What is diarrhea? How can it be diagnosed and treated? What causes diarrhea and who is likely to develop it? Get the answers in this comprehensive article.

Understanding Diarrhea: Definition and Symptoms

Diarrhea is a common and uncomfortable digestive disorder characterized by loose, watery stools that cause frequent need to defecate (usually at least three times a day). It can be acute or chronic. Acute diarrhea typically lasts a day or two and resolves on its own, while chronic diarrhea usually lasts longer than a month and may be a sign of underlying conditions.

The symptoms of diarrhea include abdominal pain, bloating, cramping, frequent loose and watery stools, nausea, and urgency. In adults, temporary diarrhea is usually not harmful, but it can sometimes signal more serious problems. Children, however, can suffer serious consequences from prolonged diarrhea due to their smaller body volume.

Causes of Diarrhea: Infectious vs. Osmotic

Diarrhea can be caused by either infectious or osmotic factors. Infectious diarrhea follows bacterial, viral, or parasitic illnesses that disrupt the normal process of gastrointestinal absorption or produce substances that draw water into the bowel. Osmotic diarrhea is caused by the inability of the gastrointestinal tract to break down and absorb something ingested, leading to the rapid passage of food and fluids through the digestive system.

Infectious diarrhea can be caused by bacteria like E. coli, Campylobacter, Salmonella, and Shigella, viruses like rotavirus, Norwalk virus, and viral hepatitis, as well as parasites like Giardia lamblia and Cryptosporidium. Osmotic causes of diarrhea can include food intolerances, certain medications, digestive disorders, chemotherapy, and high-dose radiation therapy.

Who Is at Risk for Developing Diarrhea?

Diarrhea is a very common illness that can affect people of all ages. However, it is more likely to occur in children, people with chronic digestive disorders, and those who have traveled to other countries where the local infectious agents may be unfamiliar to the digestive system. Antibiotic use can also commonly cause diarrhea by disrupting the “good” bacteria that help break down food in the gastrointestinal tract.

Diagnosing Diarrhea: Medical Evaluation and Testing

Diarrhea doesn’t usually require a formal diagnosis, but the physician may perform certain tests to determine the underlying cause. These include a medical history and physical examination, laboratory analysis of a stool sample, blood tests, fasting tests, sigmoidoscopy, colonoscopy, and imaging tests.

Conventional Treatment for Diarrhea

The conventional approach to treating diarrhea often involves anti-diarrheal medications like loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol), which can reduce the severity of symptoms but won’t speed recovery. In cases where a parasite or bacterial infection has caused the diarrhea, a course of antibiotics may be prescribed.

People with diarrhea should also avoid certain trigger foods, such as milk and dairy products, caffeine, greasy and fatty foods, spicy foods, and alcohol. On the other hand, foods like bananas, boiled potatoes, cooked carrots, cooked chicken, plain rice, and toast are generally better tolerated.

Alternative Therapies for Diarrhea

In addition to the dietary approaches, Dr. Weil recommends several safe and effective remedies for diarrhea, including the “BRAT” diet (bananas, rice, applesauce, and toast), probiotics, and herbal remedies like ginger, chamomile, and peppermint. These natural therapies can help restore the balance of gut flora and alleviate the symptoms of diarrhea.

Does drinking lots of water help diarrhea? Yes, staying hydrated by drinking plenty of water, broth, or electrolyte-rich fluids is crucial during a bout of diarrhea to prevent dehydration, especially in children.

Can probiotics help with diarrhea? Yes, probiotic supplements containing beneficial bacteria like Lactobacillus and Bifidobacterium can help restore the balance of gut flora and reduce the duration and severity of diarrhea.

Is ginger effective for diarrhea? Yes, ginger has anti-inflammatory and soothing properties that can help alleviate the symptoms of diarrhea. It can be consumed as a tea or taken in supplement form.

Diarrhea Treatments | Gastrointestinal | Andrew Weil, M.D.

What Is Diarrhea?

