Diarrhea

Also indexed as: Stools (Loose)

Any attack of frequent, watery stools is called diarrhea. It can be triggered by many different conditions.

Acute diarrhea is often caused by an infection and may require medical management. The primary role of nutrition in acute diarrhea 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, the need for rehydration 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. Diarrhea-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 diarrhea continues for more than a few days, as it may indicate a more serious health condition. Diarrhea alternating with constipation may be a sign of irritable bowel syndrome (IBS).

Checklist for Diarrhea

Rating Nutritional Supplements Herbs
3Stars Lactase (for lactose-intolerant people)
Multiple vitamin-mineral (to protect against deficiencies)
Probiotics (for infectious and antibiotic-associated diarrhea)		  
2Stars Brewer’s yeast (for infectious diarrhea)
Colostrum
Fiber		 Carob
Psyllium
Sangre de drago
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:  Homeopathic Remedies for Diarrhea
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 An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of diarrhea? 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, diarrhea may be accompanied by cramping abdominal pain, nausea, vomiting, fever, loss of appetite, and bloody or foul-smelling stools.

How is it treated? Rest and fluid replacement (sometimes with the use of oral rehydration solutions such as Pedialyte®, Ceralyte®, or Infalyte®) are often recommended. Severe diarrhea, especially in children and the elderly, may require hospitalization for urgent fluid and electrolyte replacement to correct dehydration. Medicines to stop diarrhea, such as loperamide (Imodium®), bismuth subsalicylate (Pepto Bismol®), attapulgite (Kaopectate®), diphenoxylate (Lomotil®, Lonox®, Motofen®), and opiates (codeine, paregoric) may be prescribed in some cases.

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 diarrhea.1 By reading labels, people with chronic non-infectious diarrhea 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 diarrhea after consuming milk or ice cream. People whose lactose intolerance is the cause of diarrhea 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 diarrhea, although the amount varies considerably from person to person. Unlike infectious diarrhea, diarrhea 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 diarrhea in some people.3 People with chronic diarrhea 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 diarrhea.4 For example, some infants suffer diarrhea when fed cow’s milk-based formula but improve when switched to soy-based formula.5 People with chronic diarrhea 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 diarrhea. BRAT stands for bananas, rice, apples and toast. These foods are mild, well-tolerated and good sources of fiber, potassium and other nutrients that may be helpful in diarrhea. 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 diarrhea. 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 diarrhea.6 In double-blind trials, Sb has prevented antibiotic-induced7 and other forms of infectious diarrhea.8 An intake of 500 mg four times per day has been used in some of this research. Sb has also helped tourists prevent traveler’s diarrhea, 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 diarrhea 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 diarrhea 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 Diarrhea 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 diarrhea 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 yogurts) dramatically reduces the incidence of acute diarrhea in hospitalized children.16 Active-culture yogurt, milk fermented with Lactobacillus casei and other sources of probiotic bacteria may prevent antibiotic-induced diarrhea.17 18 19

As mentioned in the dietary changes section above, if lactose intolerance is the cause of diarrhea, 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 diarrhea can lead to deficiencies of many vitamins and minerals.21 For this reason, it makes sense for people with diarrhea to take a multivitamin-mineral supplement. Two of the nutrients that may not be absorbed efficiently as a result of diarrhea 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 diarrhea 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 diarrhea. Three capsules or tablets of brewer’s yeast three times per day for two weeks was reported to improve three cases of infectious diarrhea 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 diarrhea. In a double-blind trial, children with diarrhea 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 diarrhea 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 diarrhea,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 diarrhea 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

Acute diarrhea 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 diarrhea 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 diarrhea 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 diarrhea 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 diarrhea occurred only in children who were very malnourished. For children who were not starving, vitamin A supplementation actually increased the risk of diarrhea 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 diarrhea 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., celiac 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 diarrhea. For more serious cases of diarrhea, proper medical evaluation and monitoring should occur before taking any herbal supplements.

An extract from stem bark latex of Sangre de drago (Croton lechleri), an herb from the Amazon basin of Peru, has demonstrated significant anti-diarrheal activity in preliminary36 37 and double-blind trials. Double-blind research has demonstrated the extract’s effectiveness for traveler’s diarrhea,38 non-specific diarrhea,39 and diarrhea associated with HIV infection and AIDS.40 41 For traveler’s diarrhea and nonspecific diarrhea, 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 diarrhea.42 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.

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 diarrhea.43 Some healthcare professionals recommend 15 grams of carob powder is mixed with applesauce (for flavor) when given to children. Carob can also be used for treating adult diarrhea.

While fiber from dietary or herbal sources is often useful for constipation, it may also play a role in alleviating diarrhea. For example, 9–30 grams per day of psyllium seed (an excellent source of fiber) makes stool more solid and can help resolve symptoms of non-infectious diarrhea.44 Alginic acid, one of the major constituents in bladderwrack (Fucus vesiculosus), is a type of dietary fiber and as a result may potentially help relieve diarrhea. However, human studies have not been done on how effective bladderwrack is for this condition.

Other astringent herbs traditionally used for diarrhea include blackberry leaves, blackberry root bark, blueberry leaves, and red raspberry leaves.45 Raspberry leaves are high in tannins and, like blackberry, may relieve acute diarrhea. A close cousin of the blueberry, bilberry, has been used traditionally in Germany for adults and children with diarrhea.46 Only dried berries or juice should be used—fresh berries may worsen diarrhea.

Cranesbill has been used by several of the indigenous tribes of North America to treat diarrhea. The tannins in cranesbill likely account for the anti-diarrheal activity47 —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,48 which may help resolve diarrhea. Oak is well regarded in Germany, where it is recommended (along with plenty of electrolyte-containing fluids) to treat mild, acute diarrhea in children.49

Due to of its supposed antimicrobial activity, goldenseal has a long history of use for infectious diarrhea. Its major alkaloid, berberine (also found in barberry and Oregon grape), has been shown to improve infectious diarrhea in some double-blind trials.50 Negative studies have generally focused on people with cholera, while positive studies investigated viral diarrhea or diarrhea 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 diarrhea.

Chamomile may reduce intestinal cramping and ease the irritation and inflammation associated with diarrhea, according to test tube studies.51 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 diarrhea 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 diarrhea. 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 diarrhea and malaria. However, more modern studies have used the isolated constituent artemisinin and it is unclear how effective the herb is in managing diarrhea.

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



Other integrative approaches that may be helpful: Acupuncture may be useful for the treatment of diarrhea, particularly in infants. A preliminary study of acupuncture treatment in 1,050 cases of infantile diarrhea found 95% were relieved with one to three treatments.52 Similar results have been reported in other preliminary trials53 54 and case reports.55 56 A controlled trial of acupuncture for the treatment of infantile diarrhea 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%).57

References:

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31. Warny M, Fatimi A, Bostwick EF, et al. Bovine immunoglobulin concentrate-clostridium difficile retains C difficile toxin neutralising activity after passage through the human stomach and small intestine. Gut 1999;44:212–7.

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