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Diarrhea in Adults

Overview

Diarrhea is defined as several loose or watery stools or bowel movements a day, sometimes accompanied by cramping.

Most of the time, diarrhea gets better on its own in a few days; however, it can be more severe and require treatment. If the diarrhea lasts more than 4 weeks, it is defined as chronic diarrhea.

Infections by viruses and bacteria are the most common cause, but there are a number of noninfectious causes. The most common complication of diarrhea is dehydration.

Symptoms

In addition to frequent loose bowel movements, some symptoms of diarrhea you may experience can include:

• Abdominal cramping
• Abdominal pain
• Bloating
• Nausea and vomiting
• An urgency to use the bathroom
• Fever
• Blood in the stools
• Mucus in the stools

Diagnosis

To understand the type and the severity of the diarrhea you are experiencing, we will hear your medical history and perform a medical examination. As part of this evaluation we may ask you questions about:

• How long symptoms have lasted 
• Whether they occurred suddenly or gradually 
• Frequency and description of bowel movements
• Presence of fever, abdominal pain, or cramping
• Recent travel
• Foods you ate recently 
• Family members or friends who may also have diarrhea
• Medications and supplements you use

Depending on the severity of your symptoms and history, we may order stool tests to look for:

• Bacterial infection
• Clostridium difficile toxin, if you took antibiotics recently
• Parasites
• Pus cells in the stool

If your diarrhea is chronic and we cannot find the cause, we may request a sigmoidoscopy to examine your lower intestines.

Causes

There are several types of viral infections that can cause diarrhea. Most acute diarrhea is caused by viral infections, occurs right after exposure to the virus, and gets better without treatment.

Viral Infections

Although viral infections can cause diarrhea, most viral infections are not severe. There are some types of viral infections that are serious and can cause diarrhea:

• Norovirus (Norwalk-like virus) causes acute severe vomiting and diarrhea. It occurs on cruise ships and in nursing homes, schools, and other places where large groups of people gather. It usually lasts 24 to 48 hours.  
• Adenovirus may cause diarrhea in children.
• Astrovirus causes diarrhea in daycare centers and nursing homes for the elderly.

Bacterial Infections

Bacterial infections are caused by eating or drinking contaminated food or water. Some of the more common bacterial types are:

• Salmonella
• Campylobacter from undercooked poultry
• Shigella
• E. coli (notably the 0157-H7 strain) from undercooked beef or even unpasteurized apple cider
• Vibrio from contaminated shellfish

A type of bacteria called Clostridium difficile is found in high concentration after the normal gut bacterial balance has been altered by antibiotics. With this condition, it is common to have:

• Ten to 12 watery bowel movements a day
• Cramping and fever
• Mild to severe symptoms

A more severe form of this condition is called pseudomembranous colitis, which is more common among the elderly and people with weak immune systems. This condition can lead to serious complications and must be addressed in a timely manner.

Parasites

A number of parasites, microscopic infectious agents that are neither bacteria nor viruses, can cause diarrhea:

• Cryptosporidium is found in food or water contaminated by feces. It may cause severe symptoms in people who have weak immune systems.
• Giardia is found in contaminated water such as rivers and streams. It may also be found in contaminated food or water in daycare centers.
• Entamoeba histolytica may be acquired during travel to countries outside the United States.

Medication-caused Diarrhea

Some medications may cause diarrhea, especially antibiotics. If you develop diarrhea after taking antibiotics, contact us.

Causes of Chronic Diarrhea

Diarrhea is referred to as chronic when symptoms last for more than 3 months. There are several conditions that may cause chronic diarrhea. Among them are:

Irritable bowel syndrome (IBS). IBS is a condition in which the nerves and muscles in your intestines are overly sensitive and are not working in sync with each other. It has many possible symptoms. The most common are:

• Cramps and lower abdominal pain
• Diarrhea, constipation, or alternating diarrhea and constipation
• Discharge of mucus with stools

Inflammatory bowel disease (IBD). IBD is a condition that causes inflammation of the digestive system. Unlike IBS, IBD is associated with fever. There are several types of inflammatory bowel disease, including:

• Crohn’s disease may affect the body from mouth to anus and is commonly associated with symptoms that include diarrhea, abdominal pain, weight loss, and fever.
• Ulcerative colitis mainly affects the colon and may be mild to severe. The symptoms include intermittent to constant diarrhea, rectal bleeding, discharge of mucus, abdominal pain, and fever.
• Microscopic colitis with chronic watery diarrhea usually occurs in middle-aged patients. We diagnose it using a microscope to examine biopsy samples of the colon. Microscopic colitis is classified into one of two types known as lymphocytic and collagenous.

Malabsorption. You may also develop chronic diarrhea if your digestive system is not able to digest certain foods normally. Some causes of chronic diarrhea include:

• Lactose intolerance (inability to digest milk sugar)
• Celiac disease or sprue (inability to digest gluten protein such as in wheat, rye, and barley)
• Chronic pancreatitis (inability to make digestive enzymes)

Prevention

Since most cases of diarrhea are related to eating food or drinking water that has been contaminated, it is important to:

• Wash your hands thoroughly and frequently, especially after using the bathroom.
• Cook your meat, fish, and poultry thoroughly.
• Avoid drinking water from rivers or streams unless you purify the water first.
• Avoid sharing eating utensils or food/liquids with anyone who has nausea, vomiting, or diarrhea.

