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Continence Coach: Slippery Slopes: Combating Diarrhea
Diarrhea (loose, watery stools occurring more than three times a day) can be caused by a variety of factors or agents; 2,247 medical conditions are said to cause diarrhea.1 The National Institutes of Health2 report that the average adult in the US experiences acute diarrhea four times a year and the average child experiences four to 15 episodes by age 5 years. Bacterial infections (eg, salmonella and Escherichia coli — E. coli), viral infections (eg, the Norwalk virus and traveler’s diarrhea), parasites (eg, Giardia lamblia), and food intolerance (eg, to milk lactose) often are blamed for diarrhea, especially in certain geographic locations and among the young. Accompanying symptoms often include cramping, bloating, urgency, nausea, and dry mouth.
The causes of diarrhea are likely to differ somewhat in the elderly. Reactions to and side effects of medications are frequent culprits, particularly antibiotics and medication for hypertension. Laxative overuse can trigger a bout of diarrhea. Constipation and impacted stool can actually mimic diarrhea by allowing watery feces to seep around the blockage in the lower intestine, making an accurate diagnosis critically important to appropriate intervention. Lesions occurring as a result of colon or rectal cancer can cause diarrhea. Although likely to have presented at younger ages, chronic intestinal diseases (eg, celiac sprue triggered by the gluten in wheat) and far less rare functional bowel disorders (eg, irritable bowel syndrome [IBS]) can continue to plague older adults and produce periodic episodes of diarrhea. In the past decade, researchers have discovered that 10% of patients whose gallbladders have been removed experience recurrent diarrhea; the best treatment is a medication (cholestyramine) originally developed for treating gallbladder dysfunction.3 Chemotherapy has long been known to cause diarrhea in cancer patients; studies now indicate that patients on long-term therapy for multiple myeloma encounter a high incidence of diarrhea.4
Diarrhea also has been associated with enteral tube feedings. A review of the literature5 suggests an incidence of diarrhea of 2% to 63% in patients receiving enteral tube feedings. This wide variation in incidence is believed to be related, in part, to the lack of a universal definition of diarrhea and other suspected factors such as infection, bacterial contamination of the feeding device, medication therapy, or formula-related causes. Regardless of its contribution to the problem, enteral feeding is counted among causal factors of diarrhea and demands attention in extended care.
Diarrhea is a major cause of morbidity and mortality in the elderly6 because they may be more susceptible to viruses and bacteria due to compromised health and nutritional status. The elderly are more likely to be in an institutional setting (hospital, nursing home, or assisted-living community) where infection can spread quickly. Additionally, older persons are more likely to be on multiple medications for managing health conditions and disease, increasing the likelihood of drug interaction, side effects, and reactions that potentially involve the gut.
Once they become dehydrated, the elderly are less capable of quickly replenishing fluid loss.6 Some signs of dehydration are obvious, such as thirst and less frequent urination; others may not be so apparent but are just as important, such as dry skin, faintness, weakness, and fatigue. Diarrhea lasting more than 3 days, blood in the stool, severe abdominal pain, and/or a fever of 102˚ F or above should prompt referral to a physician. After taking a history and performing a physical examination, stool tests, blood tests, and possibly diagnostic tests such as a colonoscopy, x-rays, or CT scans should follow to ascertain the precise cause and establish further treatment.
Most cases of diarrhea can be managed conservatively by replenishing with fluids that contain electrolytes (potassium and sodium salts) and altering the diet. The importance of rehydration cannot be over-emphasized. Broth works especially well; a diet of bananas, rice, applesauce, and toast (BRAT) has been recommended by many generations of healthcare providers and grandmothers. If allergies are suspected, eliminating gluten should be considered. If a functional bowel disorder such as IBS has been diagnosed, soluble fiber should be added to the diet to thicken stool. Caution should be exercised in giving anti-diarrhea medications in cases where infection is suspected where it may be best for the culprit to be expelled from the body. Extra attention should be paid to skin care — a mild pH-balanced cleansing agent and moisturizers will help keep fragile skin cleansed of urine and stool and the skin should be patted dry after each episode.
Diarrhea can be far more difficult to manage or control (and is potentially more serious) than constipation, especially in chronic circumstances. The patient with diarrhea should be provided immediate intervention and close surveillance, especially in the youngest and the oldest members of our population.
The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Management peer-review process.
1. HealthGrades™, Inc. a healthcare ratings company. www.wrongdiagnosis.com/symptoms/diarrhea/causes.htm. Accessed March 5, 2010.
2. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. www.digestive.niddk.nih.gov/diseases/pubs/diarrhea/. Accessed March 5, 2010.
3. Habba S. Letter to the editor. Am J Gastroenterol. 2000;95:2140–2141.
4. Simpson L, Rajkumar SV, Dispenzieri A, et al. High incidence of diarrhea in patients on long-term therapy with lenalidomide and dexamethasone for multiple myeloma. J Clin Oncology. 2008;26:8586.
5. Eisenberg P. An overview of diarrhea in the patient receiving enteral nutrition. Gastroenterol Nurs. 2002;25(3):95–104.
6. Merck Manual of Geriatrics. Available at: www.merck.com/mkgr/mmg/ sec13/ch110/ch110b.jsp. Accessed March 5, 2010.
