Understanding diarrhoea
Diarrhoea is defined by the World Health Organisation (1) as the passage of 3 or more, loose, or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passage of formed stools is not to be considered diarrhoea.
Diarrhoea in developed countries is a common indicator of digestive issues. Ranging from food poisoning with its self-limiting process to the indication of a poor digestive disfunction. For example it can indicate irritable bowel syndrome (IBS), a food intolerance, an allergy or overuse of antibiotic medication (2). In less developed countries diarrhoea is life threatening, particularly for young children and the elderly.
Diarrhoea is associated with malabsorption and can be linked to nerve damage. This is apparent when the nerves that control the small intestine are damaged. The most common neurologic diseases are stroke, Multiple Sclerosis, Parkinson’s, and diabetic neuropathy.
Sometimes diarrhoea is a symptom experienced in alcoholism and/or binge drinking. We sometimes observe it being linked to excessive coffee or alcohol consumption.
Diarrhoea may be acute or chronic in presentation. It may even be the early presentation of a chronic problem, serious disorder, allergy, or disease. If you are concerned, please contact your primary care practitioner for further investigation. Gastroenteritis is a non-specific umbrella term used to describe the sudden onset loose stools. Sometimes other symptoms can include nausea and vomiting and diarrhoea can be caused by contact with animals or environmental poisons, viruses, bacteria, or protozoa. Diarrhoea is essentially a symptom, of which there are many probable causes.
How does diarrhoea work?
There are different mechanisms that can cause diarrhoea and more than one may be the evident cause in an affected person. In some ways diarrhoea can be thought of as the intelligence of the body in action as it is often a protective mechanism.
Some of the ways diarrhoea can work:
- Inflammation of the intestinal lining which may have been caused by infection by viruses, bacteria, or protozoa. The natural reaction of the body is to secrete more intestinal fluid into this area. The subsequent watery flowing stools will hurry the infection through the body before it has time to increase in severity (7). Oral rehydration therapy is vital here.
- Osmotic diarrhoea is caused by poorly absorbed solutes in the bowel lumen that block normal water and electrolyte absorption. Poor digestion of certain foods like milk is a common cause of osmotic diarrhoea. Osmotic diarrhoea does not continue if the person fasts.
- Secretory diarrhoea happens because there is an increased secretion of fluid and electrolytes into the intestine with decreased absorption. Infections such as E. coli can cause secretory diarrhoea. If a person fasts, secretory diarrhoea persists.
- Inflammation of the intestinal lining is expressed as damage to the intestinal mucosal cells, which affects the absorption of fluid and electrolytes in the colon, leading to fluid and blood loss. Commonly seen in cases of bacterial infection (Shigella) and IBD. Symptoms that flare-up in the night are common in irritable bowel disease (IBD).
- Increased intestinal motility may produce increased frequency of stool passage without increased volume. Notably expressed in conditions like diabetes and hyperthyroidism. This will accelerate transit time (the time it takes for food to travel from the mouth through to the large intestine). This then reduces nutrient absorption, which may significantly contribute to states of malabsorption and nutritional deficiency.
Understanding the root of diarrhoea
Factors that contribute to diarrhoea
Diarrhoea usually occurs due to an infection in the intestinal tract, 90% is infective diarrhoea and a large percentage of these incidents are viral (3).
Diarrhoea can be associated with certain drugs (proton pump inhibitors, selective serotonin reuptake inhibitors (SSRI’s), laxatives, chemotherapy, magnesium-containing antacids, and metformin (4). Diarrhoea is also a common symptom of acute appendicitis. It may present with other symptoms in coeliac disease although, people with this condition do not always have abdominal issues. Irritable bowel syndrome (IBS) is often expressed as diarrhoea dominant (IBS-D) which can sometimes alternate with constipation. Diarrhoea is a familiar symptom of Inflammatory Bowel Disease (IBD): Crohn’s disease and Ulcerative colitis, two chronic disabling inflammatory diseases of the gastrointestinal tract linked to immune dysfunction (5).
With or without rectal bleeding or bloody stools a persistent change in bowel habit may be an indication of a certain cancer. We advise people who have concerns if their weight changes, and bowel habit changes, to seek medical attention.
Diarrhoea may well be associated with overseas travel and drinking contaminated water. It may need thorough investigation if the person is in a higher risk group: food handlers, nursing home staff & residents, or recently hospitalized people (6).
Diarrhoea can be associated with a sympathetic nerve system dominant picture ‘fight, flight, freeze’ with increased nerves and nervous exhaustion. The malfunction of the thyroid gland (Grave’s disease) can also be associated, and it may frequently accompany states of stress and anxiety.
