Chronic Diarrhea - Causes and Investigations

Chronic diarrhea has no exact definition but the American Gastroenterological Association defines it as diarrhea that persists for more than four weeks.

It also estimates that it affects approximately 5% of the population in developed countries (with higher levels in the elderly of between 7-14%). Are you one of those in the 5%? I was and I would have up to 10 loose bowel movements a day.

If you are suffering like I did you will know that it affects your whole life. I didn’t want to go out as I was always worrying about needing to dash to the bathroom with severe, chronic diarrhea. If I did go to the cinema then I would always have to select an aisle seat in case I needed to leave in a hurry. 

Once I accidentally got in the middle of a row at a theater and just spent the whole performance worrying how to escape if I needed to. Another time, I was in a shopping mall and descending from one floor to another on the escalator when suddenly my bowels just opened and I could feel the diarrhea flowing down my legs. This was my worst moment and I decided then, that I would have to search harder for a solution however long it took.

Do You Have Chronic Diarrhea ?

Check. Do you actually have chronic diarrhea? Loose or liquid bowel movements 3 or more times a day or more than 200g in volume counts as diarrhea. You may have another symptom such as:

1. Bowel movements straight after eating.
2. Incomplete evacuation: The feeling that a second bowel movement is needed straight after the first.
3. Fecal incontinence: An inability to hold onto stool until an appropriate time.
4. Rectal urgency: A sudden urgent need to have a bowel movement which may result in incontinence if a bathroom is not immediately available. 

These symptoms are not chronic diarrhea and may have different causes and need different treatment.

If you do have chronic diarrhea do not despair it can often be cured or at least managed. I sorted out my problem but first you have to find out what is causing your intestines to misbehave. It is important to think about causes of chronic diarrhea as finding out the reason for your problem is the first step to finding a solution.

The causes of diarrhea are many. Listed below are many of the things that can cause this difficulty to become chronic diarrhea. Consider this list carefully and try to think outside the box. You may have something which doctors come across all the time and therefore is easy to diagnose - or do you have one of the causes of chronic diarrhea that is a little rarer that they may not have thought about?

Medications

Medication can be one of the reasons for chronic diarrhea.This is especially true of anti-depressants, blood pressure and cancer medications but most drugs can cause this problem including magnesium containing antacids, metformin and non-steroidal anti-inflammatory drugs. Other causes of chronic diarrhea are:

• Excessive caffeine

• Excessive alcohol

• Excessive use of laxatives. This is sometimes referred to as factitious diarrhea and can be a factor in eating disorders.

• Artificial sweeteners.

• Food additives such as Sorbitol and Mannitol.

• Use of weight loss drugs.

Surgery

Gastric bypass surgery
Removal of the Gall Bladder (Cholecystectomy)
Following removal of any part of the gastrointestinal tract.

Functional

Irritable Bowel Syndrome is a functional disorder and is one of the major reasons for chronic diarrhea. It is also sometimes called Spastic Colon. The intestines appear normal and are not diseased or inflamed but are extra sensitive, causing them to function incorrectly - either too fast in the case of diarrhea or too slowly in the case of constipation. The cause has not yet been discovered.

Toddler diarrhea is a similar disorder in young children. Frequent bouts of diarrhea happen in an otherwise fit and healthy child due to fast transit times. Dietary changes can help.

From the Colon

• Colon Cancer
• Inflammatory Bowel Disease including Crohn’s Disease,  Ulcerative Colitis and Microscopic Colitis
• Ischemic colitis (reduced blood flow to the colon)
• Radiation Colitis (following radiotherapy treatment)
• Constipation causing impaction and then overflow diarrhea
• Diverticulitis
  

From the Small Intestine

• Crohn’s Disease
• Celiac Disease
• Malabsorption
• Bile Acid Malabsorption
• Whipple’s Disease
• Cancer (rare)
• Mesenteric Ischemia
• Cholecystitis (inflammation of the gallbladder). It has been found that one of the reasons for chronic diarrhea is an undiagnosed, extremely mild, gallbladder problem and people with this type of chronic diarrhea have been successfully treated with Questran, a drug normally given to people who have had their gallbladders removed.
•  Bacterial overgrowth
  

Food Intolerances

Celiac disease is an autoimmune disorder with a genetic component. It is often called gluten intolerance. The immune system mistakenly overreacts when gluten-containing foods such as wheat, rye and barley are eaten causing inflammation and changes in the small intestine. Celiac disease is one of the causes of chronic diarrhea which can be overlooked.

Lactose intolerance (small intestine); an inability to digest lactose, a sugar in dairy products due to a lack of the enzyme lactase is one of the causes of chronic diarrhea in some people, especially if they are not of European descent. This lack is normal in most mammals after weaning but Northern Europeans usually retain this enzyme. Only 5% of Northern Europeans are lactose intolerant whereas 71% of Sicilians and more than 90% of Africans and Asians are.

Disaccharidase Deficiency: This is a more generalized form of sugar intolerance where the body lacks the enzymes for breaking down the sugars sucrose, maltose and other sugars in carbohydrate foods as well as lactose. In order for the body to digest these sugars they need to be broken down into very simple sugars such as glucose.

Intolerance to specific foods, which can be determined either by using an exclusion diet (with medical supervision) or after blood testing for IgG antibodies.

Chronic Infection

• Hepatitis A B and C
• Clostridium Difficile
• Parasites do not always cause diarrhea but the parasite Giardia is a particular culprit.
  