Diarrhea is a common and uncomfortable digestive disorder characterized by loose, watery stools that cause frequent need to defecate (usually at least three times a day). It can be acute or chronic. Acute diarrhea typically lasts a day or two and resolves on its own. Chronic diarrhea usually lasts longer than a month and may be a sign of conditions such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), or malabsorption problems (the poor absorption of certain nutrients).

What Are The Symptoms Of Diarrhea?

Diarrhea typically causes symptoms such as:

• Abdominal pain
• Bloating
• Cramping
• Frequent loose, watery stools
• Nausea
• Urgency

In adults, temporary diarrhea in itself usually isn’t harmful, but it can sometimes signal more serious problems. In part because of their smaller body volume, children can suffer serious consequences from prolonged diarrhea. Patients should see the doctor if they experience any of these symptoms:

• Blood or pus in the stool
• Black, tarry-looking stools
• Diarrhea that lasts longer than three days
• Fever of 102 degrees Fahrenheit or higher
• Severe abdominal or rectal pain
• Signs of dehydration

What Are The Causes Of Diarrhea?

All diarrhea is either infectious or osmotic. Infectious diarrhea follows bacterial, viral, or amoebic illnesses that disrupt the normal process of gastrointestinal absorption, or that produce substances that draw water into the bowel. Osmotic diarrhea is caused by the inability of the gastrointestinal tract to break down and absorb something ingested. In both cases, the food and fluids a person ingests pass too quickly through the digestive system. When this occurs, nutrients aren’t absorbed properly and waste products do not have time to coalesce, resulting in loose and watery stool.
Infectious diarrhea can have many different causes, including:

• Bacterial infections, such as those triggered by E. coli, Campylobacter, Salmonella, and Shigella bacteria
• Viral infections, such as those triggered by rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis
• Parasites, such as Giardia lamblia, Entamoeba histolytica, and Cryptosporidium

Osmotic causes of diarrhea can include:

• Intolerances to certain compounds in food, such as lactose (milk sugar) and artificial sweeteners
• Medications, such as antibiotics, blood pressure medications, and some antacids
• Digestive disorders, such as IBS, IBD, and celiac disease
• Chemotherapy
• Surgical removal of the gallbladder
• High-dose radiation therapy

Who Is Likely To Develop Diarrhea?

Diarrhea is a very common illness and can affect people of all ages. It is more likely to occur in children, people who have chronic digestive disorders, and people who have traveled to other countries where both the food and the local infectious agents may be unfamiliar to the digestive system. Antibiotics can commonly cause diarrhea by disrupting the “good” bacteria that help break down food in the gastrointestinal tract.

How Is Diarrhea Diagnosed?

Diarrhea doesn’t usually require a diagnosis, but the physician may perform certain tests to determine the cause of the diarrhea. These include:

• Medical history and physical examination
• Laboratory analysis of a stool sample
• Blood tests
• Fasting tests
• Sigmoidoscopy
• Colonoscopy
• Imaging tests

What Is The Conventional Treatment?

How to stop diarrhea: Anti-diarrheal medications – such as loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol) and kaolin pectin suspension (Kaopectate) – can reduce the severity of symptoms but won’t speed recovery. They also can worsen or prolong diarrhea caused by parasites or bacteria. If a parasite or bacterial infection has caused diarrhea, a course of antibiotics may be prescribed. Occasionally treatment with antibiotics for another condition can result in disruption of normal flora in the intestines and overgrowth of pathogenic strains of bacteria, resulting in very severe diarrhea. This type of diarrhea requires immediate discontinuation of the course of antibiotics and specialized treatment.

People with diarrhea should also avoid certain foods that trigger or worsen symptoms. These include:

• Milk and other dairy products
• Caffeine
• Greasy and fatty foods
• Spicy foods
• Alcohol

On the other hand, some foods are better tolerated, such as:

• Bananas
• Boiled potatoes
• Cooked carrots
• Cooked chicken
• Plain rice
• Toast

Although avoiding high-fiber foods during a bout of diarrhea can ease symptoms, fiber can help reduce the severity of chronic diarrhea (such as that caused by IBS) by adding bulk to stools.

What Therapies Does Dr. Weil Recommend For Diarrhea?