It is important to differentiate between:
- Acute diarrhoea: Lasting less than 14 days
- Persistent diarrhoea: Lasting more than 14 days
- Chronic diarrhoea: Lasting more than 4 weeks
During this article, we will be referring to diarrhoea in adults, in its acute form.
Signs and symptoms
- Frequent loose/watery stools
- Abdominal spasm
- Cramping
- Pain
- Faecal urgency
- Reduced urination
The Bristol Stool Chart is a medical aid designed to classify faeces into 7 groups, to help give an indication of one’s health.
Types 5-7 on the Bristol Stool Chart indicate diarrhoea indicating an inflammatory process.
To understand the likely course of acute diarrhoea in adults, we should recognize the underlying cause.
- Viral: Self-limiting 2-3 days
- Untreated bacterial: 3-7 days
- Protozoal diarrhoea: Without treatment may last weeks or months
Herbal solutions
Western Herbal Medicine view of diarrhoea
Herbalists observe and appreciate the inherent wisdom of the body. They try to establish the root cause of an issue, and encourage the healing process whilst offering effective support. They help with gentle medicinal plants and a practical therapeutic approach.
Acute diarrhoea with vomiting is not best suited to herbal medicine because the patient will inevitably vomit back the herbal treatment and may consequently become averse to taking herbs (9). Many of the herbs used to treat diarrhoea are high in tannins which are chemicals that give plants their astringency, this action reduces inflammation and constricts and contracts tissues. The tannins bind to the protein layer of the inflamed mucous membranes and cause them to thicken, hence slowing the reabsorption of toxic materials and restricting secretions (10).
Cautions
Always seek immediate professional advice for any of the following symptoms:
- Severe abdominal or rectal pain
- Blood in stool
- Vomiting blood or if a person is unable to retain oral fluids
- If diarrhoea lasts longer than 7 days without improvement or becomes recurrent
- If you suspect dehydration, for example, if you have failed to urinate for 8 hours. Remember, dehydration increases the risk of complications in vulnerable people.
- If you or a close relative or friend have recently travelled abroad.
- If the person is over 60 years (there may be more risk of complications or required additional support.
- Weight loss in chronic diarrhoea is highly suggestive of significant pathology, it may be a symptom of the colon, ovarian or other types of cancer. Always contact your GP for advice.
Chamomile (Matricaria recutita L.)
Parts used: Flowers as a tea
Chamomile is an exceptionally useful healing tool as a tea or tincture for gastrointestinal spasms, because of its antispasmodic, carminative effect. A reliable nervine (nervines simultaneously relax and energize the nervous system), reducing muscular tension, anxiety, and restlessness, mildly analgesic, and a mild sedative action helps to calm and comfort the drinker, and is toning the with a (gentle) bitter principle (11). Chamomile is useful if cytotoxins or mucosal invasion are a part of the pathogenic process. Chamomile tincture and slippery elm (Ulmus rubra) powder are usually indicated (12).
Slippery elm is a soothing demulcent used to reduce inflammation and irritation protecting the mucous membrane of the gastrointestinal tract.
Please note: Slippery elm needs to be sustainably sourced due to being overharvested (13). Some herbalists today prefer to use marshmallow root instead of slippery elm.
Barberry (Berberis vulgaris L.)
Parts used: Root and stem as tincture
Useful in cases of diarrhoea with suspected infection, anti-emetic (prevents nausea and vomiting), broad-spectrum anti-microbial activity, and bitter tonic which supports liver cleansing and therefore healthy digestion (14). Research supports its use for acute infectious diarrhoea with contraindication in pregnancy and for jaundiced neonates (15). Barberry works synergistically with Chamomile tincture.
Cranesbill (Geranium maculatum f.)
Parts used: Root
An effective astringent anti-diarrhoeal plant commonly found and sometimes considered a weed in gardens in the UK. Traditional use includes diarrhoea, dysentery, and haemorrhoids (16). It is rich in tannins making it a useful astringent beneficial to tone and constrict the mucus membranes of the gastrointestinal tract. Reducing inflammation in the tissue’s cranesbill will gently control diarrhoea without risk of aggravating infection or reducing intestinal motility (17). Use internally as tea or tincture.
Blackberry (Rubus villosus T.)
Parts used: Leaves and root bark as tea
Commonly found rambling wild through the UK countryside and frowned upon by gardeners (that aren’t herbalists!). A powerful astringent, the root more so than the leaves. Astringents are useful as they tighten up tissue states which reduces the excretion and leaking of electrolytes and water. The fruit can be consumed cooked with apples and cinnamon during convalescence, as a sweet fruit compote and if sweetener is required use a small amount of maple syrup or honey. Also useful as tincture or syrup.
Bilberry (Vaccinium myrtillus L.)
