-washing:

Wash frequently- Wash your hands before and after preparing food. Wash your hands after handling uncooked meat, using the toilet, changing diapers, sneezing, coughing and blowing your nose.

Lather with soap for at least 20 seconds- After putting soap on your hands, rub your hands together for at least 20 seconds. This is about as long as it takes to sing "Happy Birthday" twice through.

Use hand sanitizer when washing isn’t possible- Use an alcohol-based hand sanitizer when you can’t get to a sink. Apply the hand sanitizer as you would hand lotion, making sure to cover the fronts and backs of both hands. Use a product that contains at least 60% alcohol.[7]

Homeopathic Treatment of Diarrhoea 

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis. 

Which includes 

• The medical history of the patient, 
• Physical and mental constitution, 
• Family history, 
• Presenting symptoms, 
• Underlying pathology, 

• Possible causative factors etc. 

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions. 

What Homoeopathic doctors do? 

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition. 

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines. 

Homeopathic Medicines for Diarrhoea 

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor. 

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).  

Medicines:

Abrotanum:

• Diarrhoea for several days, stopping suddenly or being checked, followed by rheumatism; food passes undigested
• Alternate diarrhoea and constipation.

 Aesculus Hip:

• Diarrhoea, the desire to have the bowels moved coming on suddenly, preceded by passage of flatus and followed by pain in abdomen and eructation tasting of the ingesta.
• Chronic Diarrhoea. First part hard and back, then evacuation yellow, thin or brown or mushy or white or natural in color, accompanied by severe lumbar and sacral pains, weakness, tenesmus and most unpleasant sensation in rectum and anus.
• Nervous prostration, weariness and sleepiness, pale face, liver complaint, hemorrhoids.

Agaricus:

• Diarrhoea in wet weather, mostly mornings, after rising and eating, with much rumbling.
• Stools thin, yellow, fecal, slimy, with pinching and cutting in abdomen before stool and smarting in anus afterwards, crampy colic and passing of inodorous flatus or of garlic smell.
• Drowsy in daytime hard stool, then loose and finally diarrhoea, increased micturition even with the diarrhoea.
• Great debility; chronic diarrhoea.

Aloe Socotrina:

• Want of confidence in sphincter ani; urging to stool continuously, worse immediately after eating, feeling of fulness and weight in the pelvis, with passage of urine only hot flatus passes, giving relief, but burning in anus afterwards.
• Difficulty to retain faeces, even a well-formed stool passes unnoticed, when walking or standing.
• Furthermore, Profuse watery diarrhoea, accompanied by wind, containing lumps of jellylike mucus, looking like frog- spawn.
• Diarrhoea driving out of bed very early in the morning.
• Besides this; Stools yellow, faecal, bright-yellow, bilious, great rumbling in bowels, escape of large quantities of offensive flatus.
• All in all; Aggravation in mornings, in hot damp weather, from overheating after cold in a damp room.

Alumina:

• Diarrhoea on alternate days.
• Inactivity of rectum, even a soft also thin stool requires great straining.
• Inability to defaecate till there is a large accumulation.
• Diarrhoea whenever she urinates.
• Diarrhoea with urging in rectum, with bloody scanty stool.
• Chill during stool, which is offensive and exhausts the patient.

Ammonium Mur:

• Colliquative diarrhoea of phthisis abdominals;
• Diarrhoea and vomiting during menses (spine feel cold also itchy), discharges varying in color and character.
• Diarrhoea after eating, with pain in abdomen, back, sacrum and limbs; glassy, though mucus in stool.

Argentum Nitricum:

• Nervous diarrhoea during menses, from apprehension as when ready to go to church, theatre etc., that bowels would move; from drinking; great fondness for either sugar or sweets, though their use provokes diarrhoea.
• Diarrhoea of children during dentition, after weaning.
• Chronic diarrhoea of children; stools green flaky, like spinach, mucous, with excessive flatulency, aggravation at night; green brown, bloody, after midnight.
• Slimy, watery, greenish, bloody, with tenesmus; difficulty of breathing, with long sighs.