In addition to the dietary approaches described above, Dr. Weil recommends a number of safe, effective remedies for diarrhea:

• Follow the “BRAT” diet, an acronym for bananas, rice, applesauce and toast. These foods should be added to the diet; they should not replace a normal, well-balanced diet.
• Carob powder can help soothe irritated intestines. Start with one tablespoon, mixed with some applesauce and honey to make it palatable. Take it on an empty stomach.
• Blackberry root bark (Rubus macropetalus) contains tannins, which have a desirable astringent action on the intestinal lining. Take a teaspoon of tincture in water every two to four hours.
• Probiotics help repopulate the digestive tract with healthy bacteria. Take one tablespoon of the liquid culture or one to two capsules with meals unless the label directs otherwise.
•  It is particularly important to take probiotics twice a day, with meals, as soon as you begin taking antibiotics. Continue the twice-daily ingestion of probiotics for a few days after completing the course of antibiotics.

Prevention and Treatment of Traveler’s Diarrhea

GREGORY JUCKETT, M. D.

Am Fam Physician. 1999;60(1):119-124

See related patient information handout on traveler’s diarrhea, written by the author of this article.

Common pathogens in traveler’s diarrhea include enterotoxigenic Escherichia coli, Campylobacter, Shigella, Salmonella, Yersinia and many other species. Viruses and protozoa are the cause in many cases. Fortunately, traveler’s diarrhea can usually be avoided by carefully selecting foods and beverages. Although drug prophylaxis is now discouraged, treatment with loperamide (in the absence of dysentery) and a fluoroquinolone, such as ciprofloxacin (500 mg twice daily for one to three days), is usually safe and effective in adults with traveler’s diarrhea. Trimethoprim-sulfamethoxazole and doxycycline are alternatives, but resistance increasingly limits their usefulness. Antibiotic treatment is best reserved for cases that fail to quickly respond to loperamide. Antibiotic resistance is now widespread. Nonabsorbable antibiotics, immunoprophylaxis with vaccines and biotherapeutic microbes that inhibit pathogen infection may eventually supplant antibiotic treatment. In the meantime, azithromycin and new fluoroquinolones show promise as possible replacements for the older agents. Ultimately, the best solution is improvements in sanitary engineering and the development of safe water supplies.

Travel to destinations such as Latin America, Asia, Africa and the Middle East has never been more popular, with over 20 million travelers visiting a less developed country each year.¹ Approximately one third (20 to 50 percent) of travelers to less developed areas of the world become ill from ingesting fecally contaminated food or water.^2,3 In 10 to 20 percent of cases, fever and bloody stools (dysentery) occur.²

Although traveler’s diarrhea usually resolves within three to five days (mean duration: 3. 6 days), in about 20 percent of persons the illness is severe enough to cause bed confinement and in 10 percent of cases the illness lasts more than one week.^3,4 In the very young and the very old, as well as in those who are immunocompromised, traveler’s diarrhea can occasionally be life-threatening. It is important to realize, however, that traveler’s diarrhea can be minimized by education about ways to prevent the disease. Physicians can do a great deal to ensure that their patients have a safe and enjoyable trip abroad.

Epidemiology

Traveler’s diarrhea is defined as three or more unformed stools in 24 hours in a person from an industrialized nation traveling in a less developed country. Unlike in the United States, where most diarrheal disease is viral in origin, in developing countries, bacterial infection is the cause of diarrhea in at least 80 percent of cases. Viral, protozoal or undetermined etiologies account for the remainder of cases. Enterotoxigenic Escherichia coli is the chief pathogen, accounting for 40 to 50 percent of cases. ⁵ Other common bacterial causes include Campylobacter jejuni, Shigella, Salmonella, Aeromonas and Yersinia species, Plesiomonas shigelloides and Vibrio parahaemolyticus (Table 1). All of these agents are efficiently spread by the fecal-oral route and, in some cases, such as Shigella infections, a minute inoculum (as few as 10 to 100 organisms) is all that is necessary to produce disease.

