Diarrhoea

Also indexed as: Stools (Loose)

Diarrhoea is any attack of frequent, watery stools.

Diarrhoea can be triggered by many different conditions. Acute diarrhoea is often caused by an infection and may require medical management. The primary role of nutrition in acute diarrhoea is to prevent depletion of fluid, sodium, potassium, and calories. Replenishment of all four has been achieved with “rehydration solutions” and with a variety of foods, from salted carrot soup to peeled scraped apple to rice gruel. However, diarrhoea severe enough to necessitate the use of rehydration solutions requires direct medical supervision. Therefore, nutritional approaches to overcoming depletion of fluid, sodium, potassium, and calories are not discussed here, but rather should be discussed with a doctor. Diarrhoea-induced low blood sugar, dehydration, or electrolyte imbalance can be serious or even life-threatening, particularly if prolonged in children.

A healthcare provider should be consulted if diarrhoea continues for more than a few days, as it may indicate a more serious health condition. Diarrhoea alternating with constipation may be a sign of irritable bowel syndrome (IBS).

Checklist for Diarrhoea

Rating Nutritional Supplements Herbs
3Stars

Lactase (for lactose-intolerant people)

Multiple vitamin-mineral (to protect against deficiencies)

Probiotics (for infectious and antibiotic-associated diarrhoea)

  
2Stars

Brewer’s yeast (for infectious diarrhoea)

Colostrum

Fibre

Carob

Psyllium

Sangre de drago

Tormentil root extract (for rotavirus infection)
1Star

Folic acid

Vitamin A

Zinc

Barberry

Bilberry

Blackberry

Bladderwrack

Blueberry

Chamomile

Cranesbill

Goldenseal

Marshmallow

Oak

Oregon grape

Periwinkle

Red raspberry

Sweet Annie

Tylophora
See also:  Homoeopathic Remedies for Diarrhoea
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms of diarrhoea?

Normal bowel habits vary considerably from person to person depending on age, diet, cultural factors, and individual physiology. However, loose watery stools occurring three or more times in one day is generally considered abnormal. In some instances, diarrhoea may be accompanied by cramping abdominal pain, nausea, vomiting, fever, loss of appetite, and bloody or foul-smelling stools.

Medical treatments

Over the counter antidiarrhoeal drugs include loperamide (Imodium A-D®), bismuth subsalicylate (Pepto-Bismol®), attapulgite (Kaopectate Advanced Formula®), and charcoal (CharcoCaps®).

Prescription medications used to stop diarrhoea include diphenoxylate (Lomotil®, Lonox®, Motofen®), and occasionally codeine.

Rest, along with fluid replacement using Pedialyte®, Ceralyte®, or Infalyte®, is often recommended. Severe diarrhoea, especially in children and the elderly, may require hospitalisation for urgent fluid and electrolyte replacement in order to correct dehydration.

Dietary changes that may be helpful

Some foods contain sugars that are absorbed slowly, such as fructose in fruit juice or sorbitol in dietetic confectionery. Through a process called osmosis, these unabsorbed sugars hold onto water in the intestines, sometimes leading to diarrhoea.1 By reading labels, people with chronic non-infectious diarrhoea can easily avoid fruit juice, fructose, and sorbitol to see if this eliminates the problem.

People who are lactose intolerant—meaning they lack the enzyme needed to digest milk sugar—often develop diarrhoea after consuming milk or ice cream. People whose lactose intolerance is the cause of diarrhoea will rid themselves of the problem by avoiding milk and ice cream or in many cases by taking lactase, the enzyme needed to digest lactose. Lactase is available in a variety of forms in pharmacies (and in grocery stores in the form of lactase-treated milk).

Large amounts of vitamin C or magnesium found in supplements can also cause diarrhoea, although the amount varies considerably from person to person. Unlike infectious diarrhoea, diarrhoea caused by high amounts of vitamin C or magnesium is not generally accompanied by other signs of illness. The same is true when the problem comes from sorbitol or fructose.2 In these cases, avoiding the offending supplement or food brings rapid relief.

Drinking several cups of coffee per day causes diarrhoea in some people.3 People with chronic diarrhoea who drink coffee should avoid all coffee for a few days to evaluate whether coffee is the culprit.