Arnica Montana:

• Involuntary stool during sleep.
• Brown fermented stools, with foetid breath and loathing of food; offensive, involuntary stools.
• Foul and putrid eructations and stools, with feeling of nauseous repletion after eating.

Bromium:

• Desire for acids which aggravate also cause diarrhoea.
• Aversion to tobacco and to drinking cold water.
• Emptiness in stomach or contractive pains in stomach, by eating, but diarrhoea after every meal.
• Stools bright yellow, preceded by cutting and rumbling in abdomen; stools light-yellow, slimy, painless, doorless, like scraping of guts; aggravation especially, after oysters.

Bryonia alba:

• Diarrhoea from suddenly checked perspiration in hot weather, from indulgence in vegetable food or stewed fruits, from getting overheated in summer, from drinking milk, cold drinks, or from anger and chagrin.
• Lips dry and parched, desire for cold and acid drinks, for large quantities at long intervals, with internal heat, without feeling hot outside.
• Diarrhoea preceded by colic, either at night or early morning, after rising and moving about, coming on so suddenly that escape is hard to prevent.
• Bilious diarrhoea with lancinating pain; loose stools, painless and undigested, smelling foul, like old rotten cheese.
• Brown, thin, faecal stools with burning and pricking in anus; urging, followed by copious pasty evacuations with relief of all symptoms, except confusion of head.
• Stool pasty, with much flatus, followed by hard portions and again by soft, so that he thought he would never get through.

China:

• Emission of a quantity of flatus, frequently very foetid, without relief.
• Diarrhoea comes on gradually, stools more and more watery, pale, pinkish, with rapid emaciation.
• Diarrhoea, particularly after meals, at night, painless, early in morning, In hot weather; from eating fruit; from drinking sour beet; after measles; during smallpox; after severe acute diseases; after loss of fluids; on alternate days; with trembling and debility.
• Cadaverous-smelling, brown, aggravation at night, lienteria from weakness of intestinal canal.
• Thirst during stool, if there is marked sweat.

Croton Tig:

• Extreme coldness, amounting to chilliness along spinal column downward and through entire abdomen, with nausea and vomiting, subsequently flushed face with colic, commencing in region of transverse colon and gradually extending downward.
• Very copious, pap-like, yellow, dirty-green or brown, watery stools, coming out like a shot, aggravation by motion, while eating and drinking, amelioration by warm drinks; diarrhoea coming on suddenly, pain in abdomen, faint feeling before, during and after stool.
• Every movement of the body discharges, causing at first violent pains in bowels, with tenesmus; swashing sound and feeling in abdomen.
• anxious countenance, spirits depressed, great restlessness and great prostration.

Iris Versicolar:

• Diarrhoea with burning in rectum and anus after.
• Severe rumbling of gas; excessive watery discharges, mixed with mucus, preceded by soft and more substantial stools.
• Intense aching cramp-like pains; excessive nausea and vomiting.
• Periodical night colic, relieved by two or three free discharges before morning; a mushy passage once or twice a day, with foetid flatus of a coppery sell, attended occasionally with an involuntary escape of fluid, soiling the sheet.
• Stool of scybalous matter, together with fluid, mucoid faeces of an offensive, putrid and coppery odor Nausea with burning in the mouth fauces and oesophagus; vomiting of an extremely sour fluid.
• Autumnal bilious diarrhoea, exhaustion and debility from her the start.