Without stool cultures for identifying the pathogen in diarrheal illness, it is easy to confuse the symptoms of traveler’s diarrhea with those of food poisoning produced by heat-stable, toxin-forming bacteria such as Staphylococcus aureus and Bacillus cereus or by the heat-labile toxin of Clostridium perfringens. In general, however, preformed toxins (Staphylococcus and Bacillus) produce symptoms within one to six hours, whereas infections (such as from Clostridium) that result in toxin formation in vivo cause symptoms within eight to 16 hours. Most invasive bacterial infections, on the other hand, become symptomatic after 16 hours.⁶

Viruses that are responsible for traveler’s diarrhea in the tropics include rotavirus and Norwalk agents. Diarrhea caused by viral agents is usually self-limited.

The three major protozoal causes of traveler’s diarrhea are Entamoeba histolytica, Giardia duodenalis and Cryptosporidium parvum. Diarrheal disease caused by these organisms is notable for its longer duration and failure to respond to routine antibiotic therapy.

Risk factors for traveler’s diarrhea are listed in Table 2. Persons from a developing region who have relocated to an industrialized country and who then return to their country of origin are also at increased risk, especially since they seldom take precautions. Any “native resistance” is soon lost after relocation and subsequent alteration of the intestinal flora.

Prevention

Traveler’s diarrhea is fundamentally a sanitation failure, leading to bacterial contamination of food and water. It is best prevented through proper sewage treatment and water disinfection. In the absence of these amenities, the next best option is for the educated traveler to take precautions to prevent the disease.

Preventive measures include not drinking tap water, not using ice in beverages (even alcoholic drinks), not eating salads and other forms of raw vegetables, not eating fruits that can’t be peeled on the spot and not eating mayonnaise, pastry icing, unpasteurized dairy products and undercooked shellfish.

Tying a ribbon around the faucet and keeping purified bottled water near the sink may serve as memory aids for travelers to remind them not to use tap water, even for tooth brushing. Hot cooked food, fresh bread, dry foods such as crackers, bottled carbonated beverages, coffee, tea and beer are usually safe, provided such food items are not obtained from street vendors. Helpful maxims to keep in mind include “boil it, cook it, peel it or forget it” and the “rule of P’s”: food is safe if it is peelable, packaged, purified or piping hot.³ Careful handwashing, most conveniently achieved with packaged wipes or antiseptic gel, is essential.

Active intervention involves boiling water for three to five minutes (depending on elevation), filtering water or using chlorine bleach (2 drops per quart) or tincture of iodine (5 drops per quart) in the water. Drawbacks with these methods of prevention include the need to allow sufficient time to disinfect the water, clogged filters, chlorine’s incomplete effectiveness against some protozoal cysts and iodine’s bad taste. ⁷ Antibiotics (i.e., tetracyclines) added to the water may not destroy resistant bacteria and protozoal cysts. Fortunately, the wide availability of safe bottled water makes these cumbersome interventions unnecessary for all but the most remote destinations.

Drug Prophylaxis

Table 3 summarizes the various drug therapies used for prophylaxis against traveler’s diarrhea. Bismuth subsalicylate (Pepto-Bismol), in a dosage of two 262-mg tablets four times a day (taken with meals and in the evening) can prevent traveler’s diarrhea. It has been shown to provide a 65 percent protection rate.⁸ Bismuth subsalicylate can be taken for up to three weeks. Such long-term use can, however, darken the tongue and stool, produce tinnitus and cause reactions in salicylate-sensitive patients. Bismuth subsalicylate also interferes with the absorption of doxycycline and certain other medications.⁸

Compared with bismuth subsalicylate, antibiotic prophylaxis with trimethoprim-sulfamethoxazole (Bactrim DS), in a dosage of 160 mg/800 mg daily, or doxycycline (Vibramycin), in a dosage of 100 mg daily, has been found to provide even better results for up to three weeks. ⁸ Increasingly, however, resistance to these antibiotics has become such a problem that their routine use is not recommended. For instance, trimethoprim-sulfamethoxazole continues to be effective prophylaxis for summertime travel in inland Mexico, but it is unreliable in many other situations.² Although fluoroquinolones such as ciprofloxacin (Cipro) may be the best alternatives to trimethoprim-sulfamethoxazole and doxycycline, resistance to fluoroquinolones is developing too rapidly to justify their continued use for prophylaxis against traveler’s diarrhea.

