Chronic Diarrhea

What is Chronic Diarrhea?

Chronic diarrhea is loose or watery stool, usually three or more times in 24 hours, that lasts four weeks or longer.^[1] It is a symptom with many possible causes and not one disease, which is why most people need some medical evaluation.^[2]

Common symptoms

People describe chronic diarrhea in different ways, including loose stool, more frequent stools, urgency and incontinence.^[2] Cramping and bloating often come with it.^[3]

Dehydration, weight loss or blood in the stool are signs that a physician needs to look for a specific cause.^[2]

Causes and risk factors

Chronic diarrhea has a broader range of causes than short-term diarrhea, which is often a self-limited infection.^[2] Diet, medicines, and past surgery or radiation can be important causes, and some can be suspected from the history alone.^[2] Others include irritable bowel syndrome, inflammatory bowel disease, celiac disease, bile acid diarrhea and organic disease.^{[2, 4]}

Irritable bowel syndrome with diarrhea (IBS-D) is a common cause. It is a gut-brain disorder in which pain is linked to bowel movements and stool form or frequency changes.^{[2, 3]}

How it is diagnosed and treated conventionally

A physician starts with your history and an examination, and then chooses tests such as blood and stool tests, endoscopy or imaging when alarm features are present or the cause is not obvious.^[2] Treatment follows the cause.^[4]

For functional diarrhea, Japanese guidelines place lifestyle and diet changes first, then probiotics and antidiarrheal drugs, and note that several other options, including Kampo herbal medicine, lack sufficient evidence.^[4] When no specific treatment is available, antidiarrheal medicine can be used to reduce symptoms.^[2]

Why Chronic Diarrhea calls for a whole-person approach

Chronic diarrhea is often more than a problem of the bowel alone. Gut movement, sensitivity, microbes, food, medicines and the brain-gut connection all contribute, so people often need more than one kind of support.^{[2, 3]}

Complementary care is a reasonable addition once a physician has found or excluded serious causes.

The brain-gut axis

In irritable bowel syndrome, disruptions in brain-gut signaling are part of the picture, along with visceral hypersensitivity and altered gut movement.^[3]

Gut microbes and food

Changes in gut microbes and food intolerances are also thought to contribute to irritable bowel syndrome.^[3] This is one reason diet changes and probiotics are used in conventional care.^[4]

Stress, anxiety and mood

IBS-D can affect mental health, and anxiety and depression often occur alongside it.^{[5, 6]} Guidelines for IBS include psychological interventions when indicated.^[3]

Medicines and other causes

Medicines, laxative overuse and other health conditions can cause chronic diarrhea, so your medication list is part of the evaluation.^[2]

Acupuncture for Chronic Diarrhea

What the research shows

Research suggests acupuncture may improve symptoms of diarrhea-predominant irritable bowel syndrome and functional diarrhea, although most trials come from China and many have weaknesses. The trials did not study every cause of chronic diarrhea, so this evidence does not apply to diarrhea from infection, inflammatory disease or other organic disease.

A 2020 meta-analysis of 31 studies (3,234 adults) with IBS-D or functional diarrhea rated the certainty of evidence as moderate or low. Acupuncture beat loperamide for weekly bowel movements, with no significant difference in stool form, and beat some other drugs for total symptom score and quality of life. The authors said stronger evidence is needed.^[7] More adverse effects occurred with acupuncture in some comparisons, mostly mild bleeding under the skin.^[7]

A multicenter trial in China randomized 531 people with irritable bowel syndrome, with separate groups for diarrhea and constipation predominance, to 18 sessions of acupuncture over 6 weeks or to standard medicine. Acupuncture lowered symptom severity more, with effects lasting up to 12 weeks, though it had no sham comparison.^[8] A meta-analysis of 16 trials in IBS-D with anxiety and depression also favored acupuncture over oral medicine for symptoms, anxiety and depression, but it compared acupuncture only with medicine, not with sham treatment.^[6] Moxibustion, a traditional heat therapy, has also been studied in IBS-D, with a meta-analysis of 11 trials calling for more rigorous research.^[9]

How acupuncture may work

Researchers propose that acupuncture acts on gut movement, visceral hypersensitivity, the immune system, neurotransmitters and the brain-gut axis, including gut microbes.^[10] Reviews of electroacupuncture describe its effects on gut movement as an area still being studied, with controversial results in the literature.^[11] These are proposed explanations, drawn from both laboratory and clinical studies, not settled facts.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes. The large trial gave 18 sessions over 6 weeks.^[8] We reassess after a short course of visits.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker, which matters for electroacupuncture.

