• Increase in frequency, fluidity, and volume of bowel movements
Diarrhea is a common symptom that usually indicates a mild, temporary event. However, it may also be the first suggestion of a serious underlying disease or infection. Severe bloody diarrhea, diarrhea in a child less than six years of age, or diarrhea that lasts more than three days should not be taken lightly; its cause must be determined and it must be treated appropriately.
Types of Diarrhea |
|
TYPE |
CAUSES |
Osmotic |
Saline laxatives that contain magnesium, phosphate, or sulfate |
|
Carbohydrate malabsorption (e.g., lactose intolerance) |
|
Antacids that contain magnesium salts |
|
Excess consumption of polyols, such as sorbitol |
|
Excessive vitamin C intake |
|
Excessive magnesium intake |
Secretory |
Toxin-producing bacteria |
|
Hormone-producing tumors |
|
Fat malabsorption (e.g., lack of bile output) |
|
Laxative abuse |
|
Surgical resection of the small intestine |
Exudative |
Inflammatory bowel disease (Crohn’s disease or ulcerative colitis) |
|
Pseudomembranous colitis (a post-antibiotic diarrhea caused by an overgrowth of the bacterium Clostridium difficile) |
|
Invasive bacteria |
Inadequate-contact |
Surgical removal of sections of the intestine |
|
Short bowel syndrome |
Diarrhea is divided into four major types: osmotic, secretory, exudative, and inadequate-contact. Osmotic diarrhea is caused by an excess of water-soluble molecules in the stool, which results in increased fluid retention. Secretory diarrhea results from excessive secretion of ions into the bowel, with the same result of excessive water retention in the stools. Exudative diarrhea is usually due to infections and inflammatory bowel diseases, resulting in abnormal intestinal permeability and intestinal loss of serum proteins, blood, mucus, and pus. Frequent small, painful evacuations are usually a result of disease in the rectum or at the end of the colon. Inadequate-contact diarrhea is the result of inadequate contact between the intestinal contents and the absorbing surfaces, resulting in inadequate absorption.
Causes
Diarrhea can have many causes. Again, it is important to consult a physician for an accurate determination.
Viruses are the most common cause of infectious diarrhea, accounting for at least 75% of cases. Viruses are suspected when vomiting is prominent, the incubation period is longer than 14 hours, and the entire illness is over in less than 72 hours. A virus is likely to be the cause if there are no warning signs of bacterial infection (such as high fever, bloody diarrhea, severe abdominal pain, or more than six stools in 24 hours) and there are no epidemiological clues from the history (i.e., travel, sexual contact, antibiotic use). One of the most common causes of viral gastroenteritis, especially in children, is rotavirus. It can be an extremely serious infection, especially in developing countries, where it is estimated to cause more than 800,000 annual deaths among young children.
Besides infectious diarrhea, common causes of chronic diarrhea include lactose intolerance, food allergies, celiac disease (gluten sensitivity), and inflammatory bowel disease (Crohn’s disease and ulcerative colitis).
Lactose intolerance is due to a deficiency in the enzyme lactase, responsible for digesting the lactose found in dairy products; it is common worldwide. It has been estimated that 70 to 90% of adults of Asian, black, American Indian, and Mediterranean ancestry lack this enzyme. The frequency of deficiency is 10 to 15% among adults of northern and western European descent. While almost all infants are able to digest milk and other dairy products, many children lose their lactase enzyme by three to seven years of age. Symptoms range from minor abdominal discomfort and bloating to severe diarrhea in response to even small amounts of lactose. Symptoms occur because unabsorbed lactose passes through the small intestine and into the colon.
Chronic diarrhea is also one of the most common symptoms of irritable bowel syndrome, a functional disorder of the intestines that can include chronic loose stools (see the chapter “Irritable Bowel Syndrome”), and food allergies, as ingestion of an allergenic food can result in the release of histamine and other allergic-reaction compounds that can produce a powerful laxative effect (see the chapter “Food Allergy”).
Celiac disease (see the chapter “Celiac Disease”) is caused by sensitivity to gluten, a protein in many grains. One of the hallmark features of celiac disease is chronic diarrhea.
Inflammatory bowel disease (see the chapter “Crohn’s Disease and Ulcerative Colitis”) is characterized by recurring bouts of often painful and bloody diarrhea.