Antibiotic prophylaxis for traveler’s diarrhea, always a controversial topic, is now recommended only in specific situations, such as in the seriously immunocompromised patient or the seriously ill patient who would not be able to withstand a diarrheal illness. If antibiotic prophylaxis is used, the antibiotic should only be taken for a three-week period. Other exceptions may include persons who plan short-term critical travel, such as a diplomatic mission, or persons who are unable to practice prevention.

In most people, drug prophylaxis engenders a false sense of security. In addition, drug prophylaxis always carries the remote risk of a potentially life-threatening side effect such as pseudomembranous colitis or Stevens-Johnson syndrome. Nuisance side effects such as vaginal yeast infections and, with doxycycline, photosensitivity, are common. Therefore, the Centers for Disease Control and Prevention recommends preventive measures only and not drug prophylaxis for most travelers. If diarrhea occurs despite precautions, however, a self-treatment contingency plan is reasonable.

Treatment

Mild traveler’s diarrhea can usually be managed with the judicious use of antimotility agents such as loperamide (Imodium A-D), in a dosage of two 2-mg tablets initially, then one tablet after each loose stool (maximum 24-hour dosage: 8 mg). Additionally, a single dose of ciprofloxacin—750 mg; levofloxacin (Levaquin)—500 mg; or ofloxacin (Floxin)—400 mg, usually relieves mild cases of traveler’s diarrhea in less than 24 hours. ⁹

The use of antimotility agents has traditionally been avoided in patients with dysentery, where decreased gut motility would be inadvisable. Moderate to severe traveler’s diarrhea, including dysentery, can be empirically treated with a three-day course of a fluoroquinolone such as ciprofloxacin, norfloxacin (Noroxin) or ofloxacin (Table 4). Loperamide may also be taken if the patient does not have dysentery. Before beginning antibiotic therapy, however, patients should first take a dose of loperamide to see if the antimotility agent stops the diarrhea. Antibiotic therapy should be deferred until it is clear that the diarrheal illness requires antibiotic therapy, since dietary change and stress can cause transient gastrointestinal upset.² A single antibiotic dose may be effective for mild traveler’s diarrhea, and patients should reassess their condition in 12 hours to determine if further doses are necessary.¹⁰

Ciprofloxacin is not recommended in patients with seizure disorders, in patients who are pregnant and in children under 18 years of age. Children older than two years of age can be given trimethoprim-sulfamethoxazole. Children under two years of age and pregnant women can be treated with an oral rehydration solution. Older children and other adults with traveler’s diarrhea also would benefit from oral rehydration, possibly supplemented with salted soda crackers. Commercially available packets of oral rehydration solution can be reconstituted with safe water.

If treatment with a fluoroquinolone fails to resolve the diarrhea, several other diagnostic possibilities should be considered. Protozoal infections and pseudomembranous colitis must be excluded. In addition, infection from an antibiotic-resistant organism is now a third and increasingly probable explanation for continued diarrhea. Azithromycin (Zithromax), in a dosage of 500 mg daily for three days, has been found to be very effective in treating resistant Campylobacter enteritis contracted in Thailand, and its usefulness in other situations of fluoroquinolone resistance merits investigation. ¹¹

Patients should be told to consult a physician if diarrhea does not respond to the planned regimen, especially if high fever or bloody stools are present. Patients should also be warned to avoid over-the-counter anti-diarrheals such as iodochlorhydroxyquinoline (Entero-Vioform), which has been withdrawn from the U.S. market because of its association with myelooptic atrophy. This agent, however, may still be available outside this country.

Public Health Issues

Even with the emphasis now placed on pre-cautionary measures to prevent traveler’s diarrhea rather than drug prophylaxis, the treatment of traveler’s diarrhea will be increasingly hampered by antibiotic resistance. Multidrug-resistant Shigella and Salmonella strains are now so common that it is only a matter of time until they also become resistant to fluoroquinolones. Some respite may be provided by the most recently developed fluoroquinolones and azithromycin, but eventually a new approach will be necessary.