Parts used: Fruit as a tincture
It makes a delicious tea and a dehydrated snack. In the northern parts of UK bilberries are still found in forests with acidic soil in abundance. With its useful antioxidant, anti-inflammatory and vasoprotective effect, quality bilberries contain both tannins and pectin (18). This makes them a delicious support in cases of acute non-specific diarrhoea which was thought to take place because of rapid ingestion of cold fluids in large quantities, in a hot country or during a hot season, when the body is already hot (19).
Andrographis (Panaculata B.)
Parts used: Leaf and aerial parts are commonly used, but underground stem & root may also be used as medicine.
A bitter tonic, anti-inflammatory, antioxidant, and immunostimulant. Andrographis is supportive to the liver and greatly improves immune function during bacterial and viral infections. Since Andrographis is considered a cooling herb it is ideally suited to treating acute infections, which are ‘hot’ conditions (20).
Interestingly, oral administration of 1g every 12 hours for 2 days was more effective than giving 500mg every 6 hours for 2 days when used in patients with acute diarrhoea (20).
Yarrow (Achillea millefolium L.)
A bitter tonic that is particularly useful in the treatment of gastrointestinal spasms, diarrhoea, and dysentery. Native American Indians used Yarrow infusions internally to support a weak and disordered digestion (21). Yarrow can be considered a plant that regulates digestive disorders, it is anti-inflammatory, astringent and healing. Herbalists use yarrow in sitz baths a digestive tonic, it was referred to as Englishman’s quinine.
Triphala is Sanskrit for “three” (tri) and “fruits” (phala)
With thousands of years of traditional use and held in high regard by Ayurvedic herbalists, triphala is considered the cornerstone of rejuvenating gastrointestinal treatment. Consisting of three fruits in equal parts: amla (Emblica officinalis), bibhitaki (Terminala bellerica), haritaki (Terminala chebula). It is anti-inflammatory, supports healthy gut bacteria and is a supportive bowel tonic (at low doses). Animal studies support its use in the prevention of diarrhoea (22). It is said to restore balance of all three doshas.
Wood betony (Stacchys betonica)
Another bitter tonic that builds up the body’s resources after general debility, with emotional and/or nervous exhaustion. It has an affinity for the liver, although it is known for its affinity to the head improving circulation and easing congestion. Traditionally betony is a stomachic, this is an old medicinal term referring to a plant’s usefulness in toning and improving function of the stomach and improving the appetite (23).
Garlic (Allium sativum L.)
Useful as a garlic honey, useful in capsule form and crushed fresh into soups with other vegetables, rich in proteolytic activity: onions, kale, capsicum, asparagus (27). Garlic has potent anti-inflammatory, antibacterial and antimicrobial properties. As a warming remedy, garlic will enhance an overly ’hot’ constitution and may exacerbate digestive dysfunction that is caused energetically by excessive heat.
Holistic solutions
Treatment strategies
- Rest. Fast. Stay warm and comfortable. Avoid computer screens and overstimulation. Maintain personal hygiene to avoid cross-contamination. Drink lots of herbal tea, this will reduce associated hyperperistalsis, spasm and maintain essential hydration.
- Support the immune system and encourage appropriate function with andrographis or echinacea.
- Convalescence is key when a patient is recovering from acute diarrhoea. When the patient feels strong enough to eat, introduce small soft warm foods, such as rice or carrots, with a small amount of digestive herbs such as cumin, coriander, fennel. According to Naturopath Pizzorno (24). These are binding foods that slow peristalsis (an involuntary wave-like motion that moves faeces through the digestive tract).
- Move around and slowly return gently to ‘normal’ life. The herbalist may suggest herbal baths to support and relax the patient chamomile, sage and lavender are antispasmodic herbs that soothe the nervous system. Chamomile is useful to soothe a tired disposition, sage is more robust, warming, invigorating, and supportive for people with mental confusion. Lavender is deeply relaxing and uplifting and a pleasant antiseptic, relieving stress and anxiety.
- Foot baths are therapeutically beneficial if the patient has no access to a full-sized bath. Water and electrolyte balance is important, and a salt/sugar solution in the foot bath may be employed (25).
- During diarrhoea, probiotics are not recommended but after the experience has found a healthy resolution. Improve microbiome with diet, kefir, probiotics and prebiotics, burdock and dandelion root tea every morning would support gut ecology, improving intestinal barrier integrity.
- Prioritise regular exercise, good quality sleep and eating an organic wholefoods diet to build and maintain good health. This will help you to develop long term resilience and prevent illness.
Dietary strategies
- Resume a wholesome balanced diet a homemade sugar/salt/water solution will replace lost electrolytes. Soups and stews are all important, providing appetite is sustained. Carbohydrate consumption is important to drive water and sodium absorption in the small intestine.
