Diarrhea is so popular, kids have written songs about it. As a disease, you know you’ve made it when 5 year olds not only know what you are, but use you as a barometer of humor, the thing to be avoided at all costs at school, and insults of all kinds. However, diarrhea is a serious illness, a common cause of death in developing countries, and a hallmark symptom of gastrointestinal concerns worldwide.
Diarrhea is defined by numerous loose watery stools, sometimes with blood, mucous or pus present.
Acute vs. Chronic Diarrhea
Acute diarrhea, sometimes referred to as traveler’s diarrhea, is diagnosed when symptoms persist for less than 14 days. Most cases of acute diarrhea are caused by infections in the gastrointestinal tract, usually due to ingested pathogens such as viruses, bacteria, protozoa or parasites. In as little as 6 hours, bacteria from food can infect the intestinal tract and cause symptoms of diarrhea, fever, malaise, fatigue and dehydration. Viral and parasitic infections tend to take a little longer to manifest symptoms but can be equally distressing.
The evaluation of acute diarrhea depends on the severity and specificity of the symptoms. More than 4 watery bowel movements in one day, blood or mucous in the stool, fever, or abdominal pain are signs that a doctor should be contacted. In developed countries, diarrhea caused by food borne illness can be self-limiting, but the associated dehydration can cause complications that should be managed by a doctor.
Testing for a pathogenic origin of acute diarrhea is a good idea, but sometimes it either postpones urgent treatment or leads to misdiagnosis due to false negative test results. There are several tests used to evaluate pathogens in the stool. The 2 most commonly used methods are stool culture and O&PX3.
Stool culture is used to see what kind of bacteria is present in the stool. It is a beneficial test because it can reveal not only pathogenic bacteria, but can show presence of beneficial flora such as lactobacillus acidophilus as well. However, several problems are inherent in this testing methodology. First, the sample must be preserved and sent to the laboratory for processing within a few hours of collection. The more time that passes between collection and processing increases the chances of bacterial death resulting in a false-negative culture result. The second problem is that it can take several days to process a stool sample and the initial symptoms can worsen in this time due to lack of treatment. The third problem is specificity. There are over 800 different kinds of beneficial bacteria that comprise the sensitive ecosystem, or microbiome, of the gut. If this many different types of bacteria are naturally present in the gut, it is theoretically possible to have an equally diverse population of pathogenic bacteria. This makes culture infinitely more difficult because examiners generally request an idea of the type of bacteria the ordering doctor suspects so that he or she may train their focus more acutely on the suspects. Research into the diversity of the gut microbiome is a burgeoning field that should be followed closely as it uncovers more clues as to the nature of the intestinal ecosystem.
Testing for parasites is generally done using an Ova and Parasite times 3, or O&PX3. In this test, 3 different stool samples from the same patient are sent to the lab for microscopic analysis. Why 3 samples? It is because this test evaluates not what will grow under culture, but what is currently present in the stool. To a slightly lesser extent the same issues exist as with culture in terms of expediting the samples to the lab. More importantly, parasitic infections can wax and wane and the sample sent to the lab may have been collected during a period of decreased parasitic activity. Third, and perhaps most important, is user error. Successful microscopic exams are determined by the skill and experience level of the lab technician. 3 samples are requested to maximize the chances that he or she will notice something if it is there.
Current research suggests that O&PX3 is an antiquated method of parasitic detection and newer DNA PCR testing or fluorescent in situ hybridization (FISH) testing are superior and more sophisticated testing methodologies. In these tests, one stool sample is sent to a lab to determine if parasitic DNA is present in the sample. This type of test is more specific and sensitive than an O&PX3, but is more expensive and can take up to two weeks to garner results. Though these results are more accurate, PCR and FISH can only test for common human parasites and will fail to identify uncommon infections.
Testing for pathogenic etiology of acute diarrhea must be evaluated by a doctor, the associated risks must be measured, and treatment, if necessary, may be started before results have been reported. Additional testing includes looking for infectious markers such as white blood cells and immunoglobulins in the stool. These can give clues as to whether or not an infection is present.
It is also important to remember that emotional distress can cause acute abdominal distress, and these factors must be investigated when appropriate.
Conventional medical treatment for acute diarrhea of infectious origin includes antibiotic, antiprotozoal and anti-helminthic pharmaceuticals. These drugs are often specific, can damage beneficial flora of the gut microbiome, and can cause liver toxicity. Naturopathic approaches may include these pharmaceuticals when appropriate, but often incorporate charcoal to absorb toxins produced by pathogens, broad-spectrum antimicrobial herbal medicines and probiotics to replace the beneficial flora of the intestines. Antidiarrheal drugs such as loperimide and diphenyoxylate can also be effective symptom management tools.
In conventional or naturopathic approaches, dehydration remains a concern. Loose watery stools can lead to dehydration quickly, and rapid rehydration may become necessary through oral or IV administration of fluids. It is important to seek medical attention when this becomes a concern.
