In the U.S., approximately 179 million cases of acute diarrhea occur annually. Acute diarrhea is a common gastrointestinal disorder characterized by the passage of loose, watery stools three or more times per day.
It is typically caused by infections with bacteria, viruses, or parasites and is often accompanied by symptoms such as abdominal cramps, bloating, nausea, vomiting, and fever. The duration of acute diarrhea is usually less than two weeks, and most cases resolve without any specific treatment.
Symptoms
- Abdominal pain
- Cramping
- Fecal incontinence
- Fecal urgency
- Nausea
- Three or more loose, watery stools daily
The pathophysiology of acute diarrhea involves increased secretion of fluid and electrolytes into the intestinal lumen, decreased absorption of water and nutrients, and increased motility of the intestinal tract. These changes lead to the characteristic symptoms of watery diarrhea, abdominal cramping, and dehydration. The most common causes of acute diarrhea include viral infections such as norovirus and rotavirus, bacterial infections such as Salmonella and Campylobacter, and parasitic infections such as Giardia and Cryptosporidium. Other causes include food poisoning, antibiotic use, and inflammatory bowel disease.
Adult patients with acute diarrhea should seek medical attention if they experience a fever of more than 102°F or if their diarrhea has lasted more than 1 day. Three loose stools in 1 day may not necessarily warrant immediate medical attention, but it is still important to monitor for signs of dehydration and seek medical attention if symptoms worsen or persist. Fever is a common symptom of many bacterial infections that can cause acute diarrhea, such as Salmonella and Shigella. A fever of more than 102°F may indicate a more severe infection or complications, and prompt medical attention is necessary. Acute diarrhea typically lasts for a few days, and most cases resolve without any specific treatment. However, if diarrhea persists for more than 1 day, it may be a sign of a more severe infection or other underlying condition, and medical attention should be sought. In general, it is important to monitor for signs of dehydration, such as dry mouth, decreased urine output, or lightheadedness, and seek medical attention if these symptoms occur.
Drugs known to cause acute diarrhea
- Antibiotics – Cephalosporins (e.g., cefdinir, cefpodoxime), Clindamycin, Macrolides (e.g., erythromycin, clarithromycin, azithromycin, fidaxomicin), Penicillins (e.g., amoxicillin, ampicillin)
- Cancer chemotherapeutic – Cyclophosphamide, Daunorubicin, Epirubicin, Fluorouracil, Gemcitabine, Ixabepilone, Methotrexate, Vincristine
- Copper chelators – Dimercaprol, Penicillamine, Trientine
- Corticosteroids – Dexamethasone, Prednisone
- Digitalis glycosides – Digoxin
- Magnesium salts – Magnesium hydroxide (Phillips’ Milk of Magnesia, Ducolax Milk of Magnesia, Pedi-lax Chewable Tablets)
- Mood stabilizers – Lithium
- Nonsteroidal anti-inflammatory agents – Ibuprofen, Meclofenamate sodium
- Proton Pump Inhibitors – Lansoprazole, Omeprazole, Pantoprazole
Excessive intake of laxatives could be accidental (e.g., not understanding the directions) or intentional (e.g., child abuse, bulimia, anorexia nervosa[1]), and is a specific form of medication-associated diarrhea.
The brush border of the small intestine produces the enzyme lactase. It is necessary for breaking down lactose (“milk sugar”) to digest milk. Lactase deficiency can occur when an enteric (intestinal) infection causes mucosal (lining) injury. Approximately 68% of the world’s population has some form of lactose malabsorption.
Excessive intake of artificial sweeteners can cause acute diarrhea (eg. Mannitol, sorbitol, and xylitol (found in sugar-free products). I was stricken down by a side-effect of Ozempic and ended up in the hospital for a whole week.
Lactase deficiency is more prevalent in Asia and Africa, while it occurs less frequently in northern Europe where many people carry the gene that codes for lactase. About 36% of Americans have some form of lactose malabsorption. Other forms of food intolerance can also cause diarrhea. Drinking overly salted beverages and ingesting excessive fiber (e.g., sunflower seeds) can cause diarrhea.
Hot peppers (e.g., jalapeño peppers, cayenne peppers, and some chili peppers) contain the chemical irritant capsaicin (responsible for the “burn”) which can trigger diarrhea. Similarly, onions and large amounts of spices, fruits, and vegetables can also predispose patients to dietary diarrhea. Avoiding the causative food is the best approach to managing symptoms.