Allergies and food sensitivities are common triggers for diarrhoea.4 For example, some infants suffer diarrhoea when fed cow’s milk-based formula but improve when switched to soya-based formula.5 People with chronic diarrhoea not attributable to other causes should discuss the possibility of food sensitivity with a doctor.

Some doctors recommend a diet called the BRAT diet for acute bouts of diarrhoea. BRAT stands for bananas, rice, apples and toast. These foods are mild, well-tolerated and good sources of fibre, potassium and other nutrients that may be helpful in diarrhoea. The efficacy of this diet has not been evaluated in clinical trials.

Nutritional supplements that may be helpful

An organism related to brewer’s yeast, Saccharomyces boulardii (Sb), is widely used in Europe to prevent antibiotic-induced diarrhoea. It is also available as a supplement in the United States. Animal research with Sb shows interference with Clostridium difficile, a common bacterial cause of diarrhoea.6 In double-blind trials, Sb has prevented antibiotic-induced7 and other forms of infectious diarrhoea.8 An intake of 500 mg four times per day has been used in some of this research. Sb has also helped tourists prevent traveller’sdiarrhoea, according to double-blind research.9 In one trial, positive results were obtained at amounts as low as 150–450 mg per day.10 Even diarrhoea caused by Crohn’s disease has partially responded to Sb supplementation in double-blind research.11 While not every trial shows efficacy,12 the preponderance of evidence clearly supports the use of Sb in people with diarrhoea caused by antibiotics or infection. Seriously ill patients should consult with their doctor before supplementing with Sb, as rare but serious cases of infection caused by Sb in such patients has been reported.13

Beneficial bacteria, such as lactobacilli and bifidobacteria, normally live in a healthy colon, where they inhibit the over-growth of disease-causing bacteria.14 Diarrhoea flushes intestinal microorganisms out of the digestive tract, leaving the body vulnerable to opportunistic infections. Replenishing with acidophilus and other beneficial probiotic bacteria can help resolve the diarrhoea and prevent new infections.15 The effective amount of probiotic bacteria depends on the strain used, as well as the concentration of viable organisms.

The combination of bifidobacteria and Strep thermophilus (found in certain yoghurts) dramatically reduces the incidence of acute diarrhoea in hospitalised children.16 Active-culture yoghurt, milk fermented with Lactobacillus casei and other sources of probiotic bacteria may prevent antibiotic-induced diarrhoea.17 18 19

As mentioned in the dietary changes section above, if lactose intolerance is the cause of diarrhoea, supplemental use of lactase prior to consuming milk or milk-containing products can be helpful.20 Cheese rarely has enough lactose to cause symptoms in lactose-intolerant people. Lactase products are available that can be chewed while drinking milk or added to milk directly.

The malabsorption problems that develop during diarrhoea can lead to deficiencies of many vitamins and minerals.21 For this reason, it makes sense for people with diarrhoea to take a multivitamin-mineral supplement. Two of the nutrients that may not be absorbed efficiently as a result of diarrhoea are zinc and vitamin A, both needed to fight infections. In third world countries, supplementation with zinc and vitamin A has led to a reduction in, or prevention of, infectious diarrhoea in children.22 Whether such supplementation would help people in better nourished populations remains unclear.

Brewer’s yeast supplementation has been shown to alter immune function and the flora living in the intestine, and may relieve infectious diarrhoea. Three capsules or tablets of brewer’s yeast three times per day for two weeks was reported to improve three cases of infectious diarrhoea caused by Clostridium difficile.23 Animal research has confirmed that brewer’s yeast helps fight this unfriendly bacterium.24 (Note that real brewer’s yeast is not identical to nutritional, or torula, yeast and that when asking for “brewer’s yeast” in health food stores, people are often directed toward these other products. Real brewer’s yeast is bitter, whereas other health food store yeasts have a more pleasant taste.)