Chronic Diarrhea is diagnosed when symptoms of numerous loose watery stools persist for more than 30 days. Chronic diarrhea is divided into three main etiologies: undiagnosed pathogenic infection, inflammatory bowel diseases, and irritable bowel caused by adverse food reaction, malabsorption, emotional distress or other complications.
Background
The intestines are a sensitive ecosystem susceptible to damage from various factors. The myriad beneficial bacteria that inhabit the gut serve many functions. They regulate pH, digest food, aid absorption of nutrients, assist the immune and nervous systems, fight infections, produce vitamins and hormones and influence gene expression. In fact, there are 10 times more bacterial cells living in and on people than there are human cells in the body. Healthy intestines also have small amounts of bad bacteria, yeast or fungus kept at bay by myriad immune components of the GI tract. This sensitive ecosystem is susceptible to daily damage from a range of sources. As with any ecosystem if one component is damaged it can have devastating downstream effects. Doctors must be aware of both the intrinsic and extrinsic interconnected nature of the gut microbiome with regards to the gut itself, the nervous system, the immune system, and the endocrine system.
Factors that interfere with components of the gut microbiome include antibiotic and antacid use, gluten, pathogens, low fiber consumption and oxidative stress. One of these factors alone may not cause noticeable symptoms, but synergistically they can prove hazardous. Gluten can weaken tight junctions between the cells, or enterocytes, that line the intestines. Some people’s immune systems recognize gluten as a pathogen and attack enterocytes when gluten is present within them. Pathogens ingested with food can also cause local tissue damage by releasing toxins and/or free radicals as they go through their life cycle inside the intestines. A low fiber diet allows for these toxins to remain present in the intestines for extended periods by slowing transit time, thereby increasing oxidative damage to the enterocytes. This destruction of cells cascades to decreases the local immune response within the intestines themselves, reduces an important immune component called sIgA created by enterocytes, and depletes the terrain that the beneficial flora living adjacent to the enterocytes need to thrive. This triad opens the door to opportunistic yeast or bacterial infections which further perpetuate damage to the gut terrain. When the intestines fall into this cyclical destruction pattern, it can be hard to both identify and treat the cause of the illness.
Chronic Infection: Chronic diarrhea can be more complicated to diagnose than acute diarrhea, often because the common testing for acute diarrhea has been performed and found to be negative, while presumptive treatment may have been ineffective. It is important to know the limitations of stool testing and understand the potential for false-negative results when evaluating chronic diarrhea. There is a common misconception amongst healthcare professionals that stool testing is conclusive and negative results mean no infection. This is especially unfortunate because underlying infections go undiagnosed and more invasive testing follows. If symptoms are consistent with infectious etiology, it is prudent to continue investigation for infection using more sophisticated methods. If infection has persisted that the body has not been able to resolve, it is likely that intervention is necessary and will only be effective when the infection is adequately identified.
Multiple sub-clinical infections can be present at one time. It is recommended that humans eat 20-30grams of fiber per day. However, most Americans eat less than 10 grams per day. Fiber provides bulk to the stool and decreases the transit time of stool. The longer that food cooks inside of the 98.6 degree oven that is the intestines, the higher the likelihood of it rotting and putrefying inside of the body. A low fiber diet coupled with a mild pathogenic load from a meal is enough to set in motion the negative destruction cycle while evading common pathogenic testing. A mild parasitic infection, bacterial dysbiosis and opportunistic yeast can be a difficult to confirm cause of chronic diarrhea. If multiple sub-clinical infections are suspected, PCR, FISH, IgA and yeast cultures should be performed. If these tests are inconclusive, broad-spectrum antimicrobial treatment may be employed.
Inflammatory bowel conditions such as Crohn’s disease and Ulcerative Colitis are causes of chronic diarrhea. Inflammatory bowel diseases refer to inflammation and/or ulceration of the mucosa in the small or large intestines. Inflammation in this sense is an autoimmune process where the body’s own immune system attacks the host cells. When inflammation is present in the intestines, digestion, absorption and general function are affected. Chronic inflammation in the intestines can lead to chronic diarrhea, sometimes with blood or mucous present in the stool. Symptoms tend to develop over time, may wax and wane, and can be difficult to treat.
Testing for inflammatory bowel disease begins with a series of blood work including CBC, CMP, ESR, and CRP to gauge the status of infection and involved organ systems. Next, imaging studies include CT or radiologic visualization with barium, endoscopic exam of the small or large intestine or MRI. As inflammation is visualized, a biopsy of the affected tissue may be required to confirm the diagnosis and etiology of the illness.
The cause of inflammatory bowel disease is not well understood. Naturopathic theory suggests that autoimmune inflammatory bowel disease could have several origins. First, it is critically important to rule out chronic infection as previously discussed. Chronic undiagnosed infection can take hold and with the right series of events lead to inflammation or ulceration.