• Cryptosporidium, Hookworm and Entamoeba histolytica should also be considered.
  

Pancreatic

Exocrine Pancreatic insufficiency (trouble digesting food due to a lack of enzymes secreted by the pancreas, most commonly caused by Cystic Fibrosis, Swhachman-Bodian-Diamond Syndrome and Pancreatitis)

Cancer of the pancreas

Endocrine

• Overactive thyroid
• Hypoparathyroidism
• Diabetes
• Tumors that produce hormones
• Addison’s Disease

After studying the above list of explanations for chronic diarrhea and looking at further information on this site and from other sources you may have an inkling what is wrong with you, but it is important that you see your health care professional. They will want to take a history and look for any red flag symptoms. These are symptoms which may indicate that you have something serious going on.

Red Flags

• Weight loss in spite of a normal appetite
• Painless diarrhea
• Blood in the stool (either fresh red blood or black stools which contain old blood)
• Nocturnal diarrhea especially if it wakes you
• Onset in the last three months
• Over the age of 45
• Tiredness suggestive of anemia
• Large volumes of stool
• Low protein in the blood (Hypoalbuminemia) which can indicate malnutrition
• Increased Erythrocyte Sedimentation Rate (ESR) of the red blood cells. This is an indication of inflammation.
• A family history of certain diseases especially bowel cancer
• Abdominal or rectal masses

The timing of your chronic diarrhea and the type can indicate to your doctor what may be going on. For example stools which are bulky and float (steatorrhea) can indicate malabsorption as they contain high levels of fat.

They will want to know about your recent movements. Have you been abroad to an undeveloped area where you may have picked up a parasite through contaminated water or food? After taking a history they will want to carry out some tests to find out what is causing your diarrhea or exclude certain conditions.

To begin with they will give you a physical examination. This will probably include feeling your abdomen and your neck to look for tenderness and lumps.

A rectal examination is done to look for fissures, stool impaction, masses and hemorrhoids.

I know that it is this examination that people worry about. ‘It’s embarrassing.’ ‘Will it hurt?’ Doctors do this all the time and it is all just like a normal working day for them. 

You will be asked to lie down on your side with your knees towards your abdomen. I know it is not easy but it really helps to just try and really relax your muscles. It can be uncomfortable but it is not usually very painful and it is quickly over.

They could also examine your eyes as these can be affected in some gastrointestinal disorders like Crohn's disease, Ulcerative colitis and Celiac disease.

Next your doctor will ask for blood tests and a stool sample so that it can be evaluated for blood, fat, infection, Ph. and parasites.

Many people do not like the idea of collecting their own stool and handing it in to the lab but the lab technicians are used to looking down a microscope at your poop. They just want to do a good detective job and discover any abnormalities that may be causing your problem.

Taking a stool sample

To make collection easier you may be given a special container to put in the toilet, or you could use a clean disposable plastic container that you have saved from some food wrapping, to receive the stool.

Make sure not to collect any urine (pee) first or water from the toilet along with the specimen. Use the scoop provided to transfer the required amount into the collection container. (Read the instructions carefully).

The fresher the specimen the better, so take it to the lab as soon as possible or store in a refrigerator in a sealed bag for not more than 48 hours.

Referral

If you are over 45 or have any worrying symptoms which may indicate a serious condition then you will probably be referred to a gastroenterologist and asked to have a colonoscopy or sigmoidoscopy. This is where a flexible tube with a camera is introduced via your rectum, allowing the gastroenterologist to examine the bowel wall to see if it looks normal or not and to take a biopsy so that the tissue can be looked at more closely in the lab.

You may also be asked to have other tests such as barium x-rays, scans and analysis of gut hormones.

Be aware that functional bowel disorders such as irritable bowel syndrome are diagnosed by a process of elimination. So if nothing else is found and the symptoms fit, a diagnosis is made. There is no specific test.

If you have chronic diarrhea do not suffer in silence. Yes, it is embarrassing but do not let this hold you back. Go and see a healthcare professional and find out why you are suffering like this.

My Story

So what happened to me? I was diagnosed with irritable bowel syndrome and managed to go from 10 loose bowel movements a day, to a bout of diarrhea perhaps once every six months. How did I do this?

I first improved when I started a high protein diet to lose some weight. This made me think about the food I was eating. An IgG antibody blood test showed that I was intolerant of certain foods. Cutting these out of my diet did help a lot and I improved tremendously but I was not cured completely. (Be careful when doing this and take medical advice as it is dangerous to cut out whole food groups).

What allowed me to get 95% back to normal was hypnotherapy from a therapist specializing in this area. She taught me how to control the speed of my gut. It took 12 sessions but now I feel back in control of my bowels and my life.

After eliminating certain foods for a period of time, using self hypnosis and replenishing my bowels with high quality probiotics I can eat a much more varied diet again. I just go easy on the almonds, hazelnuts and sunflower seeds that I was tested as intolerant to and only eat them very occasionally.

Start investigating today why you have this problem and get back to doing the things you love. Take back control of your life. Yes having persistent diarrhea is something which is embarrassing and difficult to talk about but remember many people suffer with this and healthcare professionals see people with your problem all the time.

In fact chronic diarrhea is the number one problem referred to gastroenterologists. For more information explore this site and look at the related pages below.  I hope you found this information on chronic diarrhea helpful.

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