Therapeutic Considerations
Since most causes of acute diarrhea, such as mild infections due to food poisoning or viral gastroenteritis, are self-limiting and will resolve on their own, only some general recommendations may be needed. If the diarrhea is severe or bloody, or if it involves a child under the age of six years, contact a physician immediately. A physician should also be consulted if any diarrhea lasts for more than three days.
Therapy for any chronic diarrhea requires identification of the underlying cause and treatment designed to restore normal bowel function. The discussion in this chapter will focus on general support for all diarrheas. Other chapters discuss treatments for some other causes of diarrhea, such as inflammatory bowel disease (see “Crohn’s Disease and Ulcerative Colitis”), celiac disease (see “Celiac Disease”), and impaired digestion (see “Digestion and Elimination”).
Causes of Diarrhea |
|
CAUSE |
MOST COMMON EXAMPLES |
Functional disorders |
Irritable bowel syndrome |
Intestinal viral infections |
Enterovirus, rotavirus |
Intestinal bacterial infections |
Campylobacter jejuni, Shigella species, Salmonella species , Yersinia enterocolitica |
Intestinal bacterial toxins |
Clostridium difficile, pathogenic Escherichia coli, Staphylococcus species. Vibrio parahaemolytica, Vibrio cholerae |
Parasitic infections |
Giardia lamblia, Entamoeba histolytica, Cryptosporidium species, Isospora species |
Inflammatory bowel disease |
Crohn’s disease, ulcerative colitis, diverticulitis |
Antibiotic therapy |
Tetracycline, amoxicillin, others |
Inadequate bile secretion |
Hepatitis, bile duct obstruction |
Malabsorption states |
Celiac disease, short small bowel, lactose intolerance |
Pancreatic disease |
Pancreatic insufficiency, pancreatic tumor |
Reflex from other areas |
Pelvic inflammatory disease |
Neurological disease |
Diabetic neuropathy, multiple sclerosis |
Metabolic disease |
Hyperthyroidism |
Malnutrition |
Severe protein and/or calorie malnutrition |
|
Food allergy |
|
Laxative abuse |
|
Heavy metal poisoning |
Miscellaneous |
Fecal impaction, cancer |
There are several measures that can be used as general support during any case of diarrhea:
• Focus on liquids and follow the BRAT diet
• Replace electrolytes
• Avoid dairy products
• Take carob powder or pectin
• Take probiotics
Focus on Liquids and Follow the BRAT Diet
During the acute phase of diarrhea, the focus should be on liquids and the BRAT diet. The components of this diet are bananas, white rice, apples, plain white toast or bread (consider bread made with rice flour instead of wheat flour), and tea. These foods are easy on the digestive system and tend to slow down the rhythmic contractions of the intestines.
Replace Electrolytes
With diarrhea, a person loses much water and a great deal of electrolytes, such as potassium, sodium, and chloride. It is important to replace these lost items. This replacement can be in the form of herbal teas, vegetable broths, fruit juices, and electrolyte replacement drinks. An old naturopathic remedy is to sip a drink made of equal parts of sauerkraut juice and tomato juice.
When there are young children in the household, it is a good idea to have electrolyte replacement drinks on hand as a precautionary measure. In addition to the well-known Pedialyte and Gatorade brands, electrolyte replacement drinks with healthier ingredients are now available at health food stores.
Avoid Dairy Products
Acute intestinal illnesses, such as viral or bacterial intestinal infections, will frequently injure the cells that line the small intestine. This results in a temporary deficiency of lactase, the enzyme responsible for digesting milk sugar (lactose) from dairy products. Avoid dairy products (with the possible exception of yogurt with live cultures) while experiencing diarrhea.
Take Carob Powder or Pectin
Since the early 1950s, there have been several reports in the medical literature indicating that brewed teas of roasted carob powder are effective and without side effects in the treatment of acute-onset diarrhea.1,2 Carob is rich in dietary fiber and compounds known as polyphenols. These two components are thought to be responsible for the beneficial effects.
Carob powder is particularly helpful in treating diarrhea in young children. One study involved 41 infants from 3 to 21 months of age, with acute diarrhea of bacterial and viral origin. The infants were treated in a hospital setting with oral rehydration fluid (e.g., Pedialyte) and randomly received either carob powder (a daily dose of 1.5 g/kg) or an equivalent placebo for up to six days.1 The powders were diluted either in the oral rehydration solution or in milk (which we do not recommend; see “Avoid Dairy Products,” above). The duration of diarrhea in the carob group was 2 days, compared with 3.75 days in the placebo group. Normalizations in defecation, body temperature, and weight, plus cessation of vomiting, were also reached more quickly in the carob group. No side effects from carob were reported.