Colostrum might be useful for certain types of infectious diarrhoea. In a double-blind trial, children with diarrhoea caused by a rotavirus were treated with immunoglobulins extracted from colostrum derived from cows immunized with rotavirus. Compared with the placebo, colostrum extract significantly reduced the amount of diarrhoea and the amount of oral rehydration solution required. The rotavirus was eliminated from the stool significantly more rapidly in the colostrum group than in the placebo group (1.5 days, vs. 2.9 days).25

In addition to a positive effect against acute rotavirus diarrhoea,26 there is also evidence that specific forms of colostrum (derived from specially immunized cows or those with confirmed presence of specific antibodies) are effective against diarrhoea caused by Cryptosporidium parvum, Helicobacter pylori, Escherichia coli, and Clostridium difficile.27 28 29 30 31 However, it is not known whether commercially-available colostrum provides significant amounts of the specific immunoglobulins that are active against these organisms. Furthermore, unless the immunoglobulins are present in high enough concentrations, the preparation is not likely to be effective.32

While fibre from dietary or herbal sources is often useful for constipation, it may also play a role in alleviating diarrhoea.

Acute diarrhoea can damage the lining of the intestine. Folic acid can help repair this damage. In one preliminary trial, supplementing with very large amounts of folic acid (5 mg three times per day for several days) shortened the duration of acute infectious diarrhoea by 42%.33 However, a double-blind trial failed to show any positive effect with the same level of folic acid.34 Therefore, evidence that high levels of folic acid supplementation will help people with infectious diarrhoea remains weak.

It is known vitamin A supplements support immune function and prevent infections. This is true, however, only under some circumstances. Vitamin A supplementation can also increase the risk of infections, according to the findings of a double-blind trial.35 In a study of African children between six months and five years old, a 44% reduction in the risk of severe diarrhoea was seen in those children given four 100,000–200,000 IU supplements of vitamin A (the lower amount for those less than a year old) during an eight-month period. On further investigation, the researchers discovered that the reduction in diarrhoea occurred only in children who were very malnourished. For children who were not starving, vitamin A supplementation actually increased the risk of diarrhoea compared with the placebo group. The vitamin A-supplemented children also had a 67% increased risk of coughing and rapid breathing, and signs of further lung infection, although this problem did not appear in children infected with the AIDS virus. These findings should be of concern to American parents, whose children are not usually infected with HIV or severely malnourished. Such relatively healthy children fared poorly in the African trial in terms of both the risk of diarrhoea and the risk of continued lung problems. Vitamin A provided no benefit to the well-nourished kids. Therefore, it makes sense not to give vitamin A supplements to children unless there is a special reason to do so, such as the presence of a condition causing malabsorption (e.g., coeliac disease).

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

The following recommendations are for milder forms of diarrhoea. For more serious cases of diarrhoea, proper medical evaluation and monitoring should occur before taking any herbal supplements.

Carob is rich in tannins that have an astringent or binding effect on the mucous membranes of the intestinal tract. A double-blind trial has suggested it may be particularly useful for young children and infants with diarrhoea.36 Some healthcare professionals recommend 15 grams of carob powder is mixed with applesauce (for flavour) when given to children. Carob can also be used for treating adult diarrhoea.

While fibre from dietary or herbal sources is often useful for constipation, it may also play a role in alleviating diarrhoea. For example, 9–30 grams per day of psyllium seed (an excellent source of fibre) makes stool more solid and can help resolve symptoms of non-infectious diarrhoea.37 Alginic acid, one of the major constituents in bladderwrack(Fucus vesiculosus), is a type of dietary fibre and as a result may potentially help relieve diarrhoea. However, human studies have not been done on how effective bladderwrack is for this condition.

An extract from stem bark latex of Sangre de drago (Croton lechleri), an herb from the Amazon basin of Peru, has demonstrated significant anti-diarrhoeal activity in preliminary38 39 and double-blind trials. Double-blind research has demonstrated the extract’s effectiveness for traveller’sdiarrhoea,40 non-specific diarrhoea,41 and diarrhoea associated with HIV infection and AIDS.42 43 For traveller’sdiarrhoea and nonspecific diarrhoea, amounts ranging from 125 mg to 500 mg taken four times daily for two days have proven effective. However, in one trial, only the 125 mg four times daily amount (but not higher amounts) was effective for acute nonspecific diarrhoea.44 The reasons for the failure of higher amounts in this study is not known. Very high amounts of these extracts (350–700 mg four times daily for seven or more days) were used in the trials involving people with HIV and AIDS. Such levels of supplementation should always be supervised by a doctor. Most of this research on Sangre de Drago is unpublished, and much of it is derived from manufacturers of the formula. Further double-blind trials, published in medical journals, are needed to confirm the efficacy reported in these studies.

