Diarrhoea (Loose Motions)

Diarrhoea is a symptom that indicates a gastrointestinal infection. It can be caused by bacteria, viruses, as well as, parasites. However, other health conditions can also cause loose stools. Diarrhoeal diseases are responsible for over 500,000 deaths annually in children under five years of age, thus, making it the second leading cause of death in children globally. Diarrhoea is responsible for more than 2000 deaths in children in a day, which is more than childhood deaths due to malaria, measles, and AIDS combined. Acute diarrhoea can last several days to a few weeks. It can lead to severe fluid loss and dehydration, which if not treated in time may also be fatal.

What is diarrhoea?

Diarrhoea is a symptom of an underlying gastrointestinal disorder. It is defined as the passage of three or more loose stools in a day. Some people have frequent normal bowel movements in a day. This does not mean that they have diarrhoea.

Clinically, there are three types of diarrhoea:

• Acute diarrhoea
  This type of diarrhoea begins suddenly and typically lasts several hours or up to 15 days. It is usually caused by a bacterial or viral infection.
• Acute bloody diarrhoea
  This is also known as dysentery, in which loose stools are mixed with blood.
• Persistent or chronic diarrhoea
  Loose stools lasting fourteen days or more is known as chronic or persistent diarrhoea. Chronic diarrhoea is usually a sign of an underlying inflammatory or chronic bowel condition.

Diarrhoea is itself a symptom of an underlying gastrointestinal disorder. However, it may be accompanied by other symptoms such as:

• Abdominal cramps.
• Stomach pain.
• Abdominal bloating.
• Increased thirst.
• Weight loss.
• Fever.
• Nausea.
• Sudden urge to evacuate bowel.

Other serious symptoms may also be associated with loose stools. These include:

• Presence of blood in the stool.
• Persistent vomiting.
• Dehydration.

It is best to see a doctor if:

• Diarrhoea persists over two days.
• Signs of dehydration are noticed.
• Severe pain in the abdomen or rectum.
• Stools are black or bloody.
• Presence of fever, over 102°F.

In very young children, loose stools can lead to dehydration rapidly. Hence, if the symptoms do not get better within 24 hours, it is best to consult a doctor.

Causes

The various factors that cause diarrhoea include:

• Viruses
  In children, rotavirus infection is the most common cause of diarrhoeal diseases. Cytomegalovirus, Norwalk virus, and viral hepatitis like hepatitis A are some of the other common viruses that cause acute diarrhoea.
• Bacteria and parasites
  In people with dysentery, Shigella is the main causative organism. As per the World Health Organization (WHO), Shigella causes approximately 10% of all acute diarrhoea cases in children. Other common organisms causing dysentery or loose bloody stools are Campylobacter, Salmonella, and Escherichia coli. Parasites like Giardia also cause loose stools. 
• Lactose intolerance
  Some people are not able to digest milk in any form due to a sharp decrease in the enzymes which break down lactose, a type of sugar found in milk and dairy products. People with lactose intolerance complain of loose stools after consuming dairy products. Hence, lactose intolerance increases with age.
• Fructose
  Fructose is a natural sugar found in fruits. It is also found in some artificial sweeteners. Individuals who are unable to digest fructose may have loose stools after consuming fructose-rich fruits and artificial beverages. 
• Medicines
  Many antibiotics can cause diarrhoea. Antibiotics destroy both the good and bad bacteria present in the gut. This disturbs the natural microbe balance in the intestines leading to diarrhoea. Cancer drugs and medicines such as antacids containing magnesium may also lead to diarrhoea.
• Artificial sweeteners
  Chewing gums and sugar-free products contain mannitol and sorbitol, which are artificial sweeteners that can cause loose stools in some people.
• Digestive disorders
  Diseases affecting the intestines often cause chronic diarrhoea. Conditions like Crohn’s disease, coeliac disease, ulcerative colitis, diverticulitis, irritable bowel syndrome, and microscopic colitis can cause loose stools that can persist for a long time. 
• Surgery
  Surgical procedures to remove the gallbladder, shortening of the bowel due to surgical removal of a part of the intestine and other abdominal surgeries may result in diarrhoea in some patients.
• Others
  Other causes of diarrhoea include:
  • Use of stimulants.
  • Alcohol.
  • Chronic pancreatitis.
  • Poorly controlled diabetes.
  • Radiotherapy.

