Diarrhea is when you have loose, watery stools or a frequent need to have a bowel movement. It is one of the most common symptoms of IBD.
Diarrhea can reflect the frequency at which you go to the washroom, the volume of stools that is being passed, the urgency of passing stools, or a combination of these factors. Therefore, it is important to describe what you are experiencing that when you talk to your healthcare provider about this symptom of IBD.
Causes related to IBD
It is important to treat the underlying disease, that is treat the gut inflammation, in cases of active Crohn's or active colitis.
During an IBD flare, the lining of the intestine becomes inflamed and cannot absorb all fluid. This results in stools being loose and watery, or even entirely liquid. The looser stool can also move more rapidly through the colon, causing more frequent bowel movements.
In general, people who have extensive inflammation of the colon (large intestine) or small intestine are more likely to have persistent diarrhea and urgency, rectal bleeding (bleeding from anus), and abdominal cramping. In ulcerative colitis, blood in the stool is common with diarrhea.
Causes not related to IBD
It is also important to take into account factors that are not directly related to IBD but that could still cause diarrhea. These non IBD-related causes of diarrhea can include:
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side effects of medications.
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bile acid malabsorption. This issue is more common in people who have had surgery to remove parts of the small bowel.
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small intestinal bacterial overgrowth (SIBO). This happens when bacteria take up residence in parts of the bowel where they are not supposed to be. There, they interfere with your digestion and compete with you for your food and in doing so, cause diarrhea.
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changes in diet and dietary intolerances. Examples include lactose and dairy products, fructose (e.g. corn syrup, fruits), caffeine, sweetener (e.g. sorbitol, sugar-free gum or candy), and alcohol. Too much fibre and fats can also lead to diarrhea.
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gut-brain axis. It could happen that changes in your bowel movements are reflective of your body's way of dealing with stress.
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infections (e.g., Clostridium difficile, which can arise after use of antibiotics).
It is important to identify the triggers of frequent and persistent diarrhea. Talk to your healthcare provider to help determine the cause of your diarrhea, and find out if you need testing for IBD inflammation.
Find out the underlying cause
Your healthcare provider will first consider the potential causes of your diarrhea in order to adjust your treatment. For example, if your IBD is active and causing inflammation, it may result in diarrhea and your treatment plan may be adjusted to deal with this symptom.
Changing your diet
In terms of diet, it may be helpful if you eat frequent, small meals. Try to sit for at least 15 to 20 minutes after meals, as it can slow down peristalsis – the rate that food passes through the gut.
Some people experience diarrhea after eating foods containing gluten, dairy, spice, fat, or high amounts of fibre. Dairy and fibre can be important to your nutrition, so speak to your physician and dietitian if you need to reduce their intake.
Examples of foods that may produce loose stool include dried beans, corn, raw vegetables, cabbage or spinach, dried fruits or foods that contain high fructose, bacon, processed meats, chips, and fried foods.
Drinks containing fructose, caffeine, alcohol, or carbonation can also trigger diarrhea so try limiting those.
If you are experiencing diarrhea, try to include foods with sodium and potassium daily. Foods that may help control diarrhea include boiled or mashed potatoes (also contains potassium), bananas or banana flakes (contains potassium), rice, noodles or pasta, peanut butter, white bread, and lean meats. Broth can help maintain hydration (it also contains sodium).
If you are experiencing persistent diarrhea, you could also discuss the possibility of trying the BRAT diet which consists of eating a banana, rice, applesauce, and toast, with your dietitian.
Try tracking what you eat, to help identify foods or fluids that may be bothersome and triggering your diarrhea. Check out our MyGut app to help you track your diet and food intake.
It is important to remember that one diet does not fit all people with Crohn's or colitis, and general dietary advice may not work for you. Visit our Diet and Nutrition section for more information.
Medications
If tests show your diarrhea is related to inflammation from IBD, medications to control disease activity include aminosalicylates (also called mesalamine or 5-ASA), corticosteroids such as prednisone, immunomodulators, and biologics. Visit our Treatment and Medication section for more information.
Other medications may include the antidiarrheal agents, loperamide or diphenoxylate. These help slow motility – movement of contents through your intestines – and increase the absorption of fluids and nutrients. Do not take antidiarrheals during a flare-up without your doctor’s advice, as they may cause further complications.
Fibre supplements may be helpful as they mix with water to form a gel, and that reduces looseness as well as frequency.
Examples of such medications and supplements to treat diarrhea include:
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Opioid anti-diarrheal - Loperamide (Imodium®), diphenoxylate (Lomotil®), eluxadoline (Viberzi®).
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Bile salt resins - Cholestyramine (Olestyr®), colestipil (Colestid®), colesevelam (LodalisTM).
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Spasmolytics - Pinaverium (Dicetel®), trimebutine (Modulon®).
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Probiotics (e.g. Align®).
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Antibiotics (e.g. Xifaxan®).
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Psyllium (Metamucil®).
Talk to your healthcare provider before starting any prescribed or over-the-counter medications for the treatment of diarrhea.
Avoiding dehydration
When you are having diarrhea, make sure to drink a lot of water and electrolytes to replace the lost fluid. You may also want to consider drinking an oral rehydration solution to help replenish any lost sugars and salts.
These solutions include three main ingredients: water, electrolytes or ‘salts’ which are chemicals your body needs to function normally, and carbohydrates, usually in the form of sugar. Packets of oral rehydration salts are available in pharmacies in most countries.
Signs of dehydration include thirst, less frequent urination, dry skin, persistent fatigue, light headedness, and dark-coloured urine.
Managing expectations
There are cases where you will not be able to get rid of diarrhea. For example, people who have a ileoanal pouch (where the small bowel is connected to the anus) are highly likely to experience diarrhea. The average person in this situation would go to the washroom about eight times a day to pass loose stools.
In these cases, it would be advised to talk to your healthcare provider about how you could manage this expectation of frequently experiencing diarrhea to improve your quality of life.
Many people with Crohn's or colitis experience an urgency to have a bowel movement that arises frequently during the day. People with colitis may also an extremely urgent need to expel feces, and yet, when they try to do so, they find out that they only have a small amount to pass. This is also known as "false urges" and is due to inflammation of the rectum.
Bowel retraining can help to manage urgent or frequent bowel movements. Create a regular time to empty your bowels and find ways to stimulate your bowels to empty more fully.
Another way to manage urgency is practicing pelvic floor exercises to strengthen the muscles around your rectum and anus to improve bowel control.