An alternative approach to carob is the use of pectin, a fiber found in citrus fruits, apples, and many other fruits and vegetables.
Take Probiotics
The term probiotics refers to bacteria in the intestine considered beneficial to health. The most important healthful bacteria are Lactobacillus acidophilus and Bifidobacterium bifidum. Probiotics have a protective effect against acute diarrheal disease and have been shown to be successful in the treatment or prevention of various types of infectious diarrhea, including rotavirus, Clostridium difficile, and traveler’s diarrhea. There is absolutely no question that probiotic supplementation shortens the duration of acute infectious diarrhea and reduces stool frequency, as numerous clinical studies now document this benefit. Probiotic supplementation is especially important in helping children susceptible to infectious diarrhea. Furthermore, probiotics exert immune-enhancing effects.3–6
Probiotic supplementation is also well documented to prevent antibiotic-induced diarrhea as well as promote recovery from it. Although it is commonly believed that acidophilus supplements are not effective if taken during antibiotic therapy, the research actually supports usage of L. acidophilus during antibiotic administration.3–9 Reductions of friendly bacteria or superinfection with antibiotic-resistant flora, or both, may be prevented by administering L. acidophilus products during antibiotic therapy. For example, in one double-blind study of 740 patients undergoing cataract surgery, the patients were given an antibiotic containing ampicillin (250 mg) and cloxacillin (250 mg) and either a placebo or a probiotic supplement. The incidence of diarrhea in patients receiving the antibiotic alone was 13.3% compared with 0% in patients receiving the antibiotic with the probiotic.9
PARASITES
Parasites are microorganisms that live off their host (in this case, a human being) and ultimately cause damage to the host. There are about 500 normal microbial inhabitants of the human digestive tract; whether any of them will become parasitic depends on whether they are living in harmony with the host or growing out of balance. Candida albicans is an example of an organism that, under normal circumstances, lives in harmony with the host. But if candida overgrows and is out of balance with other gut microbes, it can result in problems. In general, parasites cause most of their problems by interfering with digestion and/or damaging the intestinal lining, either of which can lead to diarrhea.
Diarrheal diseases caused by parasites that are not part of the normal gastrointestinal tract still constitute the single greatest worldwide cause of illness and death. The problem is magnified in underdeveloped countries that have poor sanitation, but even in the United States diarrheal diseases are the third leading cause of sickness and death. Furthermore, the ease and frequency of worldwide travel and increased migration to the United States are resulting in growing numbers of parasitic infections.
There are many types of microbes that can be classified as parasites, but usually when physicians refer to parasites they mean the organisms known as protozoa (one-celled organisms) and helminths (worms).
Common Parasites
• Common protozoa
• Amoeba (primarily Entamoeba histolytica)
• Giardia
• Trichomonas
• Cryptosporidium
• Dientamoeba fragilis
• Iodamoeba butschlii
• Blastocystis
• Balantidium coli
• Chilomastix
• Helminths
• Roundworms (Ascaris lumbricoides)
• Pinworms (Enterobius vermicularis)
• Hookworms (Necator americanus)
• Threadworms (Strongyloides stercoralis)
• Whipworms (Trichuris trichiura)
• Tapeworms (various species)
Detection of parasites involves collecting multiple stool samples at two- to four-day intervals. The stool sample is analyzed under a microscope after it has been prepared with specialized staining techniques and fluorescent antibodies (the antibodies attach to any parasites present and fluoresce when exposed to a certain wavelength of light).
There are a number of natural compounds that can be useful in helping the body get rid of parasites. However, before selecting a natural alternative to an antibiotic, try to discern what factors may have been responsible for setting up the internal terrain for a parasitic infection—decreased output of hydrochloric acid, decreased pancreatic enzyme output, and so on. Proper treatment with either an antibiotic or a natural alternative requires monitoring by repeating multiple stool samples two weeks after therapy.
Popular natural treatments for parasitic infections include high dosages of pancreatic enzymes (8–10X USP; 750 to 1,000 mg 10 to 20 minutes before meals) and berberinecontaining plants such as goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), Oregon grape (Berberis aquifolium), and goldthread (Coptis chinensis).