Ayurvedic medicine for Chronic Diarrhea

The Ayurvedic view

In Ayurveda, chronic loose stools are traditionally described as Grahani or Atisara, linked to weak digestive fire (agni) and disturbed Vata, Pitta or Kapha, depending on the person. These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Simple, warm, easily digested meals at regular times, and attention to hydration
• A steady daily routine, adequate sleep and stress-reducing practices
• Individually prescribed herbs for digestion, which are reviewed against your medicines first
• Mild oil massage of the abdomen

Panchakarma procedures such as purgation and medicated enemas are not appropriate for chronic diarrhea, since they can worsen fluid loss. They are also not appropriate in pregnancy, acute illness or frailty.

What the research shows

The research is limited and mixed, and nearly all of it is in irritable bowel syndrome, not in other causes of chronic diarrhea. A placebo-controlled crossover trial of 32 people with IBS-D tested an Ayurvedic mix of curry leaf, pomegranate and turmeric for 4 weeks and found no difference from placebo.^[13] A small trial of 48 people with IBS compared a whole-system Ayurvedic protocol with a single herbal powder, and the whole-system group improved more, but the comparison was not a placebo.^[14] A Cochrane review of herbal medicines for irritable bowel syndrome included one Ayurvedic preparation that improved global symptoms compared with placebo.^[15]

Herbal medicine for Chronic Diarrhea

Herbs and formulas that have been studied

Most herbal research is in IBS-D, not in all chronic diarrhea. One Chinese formula that has been studied is Tongxie Yaofang, made of four herbs: white atractylodes, white peony, tangerine peel and saposhnikovia root.^[5] Chinese herbal therapies that combine soothing the liver with strengthening the spleen have also been compared.^[16]

What the research shows

The evidence is limited and comes mostly from lower-quality trials in China. A 2022 review of 11 trials (985 adults) found Tongxie Yaofang was better than placebo and Western medicine for overall symptom improvement, with moderate-certainty evidence, but the authors said trial design was inadequate for a firm conclusion.^[5] An earlier meta-analysis of 23 trials of a modified version found better results than routine drugs, and also asked for higher-quality trials.^[17] A network meta-analysis of 14 double-blind placebo-controlled trials found some Chinese herbal approaches improved symptoms, and noted small samples and likely geographic publication bias.^[16]

A Cochrane review of 75 trials of herbal medicines for irritable bowel syndrome found some herbal medicines may improve symptoms but said positive findings from weaker trials need caution.^[15]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. A review describes bleeding when warfarin was combined with dan shen or ginkgo, and lower levels of the immune-suppressing drugs ciclosporin and tacrolimus with St. John's wort.^[18] Herbal and dietary supplements account for about one fifth of drug-induced liver injury cases in the United States.^[19]

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Some herbs act as laxatives and can worsen diarrhea, so tell us about every supplement. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes chronic diarrhea as spleen deficiency, sometimes with liver qi stagnation, which is the pattern Tongxie Yaofang and related formulas are designed to address.^{[5, 16]} Researchers studying these approaches look at gut movement, visceral sensitivity, brain-gut signaling and neurotransmitters such as serotonin.^{[10, 16]}

Ayurveda's weak agni and disturbed Vata or Pitta describe poor digestion and bowel irritability. No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for chronic diarrhea is complementary. Please have the cause of persistent diarrhea evaluated by a physician before or alongside any complementary care.^[2] We do not diagnose the cause of diarrhea.

Keep your physician or gastroenterologist, and do not stop or change prescribed medicines without your prescriber. Please bring your diagnosis, stool, blood and colonoscopy results, a full list of medicines and supplements, and a note of foods that seem to trigger symptoms.

When to seek urgent medical care

Chronic diarrhea with alarm features needs prompt testing.^[2]

• Blood in the stool, or black, tarry stools
• Unexplained weight loss
• Fever with diarrhea
• Diarrhea that wakes you at night or is severe and watery
• Signs of dehydration such as dizziness, very dark urine or a very fast heartbeat
• Severe or worsening abdominal pain

If you have any of these, contact your physician right away. For emergencies, call 911 or go to the nearest emergency department.