Traveler's diarrhea

To prevent a condition known as traveler’s diarrhea (diarrhea that occurs during travel to developing countries) there are several steps you can take:

• Do not drink unpasteurized milk or eat dairy products made from unpasteurized milk.
• Avoid eating raw and rare meat, and fish or shellfish that is not served hot.
• Do not eat raw vegetables and fruit unless you can peel them yourself.
• Avoid eating food sold by street vendors.
• Avoid swimming in unchlorinated water.
• Avoid drinking water from the tap.
• Avoid ice cubes made from tap water.
• Bring hand sanitizer with you when you travel.

Beverages you can safely drink include:

• Bottled water if the seal is intact
• Carbonated beverages
• Hot drinks, like coffee or tea

Prevention of traveler’s diarrhea with medication is controversial. No antibiotic medicines have been approved by the Food and Drug Administration for prevention. Sometimes antibiotics are prescribed for travel so that, in case you develop traveler's diarrhea, you will have medication with you. For prevention using over-the-counter medicines, some people try:

• Pepto-Bismol (bismuth subsalicylate): 2 tablets 4 times a day may prevent diarrhea.
• Some probiotics (beneficial bacteria present in foods such as yogurt or in capsules).

Treatment

You can treat most bouts of diarrhea at home. It is important to drink plenty of fluids and stay hydrated. You may also want to avoid foods (such as milk products) that may make the diarrhea worse. There are also over-the-counter medications that help decrease the discomfort, which you can use if your diarrhea is mild and you have no fever.

You should contact us if your diarrhea does not respond to home treatment in a couple of days or if you have fever or abdominal pain.

Dehydration

When you have diarrhea, it is important to drink plenty of fluids that are not caffeinated. Avoid coffee, black tea, and cola. This will help prevent dehydration. If you do become dehydrated, you need to drink fluid immediately. The signs and symptoms of dehydration are:

• Thirst
• Less frequent urination
• Dry mouth
• Dry skin or skin that does not bounce back when pinched
• Dark urine

Treatment of dehydration depends on how severe your symptoms are.

For mild cases: Drink broth, soup, fruit juice, or a sports drink. If you are experiencing diarrhea, you may wish to avoid:

• Milk products
• Caffeine
• Greasy foods
• Spicy or very sweet foods
• Foods high in fiber, such as vegetables and whole grains

When your symptoms improve, you can resume eating soft bland food such as:

• Bananas
• Toast and crackers
• Baked skinless chicken
• Rice

For moderate to severe cases (if you cannot get to a doctor): If you cannot get to a doctor, you may still be able to manage a moderate to severe case of dehydration. It is important to know that sports drinks do not have enough of the kinds of salts that are needed to treat moderate to severe dehydration. Instead, you can make a solution that can help replenish blood salts by mixing the following:

• One-half teaspoon of table salt
• One-half teaspoon of baking soda
• Four tablespoons of sugar
• One liter of water (1.06 quarts)

Drink the liquid until symptoms of dehydration are gone or significantly improved.

If you think you are becoming dehydrated, call us immediately.

Medication Treatment

Over-the-counter medications

Imodium (loperamide) is available without a prescription to treat diarrhea. You can use it if you have no fever. Take 2 tablets to start, then 1 after each watery stool, not to exceed 8 daily.

Pepto-Bismol (bismuth subsalicylate) may also be helpful. You can use it if you have a fever. Take 30 mL or 2 tablets every 30 minutes for total of 8 doses daily as needed.

Do not take over-the-counter medications to stop diarrhea if you have been diagnosed with Clostridium difficile or have bloody diarrhea.

Antibiotic medications

For viral infections:

Antibiotics are not effective for viral infections. The only treatment is fluids orally or intravenously (directly into a vein) if you are dehydrated. Otherwise, we recommend rest and home care until you feel better.

For bacterial infections:

Using antibiotics too often makes them ineffective, since bacteria become resistant to them. If your symptoms are mild, we will recommend that you not take antibiotics since your body will likely fight off the infection.

We may use an antibiotic before culture results are available if you have been traveling in an area where bacterial infections are common or you are having severe symptoms like:

• Fever
• Bloody stools
• Pus or mucus in stool

Ciprofloxacin is the most common antibiotic used now, pending the results of stool culture testing. Stool cultures or stool toxin tests take 2 to 5 days to come back. A more specific antibiotic for the bacterial infection found in your test may be prescribed once the stool test result is available.

Treatment of chronic diarrhea can vary widely depending on whether it is caused by:

• Irritable bowel syndrome (IBS)
• Inflammatory bowel disease (IBD)
• Crohn’s disease
• Ulcerative colitis
• Celiac disease

In these cases, we will create a treatment plan specific to your condition.

If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.

This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.