Antibiotics often cause diarrhea by altering the type of bacteria in the colon or by promoting the overgrowth of Candida albicans. Antibiotic use can result in a severe form of diarrhea known as pseudomembranous enterocolitis. This condition is attributed to an overgrowth of one type of bacteria (Clostridium difficile) that results from the death of the bacteria that normally keep it under control. We recommend a dosage of at least 15 billion to 20 billion organisms during antibiotic therapy; leave as much time as possible between the dose of antibiotic and the probiotic supplement. If pseudomembranous enterocolitis develops, in addition to Lactobacillus and Bifidobacter species we also recommend supplementing with Saccharomyces boulardi (also known as S. cerevisiae), a nonpathogenic probiotic yeast shown to be very helpful alone or in combination with the antibiotic vancomycin for pseudomembranous enterocolitis.10 Although Saccharomyces boulardi is generally safe, a few case reports have demonstrated that it should not be used in patients with impaired immune function (such as those with AIDS, cancer patients going through chemotherapy, or people taking immune-suppressing drugs).
Berberine
Plants that contain the alkaloid berberine such as goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), Oregon grape (Berberis aquifolium), and goldthread (Coptis chinensis) have a long history of use in infectious diarrhea. Clinical studies with pure berberine have shown significant success in the treatment of acute diarrhea. It has been found effective against diarrheas caused by E. coli (traveler’s diarrhea), Shigella dysenteriae (shigellosis), Salmonella paratyphi (food poisoning), Klebsiella pneumoniae, Giardia lamblia (giardiasis), Entamoeba histolytica (amebiasis), and Vibrio cholerae (cholera).11–17
Berberine appears to be effective in treating the majority of common gastrointestinal infections. Clinical studies have shown berberine comparable to standard antibiotics in most cases; in fact, results were better in several studies. For example, one study focused on 65 children under five years of age who had acute diarrhea caused by E. coli, Shigella, Salmonella, Klebsiella, or Faecalis aerogenes. The children who were given berberine tannate (25 mg every six hours) responded better than those who received standard antibiotic therapy.15
Another study involved 40 children, ages 1 through 10 years, who were infected with giardia. The children received daily divided doses of either berberine (5 mg/kg per day), the drug metronidazole (10 mg/kg per day), or a placebo of vitamin B syrup.16 After six days, 48% of the children treated with berberine were symptom-free, and upon stool analysis 68% were found to be giardia-free. In the metronidazole group, 33% of the children were without symptoms and, upon stool analysis, all were found to be giardia-free. In comparison, 15% of the children who took the placebo were without symptoms and, upon stool analysis, 25% were found to be giardia-free. These results indicate that berberine was actually more effective than metronidazole in relieving symptoms at half the dose, but less effective than the drug in clearing the organism from the intestines.
Finally, in a study of 200 adult patients with acute diarrhea, the subjects were given standard antibiotic treatment with or without berberine hydrochloride (150 mg per day). Results of the study indicated that the patients who received berberine recovered more quickly.17 An additional 30 cases of acute diarrhea were treated with berberine alone. Berberine arrested diarrhea in all of these cases, with no mortality or toxicity.
Despite these results, owing to the serious consequences of an ineffectively treated infectious diarrhea, the best approach may be to use berberine-containing plants along with standard antibiotic therapy. Much of berberine’s effectiveness is undoubtedly due to its direct antimicrobial activity. However, it also has an effect in blocking the action of toxins produced by certain bacteria.18–20 This toxin-blocking effect is most evident in diarrheas caused by the enterotoxins Vibrio cholerae (cholera) and E. coli (traveler’s diarrhea).
Cholera is a serious disorder that needs standard therapy. However, traveler’s diarrhea is usually self-limiting. Good results have been obtained using berberine in the treatment of traveler’s diarrhea. In one study, patients with traveler’s diarrhea randomly served as controls or received 400 mg berberine sulfate in a single dose.21 In treated patients, mean stool volumes were significantly less than those of controls during three consecutive eight-hour periods after treatment. Twenty-four hours after treatment, significantly more treated patients than controls stopped having diarrhea (42% vs. 20%).
QUICK REVIEW
• Severe bloody diarrhea, diarrhea in a child under six years of age, or diarrhea that lasts more than three days should not be taken lightly; its cause must be determined and it must be treated appropriately.