- Pectin is a soluble fibre that adds bulk to stools and soothes the gut.
- Malus domestica and Cinnamomum verum (apples and cinnamon powder). Keep apple skin on to maintain the pectin. Cook gently in a small amount of water to create a mush.
- Cooked carrots are an age-old remedy for diarrhoea (26). Also rich in carotenes and essential ingredient for correct immune function. Make a soup and garlic, turmeric and black pepper). Enjoy!
References
- World Health Organisation [WHO] (2017). Diarrhoeal Disease. [online] Available at: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease [Accessed 12 October 2022].
- Elvers.K. et al. (2020). Antibiotic-induced changes in the human gut microbiota for the most commonly prescribed antibiotics in primary care in the UK: a systematic review. BMJ Open. 10(9):035677.
- Farthing,M. MD. (2019). Management of Acute Diarrhoea in Adults: A Global Perspective. [online] Available at: https://www.youtube.com/watch?v=bL8swIDbVEo [Accessed 4 November 2022].
- National Institute for Health and Care Excellence [NICE] (2021). Diarrhoea – Adults Assestment. [online] Available at: https://cks.nice.org.uk/topics/diarrhoea-adults-assessment/ [Accessed 11 October 2022].
- Wen, Z. & Fiocchi, C. (2004). Inflammatory Bowel Disease: Autoimmune or Immune-mediated Pathogenesis? Clinical & Developmental Immunology. [pdf] Vol 11(3/4), pp,195-204[Accessed 14 October 2022].
- National Institute for Health and Care Excellence [NICE] (2021). Diarrhoea – Adults Assestment. [online] Available at: https://cks.nice.org.uk/topics/diarrhoea-adults-assessment/ [Accessed 11 October 2022].
- Campbell, J. (2011) Campbell’s Physiology Notes(2nd Edition). Great Britain: Bell & Bain.
- Continence Foundation of Australia (2021). Bristol-Stool-Chart. [online] Available at: https://www.continence.org.au/bristol-stool-chart
- Bone & Mills (2013). Principles and Practice of Phytotherapy:Modern Herbal Medicine(2nd Edition). UK: Churchill Livingstone.
- Duke, J. (1997). The Green Pharmacy. UK: Bath Press.
- Bone, K. (2002). A Clinical Guide to Blending Liquid Herbs. Missouri: Churchill Livingstone.
- Bone & Mills (2013). Principles and Practice of Phytotherapy: Modern Herbal Medicine (2nd Edition).UK: Churchill Livingstone
- International Union for the Conservation of Nature [IUCN] (2018). Slippery Elm. [online] Available at: https://www.iucnredlist.org/species/61967382/61967384 [Accessed 2 November 2022].
- Bone, K. (2002). A Clinical Guide to Blending Liquid Herbs. Missouri: Churchill Livingstone.
- Bone, K. (2021). Functional Herbal Therapy: A Modern Paradigm for Clinicians. London: Aeon Books Ltd.
- Bone, K. (2002). A Clinical Guide to Blending Liquid Herbs. Missouri: Churchill Livingstone.
- Bone & Mills (2013). Principles and Practice of Phytotherapy: Modern Herbal Medicine(2nd Edition).UK: Churchill Livingstone.
- Bone, K. (2002). A Clinical Guide to Blending Liquid Herbs. Missouri: Churchill Livingstone.
- British Medical Journal, BMJ. (1947). Acute nonspecific diarrhoea and dysentery: Local chilling of the abdomen as a causative factor. [pdf] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2053389/pdf/brmedj03782-0013.pdf [Accessed 02 November 2022].
- Bone & Mills (2013). Principles and Practice of Phytotherapy: Modern Herbal Medicine (2nd Edition).UK: Churchill Livingstone
- Bone, K. (2002). A Clinical Guide to Blending Liquid Herbs. Missouri: Churchill Livingstone.
- Tara Peterson, C. et al. (2017). Therapeutic uses of Triphala in Ayurvedic Medicine. J Alternative Complement Med. 23(8): pp.607-614.
- The Hospital. (1890). The History and Capabilities of Herbal Simples. [pdf] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5236853/pdf/hosplond69274-0010a.pdf [Accessed 1 November 2022].
- Pizzorno, J. et al. (2016). The Clinician’s Handbook of Natural Medicine (3rd Edition). Missouri: Elsevier.
- World Health Organisation [WHO] (2017). Diarrhoeal Disease. [online]
- Available at: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease [Accessed 12 October 2022].
- Duke, J. (1997). The Green Pharmacy. UK: Bath Press.
- Bone, K. (2021). Functional Herbal Therapy: A Modern Paradigm for Clinicians. London: Aeon Books Ltd.