Understanding triggers that cause the autoimmune attack of healthy cells can help effectively manage symptoms. If the immune system is over stimulated, or constantly producing antibodies against antigens that it recognizes as foreign invaders, ‘cross over’ reactions can occur. A cross over means that the immune system produces antibodies that react with body tissues that closely resemble the target antigen. There are trillions of cells in the body and it is conceivable that antibodies can mistake antigen identity and cross-react with human tissue. This cross-over reaction could be responsible for a portion of auto-immune reactions and must be evaluated thoroughly. This is not an easy task. Its difficult to directly measure this phenomenon, and a fair amount of clinical observation becomes necessary to diagnose this etiology.
Diet can play a big roll in gut inflammation. The food many people eat is rich in xenobiotic environmental toxins such as hormones and pesticides and devoid of the protective qualities of nutrients and dietary fiber. The general food supply has been reduced from a cornucopia of vegetables and grains to a relatively consistent serving of corn, wheat, sugar, and the occasional fruit or vegetable. Our bodies have evolved over thousands of years to depend on a variety of food to keep us healthy. In merely the last 200 years, the food supply has mutated to a place of processed baron repetition. This could be why gluten sensitivity has become a spectrum illness with Celiac Sprue on one end, and chronic insidious sensitivity on the other. Identifying and reducing the antigenic load from the diet can have profound effects on inflammatory bowel disease.
Irritable Bowel Syndrome, or IBS, is another cause of chronic diarrhea, with a common characteristic being abdominal pain and fluctuations between diarrhea and constipation. The cause of irritable bowel largely remains a mystery to the conventional medical community, though it is being diagnosed with increasing occurrence. The diagnosis of IBS is known as a diagnosis of exclusion, meaning that once all other causes of diarrhea have been ruled out, the diagnosis of IBS can be applied. It is important to remember that diagnosing IBS does not mean targeted therapy will follow. Often times the diagnosis means that doctors can stop looking for a cause, and the patient is left to manage symptoms alone.
When infection, inflammation and adverse food reactions have been thoroughly ruled out, is appropriate to apply the diagnosis of IBS. At this point it is important to investigate neurologic and emotional stressors, as both can have profound impacts on GI function.
The gastrointestinal system has a nervous system all its own called the enteric nervous system. There are more neurons in the gut than there are in the brain. This suggests 2 important points: first, neurotransmitters play a major role in GI function, and second, emotional distress can manifest as serious and tangible gastrointestinal symptoms. Testing, regulating and treating this system can be difficult. New lab tests are able to determine neurotransmitter status by measuring the elimination of their metabolites in the urine. These tests suggest neurotransmitter status and can help direct treatment. More importantly, emotional stressors must be investigated and managed via means appropriate to the individual. Stress alone is enough to cause diarrhea in some individuals. Stress relieving pharmaceuticals and herbs have been show to be effective means of treating stress induced diarrhea but do not treat the cause of the problem. Deep breathing techniques, visualizations and as little as 5 minutes of meditation per day are tools that people can learn to effectively manage stress and symptoms of IBS.
Treatment
Successful treatment for chronic diarrhea includes eliminating all infections, repairing the terrain of the gut, examining and correcting dietary factors, and addressing neuro-emotional components of the enteric nervous system.
Chronic infections are treated with either pharmaceuticals or herbal medicines. Common drugs include antibiotics, anthelminthics, and antifungals. Herbal antimicrobials include juglans nigra, artemesia, and quassia. Combining pharmaceutical and herbal therapy can be helpful because it increases the killing spectrum and some botanical medicines can be used for long durations with minimal side effects. Plants contain many chemical components while pharmaceuticals generally contain one isolated active ingredient. As pathogens in our environment evolve over time, so do the constituents in botanical medicines. It is theorized that local botanical medicines have greater medical efficacy in treating resistant pathogens because of their ability to adapt to changes in the environment. Though clinical evidence for this remains anecdotal, it is still advised to use combination theory.
Repairing damaged cells that line the intestines can best be accomplished through supplementation with a variety of reparative nutrients. Glutamine is an amino acid that feeds enterocytes and increases their ability to carry out proper function. N-Acetyl Cysteine and N-Acetyl-d-Glucosamine, among others, act to rebuild the junctions between cells and keep a tight border between the gut and the immune system.
Reestablishing a healthy thriving bacterial community is the final and most crucial step to treatment. Long term resolution of symptoms is gained when the gastrointestinal system can self-regulate. Targeted gut antioxidants and the right probiotics reestablish healthy flora and maintain proper function of the microbiome.
Diarrhea is a symptom that affects thousands worldwide. Acute diarrhea may be self-limiting, but severe untreated diarrhea can lead to complications including dehydration, fatigue, and malabsorption. Chronic diarrhea is a much more complicated disease process that must to be evaluated thoroughly by a healthcare professional. When a diagnosis is reached, infections should be eradicated, the enterocytes and microbiome of the gut should be supported, and dietary and lifestyle factors should be adjusted to maximize proper gastrointestinal function.
Article written by Dr. Andrew Brandeis