• The therapy for any chronic diarrhea requires identification of the underlying cause and then treatment designed to restore normal bowel function.
• Replace lost water and electrolytes by drinking herbal teas, vegetable broths, fruit juices, or electrolyte replacement drinks.
• Avoid dairy products (with the possible exception of yogurt with live cultures) while experiencing diarrhea.
• Carob powder is particularly helpful in treating diarrhea in young children.
• Supplementation with probiotics is crucial in the treatment of diarrhea of any kind, but particularly in antibiotic-associated diarrhea.
• Chronic diarrhea is one of the most common symptoms of food allergy.
• It has been estimated that 70 to 90% of adults of Asian, black, Native American, and Mediterranean ancestry lack the enzyme required to digest milk sugar (lactose).
• Diarrheal diseases caused by parasites still constitute the single greatest worldwide cause of illness and death.
• Popular natural treatments of parasitic infections include high dosages of pancreatic enzymes and berberinecontaining plants, such as goldenseal.
• Berberine has shown significant success in the treatment of acute diarrhea in several clinical studies.
If you are planning to travel to an underdeveloped country or an area where there is poor water quality or poor sanitation, the prophylactic use of berberine-containing herbs (and probiotic preparations) may be appropriate. Take them one week prior to your trip, during your stay, and one week after visiting.
Tormentil Root
An extract of tormentil root (Potentilla tormentilla) has been shown to be useful to treat infectious diarrhea, shorten the duration of rotavirus diarrhea, and decrease the requirement for rehydration solutions.22 A randomized, double-blinded trial was conducted at a children’s hospital in Saint Petersburg, Russia. In this study, 40 children ranging in age from three months to seven years with rotavirus diarrhea were divided into two groups: a treatment group that consisted of 20 children given 3 drops of tormentil root extract per year of life three times per day until discontinuation of diarrhea or a maximum of five days, and a control group of 20 children who received a placebo. The duration of diarrhea was 60% less in the tormentil root extract treatment group than in the placebo group (three days compared with five days in the control group). In the treatment group 8 of 20 children (40%) were diarrhea free 48 hours after admission to the hospital, compared with 1 of 20 (5%) in the control group. Children in the treatment group also needed smaller volumes of parenteral fluids than subjects in the control group.
TREATMENT SUMMARY
Since most acute cases of diarrhea are self-limiting, the general recommendations given are often all that are needed. If any of the following apply, a physician should be consulted:
• Diarrhea in a child under six years of age
• Severe or bloody diarrhea
• Diarrhea that lasts more than three days
• Significant signs of dehydration (sunken eyes, severe dry mouth, strong body odor, etc.)
After identification of the cause of chronic diarrhea, appropriate treatment can be determined with the help of a physician.
There are several measures that can be used as general support during any case of diarrhea:
• Focus on liquids and follow the BRAT diet
• Replace electrolytes
• Avoid dairy products
• Take carob powder or pectin
• Take probiotics
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day
• Probiotic supplement: For prevention of antibiotic-induced diarrhea, a dosage of at least 15 billion to 20 billion organisms, with as much time as possible between the dose of antibiotic and the probiotic supplement; in children younger than age six experiencing antibiotic-induced diarrhea, the probiotic should be taken every day of the antibiotic dose and continued for 1 week after the antibiotic is discontinued.
• Saccharomyces boulardi: to treat Clostridium difficile, 500 mg twice per day for at least four weeks; can be used to support the antibiotic vancomycin
• Berberine-containing plants: Dosage of any berberine-containing plant should be based on berberine content, to equal 25 to 50 mg berberine three times per day for adults, 5 to 10 mg/kg daily for children (standardized extracts preferred); doses listed below are for goldenseal.
Dried root or as infusion (tea), 2 to 4 g three times per day
Tincture (1:5), 6 to 12 ml (1.5 to 3 tsp), three times per day
Fluid extract (1:1), 2 to 4 ml (0.5 to 1 tsp), three times per day
Solid (dry powdered) extract (4:1 or 8% to 12% alkaloid content), 250 to 500 mg three times per day
• Tormentil liquid extract:
For adults: 2–4-ml drops three times per day until discontinuation of diarrhea or a maximum of five days
For children: 3 drops per year of life three times per day until discontinuation of diarrhea or a maximum of five days