Toddler diarrhea—also known as functional diarrhea or non-specific diarrhea of childhood—often occurs when children drink considerable amounts of hyperosmolar fluids, such as fruit juices. According to the American Academy of Pediatrics, toddlers between one and three years of age should limit their juice intake to no more than four ounces per day.23 Toddler diarrhea management involves reducing the volume of fruit juices or other osmotically-active carbohydrate beverages that contain sorbitol or fructose. Similarly, children may develop self-limiting “Halloween diarrhea” after ingesting sorbitol- and fructose-rich candies.
Relief
Provided they are able to drink, most patients with mild-to-moderate dehydration should use oral rehydration solutions (ORSs) to manage diarrhea symptoms. You should tend to use things like Pedialyte and stay away from Sports drinks like Gatorade. Sports drinks are designed to provide energy during exercise and contain a high concentration of carbohydrates to provide fuel for working muscles.
They also contain electrolytes, including sodium, potassium, and chloride, which are lost through sweating during exercise. However, the concentration of electrolytes in sports drinks is typically lower than that in ORSs. ORSs, on the other hand, are designed to treat dehydration caused by diarrhea or vomiting. They contain a specific balance of electrolytes, including sodium, potassium, and chloride, in concentrations that match the fluid lost through diarrhea or vomiting. ORSs also typically have a lower concentration of carbohydrates than sports drinks. While both sports drinks and ORSs can help to rehydrate the body, they are designed for different purposes and should not be used interchangeably. ORSs are recommended for the treatment of dehydration caused by diarrhea or vomiting, while sports drinks are recommended for the replacement of fluids and electrolytes lost during exercise.
Patients use bismuth subsalicylate (Pepto-Bismol) to treat mild, nonspecific diarrhea. It has anti-secretory, anti-inflammatory, and antimicrobial properties.46 Developed more than 100 years ago by a physician to treat cholera, it was originally called Mixture Cholera Infantum. Despite its cheery pink color, pharmacy staff should remind patients and caregivers that bismuth subsalicylate can darken the stools and tongue with repeated use.
Typical dosing for patients older than 12 years of age for acute diarrhea is 524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed for up to 2 days (maximum: 4,200 mg/24 hours). Most patients will experience relief within 30 to 60 minutes of a dose. Children and adolescents who have or are recovering from influenza or chicken pox should not use bismuth subsalicylate due to its association with Reye syndrome.
Loperamide is an antidiarrheal medication that is available without a prescription in many countries, including the United States. While it is generally considered safe and effective when used as directed, high doses of loperamide can be dangerous and even deadly.
To prevent misuse and overdose, the US FDA (Food and Drug Administration) limits the amount of loperamide that can be sold in a single OTC container. The current limit is 48mg, which is equivalent to a maximum of twenty-four 2-mg capsules or tablets. It is important to follow the recommended dosing instructions and not exceed the maximum daily dose of loperamide, which is usually 8mg for OTC use and 16mg for prescription use. If diarrhea persists for more than two days or is accompanied by fever, severe abdominal pain, or blood in the stool, medical attention should be sought.
Not Recommended
Wood-tar creosote, a byproduct of the dry distillation of wood, has been used for centuries as a traditional medicine for various ailments, including diarrhea. Creosote’s anti-diarrheal properties are attributed to its ability to inhibit intestinal motility and fluid secretion, which can help alleviate symptoms of diarrhea.
While the use of creosote as a medicinal agent has declined due to safety concerns related to its toxicity, there is some evidence to suggest that it may be effective in treating certain types of diarrhea. However, further research is needed to determine the safety and efficacy of creosote as an anti-diarrheal agent.
Attapulgite is a type of natural clay mineral that has been used as an anti-diarrheal medication for many years. Attapulgite works by adsorbing or binding to the toxins and other harmful substances in the digestive tract, preventing them from causing further damage and irritation to the intestines. This results in a decrease in the frequency and severity of diarrhea.
Attapulgite has been shown to be effective in treating acute diarrhea and is generally safe and well-tolerated. However, it is important to use caution when using attapulgite, especially in individuals with kidney disease, as it may lead to elevated levels of aluminum in the body.