Risk factors

The risk factors of diarrhoea include:

• Demography
  Diarrhoea is more common in younger children and the incidence rate decreases with age. The rate of occurrence is highest in babies in the age-group of 6 to 11 months. Loose stools are more common in young males than females. Other factors like maternal age (younger mothers), low education level of mothers, early weaning, and more number of babies are associated with higher chances of diarrhoea.
• Socio-economic factors
  Poor housing facilities, low-income families, and crowded living conditions have shown a higher rate of diarrhoea.
• Water-related issues
  Diarrhoea caused by microorganisms spreads through contaminated food and water. Hence, factors like poor water storage, using unsafe water sources, and storing water in wide containers increasing contamination are strong risk factors.
• Sanitation and hygiene
  Improper disposal of garbage, lack of hygienic latrine facilities and sewage system at home increase the risk of diarrhoeal diseases.
• Hygiene
  Poor hygiene practices like not washing hands before meals and after defecating, household members not washing hands while cooking or feeding, children eating with unclean hands, dirty feeding bottles, the presence of flies and animals inside the house are associated with higher rates of diarrhoea.
• Eating habits
  Eating street food, uncooked food, raw meat and drinking unfiltered water increase the risk of diarrhoea. Travellers visiting foreign countries, especially tropical regions with poor sanitations can get diarrhoea.
• Seasons
  In the summer and winter seasons, the concentration of bacteria and viruses is very high, respectively, making people more susceptible to infections. The risk of loose stools is also higher in the rainy season.
• Breastfeeding
  The risk of diarrhoea is low in babies who are exclusively breastfed. The risk increases with partially breastfed babies and those who are weaned off early. The risk is highest in fully weaned children. Another risk of diarrhoea is linked with bottle fed babies.
• Malnutrition
  The link between malnutrition and diarrhoea in low-income families is very high causing both these factors to be part of a vicious circle. Malnutrition leads to poor immune systems making such individuals prone to infections. Chronic diarrhoea leads to poor nutrition, nutrient absorption, and health. 
• Immunodeficiency
  HIV infection is a major cause of diarrhoea not only in children, but also in adults. Cases of diarrhoea are as high as 60% in people affected with AIDS. Diarrhoea in HIV infected children has a poor prognosis and such children have a low chance of survival.

The following measures should be taken to prevent future occurrence of diarrhoea

• Drinking boiled (properly filtered) water.
• Improved sanitation.
• Good hygiene practices.
• Promoting handwashing with soap and water before and after using the bathroom, and before handling food.
• Community health education about infections.
• Rotavirus vaccination in children.
• Ensure availability of oral rehydration solution to all.
• Facilities for the disposal of waste.
• Encouraging proper antibiotic use to prevent diarrhoea.
• Construction of latrines, septic tanks, and disposal system.
• Discouraging people from defecating in the open.

The doctor will establish a diagnosis on the basis of medical history, physical examination, and investigative tests to find the cause of diarrhoea in a person.

• Physical examination
  After a complete medical history is obtained, the doctor will check for signs of dehydration by examining the blood pressure, pulse, body temperature and listen for bowel sounds in the abdomen. The doctor will also examine the abdomen to look for pain and tenderness. In some cases, the doctors will perform a rectal examination to check for causes that may lead to blood in the stool.
• Stool examination
  Stool examination will reveal the exact cause of diarrhoea as it can detect the presence of bacteria, viruses, parasites, and blood.
• Hydrogen breath test
  People who are lactose intolerant will be asked to undergo the hydrogen breath test. Undigested lactose will produce elevated levels of hydrogen which will confirm the cause of diarrhoea.
• Allergy tests
  If the doctor is suspecting diarrhoea due to a food intolerance or an allergy, specific allergy tests will be required to make a diagnosis of the underlying cause.
• Endoscopy
  In some people, doctors perform an endoscopy like colonoscopy and upper gastrointestinal endoscopy to find out the cause of diarrhoea.

