Normal bowel movements occur once or twice in day, the stool is passed out with ease and is well formed, firm and brown in color. It is still normal to pass out bowel movements less frequently or more often provided that there is no straining, pain, very hard and dry or very loose and watery stool. Diarrhea is defined as the passage of more than 200g or 200ml of stool usually in three or more movements in a day.
It is not uncommon to experience diarrhea for various reasons several times in life and it remains one of the most common intestinal disorders. However, diarrhea is more often acute, lasting for just a few days, and resolves quickly on its own or with medical treatment and further complications rarely arise. Diarrhea is a sign of an underlying gastrointestinal or systemic disturbance and always needs to be investigated thoroughly if it is persistent or recurrent.
What is Recurrent Diarrhea or Repeated Diarrhea?
Recurrent diarrhea or repeated diarrhea is any large volume of stools, frequent bowel movements and/or watery loose stools that arise and resolve over and over again. It can be further defined as chronic diarrhea, when it recurs frequently for more than 2 weeks but should be differentiated from persistent diarrhea (constant diarrhea) which does not resolve even for a few days. Recurrent diarrhea resolves completely for a days or weeks before arising again. During these “normal” periods in-between, the bowel movements are fairly normal and the stool is well formed. Persistent diarrhea may ease slightly for short periods but does not return to normal.
Initially there is confusion among patients whether repeated bouts of diarrhea are due to the same causes or not. The more common causes of acute diarrhea are infections (gastroenteritis), food poisoning, unusual foods that deviates from a person’s normal diet and certain drugs. The diarrhea typically lasts for less than 4 days and is unlikely to recur if the causative organism or factor has been eradicated or removed. Complications may, however, arise which can further aggravate the diarrhea or allow it to persist beyond the acute phase. Persistent diarrhea on the other hand tends not to be as severe and therefore allows a person to go for a period of time without acute complications arising.
Signs and Symptoms
The form of the stool and frequency of bowel movement varies among patients with recurrent diarrhea. Some may experience episodes of severe diarrhea characterized by violent bowel movements of watery stool (explosive diarrhea) that is uncontrollable. Others may experience only mild diarrhea with loose but not watery stool and more frequent than normal bowel movements in a day. Recording of symptoms and keeping a food diary are important tools to assist with a diagnosis and identify trigger factors that may be uncharacteristic of the underlying disease.
Other symptoms that may appear during the bouts of diarrhea may include :
- Vomiting, although this is unlikely to be severe if at all present. However, in acute infectious diarrhea vomiting is a prominent feature that often precedes the onset of diarrhea and is violent.
- Abdominal pain
- Bloating – sensation of fullness
- Abdominal distension
- Excessive flatulence, possibly accompanied by excessive belching
- Signs of dehydration
Causes of Recurrent Diarrhea
Infections that typically cause acute diarrhea may persist and cause constant diarrhea. It is unlikely to cause recurrent diarrhea unless there are repeated new infections. Surgical resection of the stomach or bowels and tumors in these organs may also cause diarrhea but this is usually persistent and may aggravate with certain foods, drugs, substances and stresses.
Drugs and Substances
The use or misuse of drugs and substances can cause acute, persistent or recurrent diarrhea. This largely depends on the type and manner in which these drugs or substances are used. Use for short periods may cause acute diarrhea or even persistent diarrhea if it disrupts the intestinal flora (normal bowel bacteria) as is seen with antibiotic use. Recurrent diarrhea may correlate with the period of use of these drugs and substances. This may include :
- Antacids, particularly those containing magnesium.
- Antibiotics, repeat courses.
- Prostaglandin analogues for gastric or duodenal ulcers.
- Analgesics used intermittently for pain
- Caffeine, episodes of excessive intake or occasional use in a sensitive person
- Alcohol, episodes of excessive intake (binge drinking)
Dietary changes may cause acute bouts of diarrhea that are recurrent if the irritant is consumed regularly. Spicy foods are a common cause but is dependent on individual tolerance. At times this can be due to excessive consumption of otherwise commonly eaten foods. Chewing gum is another known irritant if consumed in excess. These irritant foods are not associated with food intolerance and malabsorption described below. Therefore patients who notice specific food substances, like milk, wheat and fruit sugar, that can cause diarrhea in even small amounts should undergo further investigation for food intolerance and malabsorption.
Food Intolerance and Malabsorption
Conditions like lactose intolerance, gluten intolerance and fructose malabsorption may lead to repeated episodes of diarrhea when these foods are consumed. Patients are usually aware of the condition as it is almost always chronic in nature. Therefore there is tendency to avoid these foods as far as possible. However, at times it may be consumed unknowingly or purposely and can cause diarrhea.
There are a wide range of causes of malabsorption syndromes and most of these that cause diarrhea tend to present as persistent diarrhea. This may include conditions such as pancreatic insufficiency, recurrent gallstones and other gallbladder disease, celiac sprue and the enteritis. Certain foods are more likely to exacerbate diarrhea but it can be episodic if the condition tends to aggravate for short periods (flareups).
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the small and large intestine. The exact cause is unknown but it is related to an immune-mediated response directed at the wall of the bowels. There are frequent aggravations characterized by severe diarrhea among other gastrointestinal symptoms. This may occur spontaneously or arise with certain triggers like stress, alcohol, caffeine and nicotine use, certain foods and other unknown factors.
Functional bowel disorders are disturbances in bowel function despite no detectable abnormalities. Irritable bowel syndrome (IBS) is a typical example of a functional bowel disorder and is a common condition that is seen globally. The disturbances in bowel movement may vary and therefore IBS is classified as diarrhea-predominant or constipation-predominant.
In diarrhea-predominant IBS, the patient may present with recurrent episodes of diarrhea which may persist for varying periods of time. It is often associated with stress, alcohol use, certain foods that may be unique to each case and may arise with other, even non-digestive, conditions. There may be no identifiable pattern to the bouts of diarrhea. The condition tends to persist for years or even throughout life.
Psychological causes may vary and is often associated with periods of anxiety, nervousness and depression. Mood changes can lead to bouts of loose stool or frequent defecation that may not always fit the definition of diarrhea but is nevertheless out of the norm.
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