Tormentil root (Potentilla tormentilla) is an herb that has been used for many years in different European folk medicines for the treatment of diarrhoea. In a double-blind study of children with diarrhoea caused by rotavirus infection, the duration of diarrhoea averaged three days in children who received tormentil root extract, compared with five days in those who received a placebo.45 No adverse effects were seen. The amount of tormentil root extract used was 3 drops for every year of life, taken three times a day until diarrhoea stopped, or for a maximum of five days.

Other astringent herbs traditionally used for diarrhoea include blackberry leaves, blackberry root bark, blueberry leaves, and red raspberry leaves.46 Raspberry leaves are high in tannins and, like blackberry, may relieve acute diarrhoea. A close cousin of the blueberry, bilberry, has been used traditionally in Germany for adults and children with diarrhoea.47 Only dried berries or juice should be used—fresh berries may worsen diarrhoea.

Cranesbill has been used by several of the indigenous tribes of North America to treat diarrhoea. The tannins in cranesbill likely account for the anti-diarrhoeal activity48 —although there has been little scientific research to clarify cranesbill’s constituents and actions.

In laboratory experiments, a tannin in oak, known as ellagitannin, inhibited intestinal secretion,49 which may help resolve diarrhoea. Oak is well regarded in Germany, where it is recommended (along with plenty of electrolyte-containing fluids) to treat mild, acute diarrhoea in children.50

Due to of its supposed antimicrobial activity, goldenseal has a long history of use for infectious diarrhoea. Its major alkaloid, berberine (also found in barberry and Oregon grape), has been shown to improve infectious diarrhoea in some double-blind trials.51 Negative studies have generally focused on people with cholera, while positive studies investigated viral diarrhoea or diarrhoea due to strains of E. coli. These studies generally used 400–500 mg berberine one to three times per day. Because of the low amount of berberine in most goldenseal products, it is unclear how effective the whole root or root extracts would be in treating diarrhoea.

Chamomile may reduce intestinal cramping and ease the irritation and inflammation associated with diarrhoea, according to test tube studies.52 Chamomile is typically taken as a tea. Many doctors recommend dissolving 2–3 grams of powdered chamomile or adding 3–5 ml of a chamomile liquid extract to hot water and drinking it three or more times per day, between meals. Two to three teaspoons (10–15 grams) of the dried flowers can be steeped in a cup of hot water, covered, for ten to fifteen minutes as well.

Tylophora has been used traditionally in the Ayurvedic system for diarrhoea probably due to its anti-inflammatory and antimicrobial actions, although human studies have not confirmed this use.

Herbs high in mucilage, such as marshmallow or slippery elm, may help reduce the irritation to the walls of the intestinal tract that can occur with diarrhoea. A usual amount taken is 1,000 mg of marshmallow extract, capsules, or tablets three times per day. Marshmallow may also be taken as a tincture in the amount of 5–15 ml three times daily.

Sweet annie has been used traditionally to treat infectious diarrhoea and malaria. However, more modern studies have used the isolated constituent artemisinin and it is unclear how effective the herb is in managing diarrhoea.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

Integrated approaches that may be helpful

Other integrative approaches that may be helpful: Acupuncture may be useful for the treatment of diarrhoea, particularly in infants. A preliminary study of acupuncture treatment in 1,050 cases of infantile diarrhoea found 95% were relieved with one to three treatments.53 Similar results have been reported in other preliminary trials54 55 and case reports.56 57 A controlled trial of acupuncture for the treatment of infantile diarrhoea compared scalp acupuncture or traditional body acupuncture with drug therapy, primarily antibiotics. The cure rate for scalp and body acupuncture was significantly higher (90% and 89%) than that of drug treatment (46%).58

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