Kali Bichromicum:

• Watery, gushing diarrhoea in the morning awakes with violent tenesmus, which prevents her rising prevents her rising, later burning in abdomen, nausea and violent straining to vomit.
• Stools brownish, frothy, jellylike, lumpy; large insular red patches on the white and cracked tongue; desire for ale and acid drinks; much debility and desire to lie down.
• Chronic diarrhoea off and on. [5]

Diet & Regimen of Diarrhoea

• Drink 8-10 cups of fluid per day, like water, half-strength juice, weak tea, or electrolyte replacement drinks.
• Eat small frequent meals slowly during the day.
• Try sources of soluble fibre to help firm up stool.
• Limit fried or fatty foods since these can worsen diarrhea.
• Some high fibre foods may contribute to diarrhea.
• Foods with lots of sugar may worsen diarrhea, such as regular pop, candy, large quantities of juice, and chocolate milk.
• Some people may become temporarily lactose intolerant when experiencing diarrhea. [6]

Do’s:

• Hydrate: Drink plenty of fluids to replace lost fluids and electrolytes. Water, clear broths, electrolyte solutions (like Pedialyte), and weak tea are good options.
• Follow the BRAT diet: Bananas, rice, applesauce, and toast are bland and easy to digest, which can help solidify stools.
• Eat small, frequent meals: This can be easier on your digestive system than large meals.
• Rest: Allow your body to recover.
• See a doctor: If your diarrhea lasts more than a few days, is severe, or you have signs of dehydration (like dizziness, dry mouth, or dark urine), seek medical attention.

Don’ts:

• Don’t eat greasy, fatty, or fried foods: These can worsen diarrhea.
• Avoid drink alcohol or caffeine: These can dehydrate you.
• Avoid eating high-fiber foods: These can be hard to digest and may make diarrhea worse.
• Don’t take over-the-counter anti-diarrheal medications without consulting a doctor: These may not be appropriate for all types of diarrhea and can have side effects.

Terminology

Diarrhea:

• The passage of loose, watery stools more frequently than usual.

Dysentery:

• A type of diarrhea characterized by bloody stools, usually caused by infection or inflammation.

Flux:

• An old-fashioned term for diarrhea.

Montezuma’s Revenge/Tourista/Delhi Belly:

• Informal terms for traveler’s diarrhea, often caused by consuming contaminated food or water while traveling.

Acute Diarrhea:

• Diarrhea lasting less than 14 days.

Persistent Diarrhea:

• Diarrhea lasting 14-29 days.

Chronic Diarrhea:

• Diarrhea lasting more than 30 days.

Osmotic Diarrhea:

• Diarrhea caused by poorly absorbed substances drawing water into the intestines.

Secretory Diarrhea:

• Diarrhea caused by increased secretion of fluids into the intestines.

Inflammatory Diarrhea:

• Diarrhea caused by inflammation and damage to the lining of the intestines.

Steatorrhea:

• Fatty stools, often a sign of malabsorption.

Tenesmus:

• A feeling of incomplete bowel evacuation.

BRAT Diet:

• A diet of bananas, rice, applesauce, and toast, recommended for mild diarrhea.

Fecal Calprotectin:

• A stool test that measures inflammation in the intestines.

Ileocolonoscopy:

• A procedure to examine the colon and last part of the small intestine.

References

1. Golwala’s Medicine for student 25th edition 2017 
2. Davidsons Principles and practice of medicine_22Ed 
3. Pathophysiology of Disease Second Edition 
4. The Harrisons Manual of Medicine 
5. Homoeopathic Therapeutic by Lilienthal 
6. https://badgut.org/information-centre/health-nutrition/diarrhea-and-diet/ 

7.  https://www.mayoclinic.org/diseases-conditions/diarrhea/symptoms-causes/syc-20352241 

8. The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: evidence from the global burden of disease study (2022)
9. Diarrheal diseases among children in India: Current scenario and future perspectives (2015)
10. Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from Longitudinal Ageing Study in India, 2017–18 (2022)
11. Identifying spatial clustering of diarrhoea among children under 5 years across 707 districts in India: a cross sectional study (2023)
12. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 11th Edition, Editors: Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt (2021), Published by Saunders

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