Red Flag Symptoms
While diarrhea is a common condition that usually resolves on its own, there are some “red flag” symptoms that may indicate a more serious underlying condition requiring immediate medical attention. These include severe abdominal pain, high fever, bloody or black stools, dehydration, persistent vomiting, and signs of shock,
such as lightheadedness, rapid heartbeat, shallow breathing, and diarrhea lasting more than 2-3 days. These symptoms may indicate a more serious condition, such as inflammatory bowel disease, infection, or a severe electrolyte imbalance, and should prompt urgent medical evaluation and treatment.87
Footnotes
- Anorexia nervosa is a serious eating disorder characterized by a distorted body image and an intense fear of gaining weight. Individuals with anorexia often engage in behaviors such as restrictive dieting, excessive exercise, and the use of laxatives or diuretics in order to lose weight, and may exhibit other physical and psychological symptoms, including a low body weight, fatigue, dizziness, difficulty concentrating, mood swings, and social withdrawal. In severe cases, anorexia can lead to serious health complications, including malnutrition, dehydration, electrolyte imbalances, heart problems, and even death. Treatment typically involves a multidisciplinary approach, including medical care, nutritional counseling, psychotherapy, and, in some cases, medication. [Back]
Further Reading
Sources
- National Institute of Mental Health. Eating Disorders. Accessed May 8, 2023, from https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml.
- US Food and Drug Administration. FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-heart-problems-high-doses-antidiarrheal-medicine-loperamide-imodium-including. Accessed May 8, 2023.
- Loperamide. In: Lexicomp Online. Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; 2023. https://online.lexi.com. Accessed May 8, 2023.
- Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32(3):331-351.
- Guerrant RL, Oria RB, Moore SR, Oria MO, Lima AA. Malnutrition as an enteric infectious disease with long-term effects on child development. Nutr Rev. 2008;66(9):487-505.
- DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med. 2014;370(16):1532-1540
- American Academy of Pediatrics Committee on Nutrition and the Council on Sports Medicine and Fitness. Clinical report–Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127(6):1182-1189.
- World Health Organization. Oral rehydration salts (ORS): a joint WHO/UNICEF statement. Geneva, Switzerland: World Health Organization; 2003.
- Mehler PS, Krantz MJ, Sachs KV. Treatments of medical complications of anorexia nervosa and bulimia nervosa. J Eat Disord. 2015;3:15.
- Soffer EE. Adverse effects of laxatives. Dis Colon Rectum. 2001;44(8):1201-1209.
- Klarich DS, Brasser SM, Hess AM. Substance use disorders and the gastrointestinal system. Prim Care Companion CNS Disord. 2018;20(5).
- World Health Organization. Oral rehydration salts: production of the new ORS. Available at: https://www.who.int/maternal_child_adolescent/documents/emergency_neonatal_care/9241591010/en/. Accessed May 8, 2023.
- GBD 2017 Diarrhoeal Disease Collaborators. Quantifying risks and interventions that have affected the burden of diarrhea among children younger than 5 years: an analysis of the Global Burden of Disease Study 2017. Lancet Infect Dis. 2020;20(3):319-329.
- Eggleston W, Marraffa JM, Stork CM, et al. Notes from the Field: Cardiac Arrests Associated with Overdoses of Loperamide – New York, 2008-2016. MMWR Morb Mortal Wkly Rep. 2016;65(22):544-545.
- Drug Enforcement Administration. Drug Fact Sheet: Loperamide. Accessed May 8, 2023, from https://www.dea.gov/sites/default/files/2021-04/Loperamide-2020.pdf.
- U.S. National Library of Medicine. Creosote. Accessed May 8, 2023, from https://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3669.
- World Health Organization. Creosote. Accessed May 8, 2023, from https://www.who.int/ipcs/publications/cicad/en/cicad62.pdf.
- Asha MK, Prashanth D, Murali B, et al. Pharmacological evaluation of the anti-diarrheal activity of the stem bark of Mangifera indica Linn. in experimental animals. Afr Health Sci. 2012;12(4):454-459.
- Kanchanapoom T, Taesotikul T, Boonlue S, Kasisit J, Srichairatanakool S. Chemical constituents and anti-diarrheal activity of the stem bark of Cananga odorata. Nat Prod Res. 2009;23(11):1038-1047.
- Olajide OA, Awe SO, Makinde JM. Pharmacological studies on the leaf of Ficus exasperata Vahl. (Moraceae). J Ethnopharmacol. 1999;65(3):181-185.
- Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP, et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis. 2020; 34:101623.
- Thanacoody R, Green R, Brown H, Brown R, Warrington S. Attapulgite (Diasorb) in the treatment of acute diarrhea in adults: a double-blind placebo-controlled study. Aliment Pharmacol Ther. 2003;18(8):811-816.
- Kuo HW, Chiang CP, Wang SJ, et al. The aluminum content of foods and beverages from Taiwan: market basket survey. J Food Drug Anal. 2017;25(2):461-470.
- Hillman L, Yadav D, Dyson G, et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol. 2021;116(2):217-241.
- Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol. 2018;113(Suppl 2):1-18.
- Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32(3):331-351.
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