One future option might be nonabsorbable antimicrobial drugs such as bicozamycin, furazolidone (Furoxone), aztreonam and rifaximin, which have already shown some benefit in the treatment of traveler’s diarrhea. Bicozamycin might also be an effective prophylactic agent that would treat only the gastrointestinal tract and, therefore, be more acceptable from the standpoint of safety.² Although not yet marketed in the United States, zaldaride, a new type of drug called a calmodulin inhibitor, is a promising treatment.¹⁰

Use of biotherapeutic agents made of microorganisms that suppress pathogenic infection is another option. Lactobacillus casei and Saccharomyces boulardii, a nonpathogenic yeast, have been studied as prophylactic agents in travel scenarios, but the results have been inconsistent. The use of these organisms to treat other types of diarrhea has been encouraging, and improvements in bioengineered forms of these organisms may in the future yield an alternative to antibiotics. ¹²

Immunoprophylaxis by means of oral vaccines may become a third alternative to systemic antibiotics. Vaccines have already been developed for typhoid, enterotoxigenic E. coli and cholera (the latter two are not yet available in the United States). Shigella and Campylobacter vaccines are in the development stage, and a pediatric rotavirus vaccine has recently been labeled. A combination, or “super,” vaccine could be an effective way to reduce the most common types of traveler’s diarrhea. The limiting factor is the vast array of potential pathogens that cannot be included in any single vaccine.^3,10

The most sensible, yet most problematic, approach to preventing traveler’s diarrhea is to eliminate the basic problem of poor hygiene and water contamination through sanitary engineering, public education and, most importantly, the development of a safe water supply. Unfortunately, much of the developing world is in a “Catch-22” situation: poverty and unclean water hinder the tourism and investment money needed to correct these problems. Progress through international aid and economic development is difficult, but in an increasing number of transitional nations, such as Thailand, economic growth has reduced the country’s risk profile in less than a decade. Ultimately, the elimination of poverty, and not new drugs, will resolve the problem of traveler’s diarrhea.

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The Economist

The pound sterling is not reliable: crises affect it more than the currencies of other developed countries. Nevertheless, the pound remains in high demand among investors

Photo: Stefan Wermuth / Getty Images

The pound sterling was once the world’s dominant reserve currency. And although over time the dollar became a leader, pushing the British currency into the background, it still remained significant for the global economy. For decades, this situation suited everyone. But lately, the luster of the pound seems to be fading again. Bank of America analyst Kamal Sharma even said that the pound “has become like emerging market currencies.”

Of course, the pound did not become the Turkish lira or the Argentine peso. It is still among the top five most actively traded currencies in developed countries along with the dollar, euro, Japanese yen and Swiss franc. Nevertheless, crises affect the British currency more than other currencies.

Pound at 30 year low due to Brexit fears

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• Vesti. Economics

The British pound sterling has fallen to a record low in more than 30 years amid fears about the likelihood of a rather harsh exit of the UK from the European Union, reports Reuters.

The British pound sterling fell to a record low in more than 30 years amid fears about the likelihood of a rather tough exit from the EU, reports Reuters.

EPA/ANDY RAIN

The fear-driven sell-off left the British currency vulnerable to further declines, despite the fact that part of the losses were offset.

On a number of trading floors in Asia, the pound lost about 10% against the dollar, dropping from $1.2600 to $1.1378. Then the pound quickly recovered to the level of about $1.25, and after some fluctuations it stopped at $1.2445. Thus, the British currency fell in price by 1.35% compared to the previous trading day.

Investors primarily fear that negotiations on the final withdrawal of Britain from the EU will end with the country losing free access to the European market in order to control its own borders.

The latter implies that the migration flow to the United Kingdom will be severely restricted. This was one of the demands of Brexit supporters before the British referendum.

Related links

• Labor productivity in Britain as before the crisis
• Bank of England: Brexit will lead to non-obvious problems

French President Francois Hollande said earlier that the European Union must defend its position during negotiations with Britain, which, according to some reports, could begin in the second quarter of 2017. There has also been a lot of speculation lately that British Prime Minister Theresa May has decided to take the harder option of leaving the EU.

British currency held at its lowest since mid-1980s throughout the last week.