Diarrhoea is one of the most common health complaints worldwide. Globally, an estimated 2 billion cases of diarrhoea are reported a year. In Singapore, diarrhoea often happens when you consume raw or poorly cooked food, or food that has been left in the open for hours. 

Diarrhoea is characterised by an abnormal increase in frequency of passing watery, loose stools. It can range from a mild, temporary condition to a potentially life-threatening one – as often is the case in children with weaker immune systems.

Diarrhoea can present in two forms: acute diarrhoea, and chronic diarrhoea. The onset of acute diarrhoea is sudden and usually lasts for days. Chronic diarrhoea, while less common, can persist for over a month.

Why does diarrhoea happen?

Acute diarrhoea is the result of an infection caused by microorganisms like bacteria, virus or parasite. Some common causing agents include norovirus and rotavirus, and E coli. Acute diarrhoea usually resolves on its own after a couple of days.

Chronic diarrhoea, on the other hand, can point to an underlying condition. Some cases of chronic diarrhoea are called “functional” because the digestive organs are not functioning as ideally as they look. Today, Irritable Bowel Syndrome is the most common cause of chronic diarrhoea.

Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS) affects the normal functioning of the colon but does not lead to permanent damage. People with this condition are usually on either ends of the spectrum: passing too quickly and too frequently in the case of diarrhoea, or passing too slowly and infrequently in the case of constipation. 

Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a collective term used to refer to disorders involving the chronic inflammation of the digestive tract. The two types of IBD are ulcerative colitis and Crohn’s disease. Ulcerative colitis is a condition where ulcers form along the superficial lining of the colon and rectum, while Crohn’s disease is the inflammation of the lining of the digestive tract. Both types of IBD are characterised by diarrhoea, rectal bleeding, stomach pain, fatigue, and weight loss.

Microscopic Colitis

Microscopic colitis is a rare inflammatory disorder of the colon. The inflammatory mechanism is loosely understood to be triggered by environmental factors such as an infection, toxin, or drugs. This is a persistent type of diarrhoea that usually affects older adults. Besides diarrhoea, patients with this condition also experience abdominal pain, weight loss, and fatigue.

Malabsorption and Maldigestion Diarrhoea

Malabsorption is a condition involving impaired nutrient absorption where the body is unable to absorb nutrients from foods such as carbohydrates, fats, minerals, proteins, or vitamins, which are essential to a healthy body. Some commonly known disorders related to malabsorption include lactose intolerance and celiac disease.

Chronic Infections

Infections are an uncommon cause of chronic diarrhoea but there are exceptions. In the rare cases of chronic diarrhoea, parasites or various bacteria are the most likely culprit. A history of antibiotic use or travel can be important clues in chronic diarrhoea.

Cancer-related Causes

Certain cancers, especially those affecting the gut, can cause diarrhoea. These include and are not limited to colon cancer, stomach cancer, and pancreatic cancer. Besides the cancer itself, cancer patients undergoing treatment involving chemotherapy, radiation, immunotherapy, targeted therapy, and bone marrow transplants, may also experience diarrhoea as a result of the treatment.

Drug-induced Diarrhoea

A study published in 2012 found that drug-induced diarrhoea accounts for about 7% of all drug-related adverse effects. Over 700 drugs, including laxatives and certain antibiotics and antacids, are part of the list. 

Endocrine-related Causes

Hormonal imbalance, as in the case with thyroid issues, can cause chronic diarrhoea. Other hormonal factors, such as in the case of Addison’s disease and carcinoid tumours, can also lead to diarrhoea. In diabetic patients, chronic diarrhoea can happen if the nerves that supply the digestive tract are damaged.

When should I seek help?

Most cases of diarrhoea resolve on their own without treatment. Persistent or chronic diarrhoea, however, can be dangerous because it can lead to dehydration, electrolyte imbalance, and kidney failure in extreme situations.

Consult your healthcare provider if diarrhoea persists more than a few days and you start developing other symptoms such as nausea and vomiting, stomach or rectal pains, blood in stool, or high fever above 39°C.

Elderly patients with existing and/or multiple medical problems should not delay seeking medical attention.

What are the investigations into diarrhoea?

The first priority is to determine whether it is a case of acute or chronic diarrhoea.

In cases of acute diarrhoea, the doctor will ask about your travel history and determine the severity of the illness, any fever, and blood in stool. Treatment may begin just based on clinical signs, without any investigations. Stool microbial assessment may be considered if diarrhoea persists for over a week and antibiotics administered to manage the symptom. Patients will also be advised to consume sufficient fluids to prevent dehydration.

In cases of chronic diarrhoea, the doctor will differentiate between functional and organic diarrhoea. Most chronic diarrhoea will require a series of tests, including endoscopy and imaging, to determine the exact cause. Depending on your family and medical history, these may include tests to identify any of the above conditions and/or stool tests to identify parasites, bacteria, or viruses that could be the affecting agent.

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