The treatment modality for different types of diarrhoea is given below:

• Acute diarrhoea
  Acute diarrhoea can be treated with over-the-counter medicines. However, people who have bloody stools or fever along with diarrhoea should not opt for over-the-counter medicines. If the diarrhoea persists for over 2 days, it is best to visit a doctor.
• Acute diarrhoea in children
  Treating childhood diarrhoea with over-the-counter drugs can be harmful, especially in infants and toddlers. Speak with a doctor or a paediatrician before administering the medicine. If the symptoms last for over 24 hours, visit a doctor. 
• Chronic and persistent diarrhoea
  Treatment of chronic and persistent diarrhoea depends on the cause. Several antibiotic medications that kill or prevent the growth of parasites and bacteria are prescribed. Specific medicines for diarrhoea that is due to Crohn’s disease, ulcerative colitis and irritable bowel syndrome are also prescribed.

Lifestyle management

Certain lifestyle changes can resolve symptoms of diarrhoea quickly and prevent them in the future. These include:

• Reducing the chances of infection by:
  • Washing hands with soap after using the bathroom.
  • Washing hands before and after cooking, and after changing diapers.
  • Drinking boiled or bottled water.
  • Drinking hot beverages.
  • Giving infants and children age-appropriate diet.
  • Exclusive breastfeeding up to 6 months.
  • Proper storage and handling of foods.
• Avoiding:
  • Tap water for drinking.
  • Using tap water to make drinks, juices, and ice.
  • Drinking unpasteurized milk.
  • Eating roadside food.
  • Eating raw and uncooked food and meat.
  • Alcoholic beverages.
  • Spicy foods.
  • Fruits like apples and pears.
  • Caffeinated drinks.
  • Dairy foods.
  • Diet cola drinks, candies, and gums containing artificial sweeteners.
• Preventing dehydration by:
  • Oral Rehydration Solution (ORS)
    The ORS solution is a mixture of water and electrolytes which is given to a person to restore the loss of fluids due to diarrhoea. It is the best treatment for diarrhoeal diseases, irrespective of the cause. Readymade ORS sachets are available in pharmacies, but if they are not available, an ORS solution can also be prepared at home by mixing 6 teaspoons of sugar and ½ teaspoon of salt in 1 litre of potable water (boiled and cooled). Children under the age of 2 years should drink at least 1/4th to ½ a cup of ORS after every loose stool. Those above 2 years can take ½ to a full cup of ORS after every stool safely.
  • Supplements
    Vitamin A supplements are recommended in HIV infected children with diarrhoea, aged between 6 months to 5 years. A combination of vitamin A, zinc, and other vitamins are sometimes prescribed to children to prevent diarrhoea.
  • Rotavirus vaccination
    Oral rotavirus vaccines are administered to children in multiple doses to prevent diarrhoeal diseases. These vaccines have reduced the incidence of hospitalization due to rotavirus infection in children.

Prognosis

Prognosis of diarrhoeal diseases depends on the cause. Acute diarrhoea resolves quickly with prompt treatment and rehydration therapy. Prognosis of chronic and persistent diarrhoea differ with the cause and the condition of the person.

Complications

The most potential complications of diarrhoea are dehydration and malabsorption. All these signs and symptoms can be life-threatening and hence require immediate medical attention. The symptoms include:

• Symptoms of dehydration:
  • Increased thirst.
  • Less urination.
  • Tiredness.
  • Sunken cheeks and eyes.
  • Feeling of faintness.
  • Dryness of mouth.
  • Dark coloured urine.
  • Loss of skin turgor- when the skin is pinched, the skin does not return to normal immediately.
• Symptoms of dehydration in infants, toddlers and children
  • No tears while crying.
  • Less urination.
  • Increased thirst.
  • Dryness of mouth.
  • Weakness and loss of energy.
  • No wetting of diapers for 3 hours or more.
  • Sunken eyes and cheeks.
  • Soft spot in the skull.
• Symptoms of malabsorption in children and adults
  • Change in appetite.
  • Gas and bloating.
  • Greasy stools.
  • Weight loss.