DAVID MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks. Today we're talking about the treatment of diarrhea. There are almost as many treatments as there are causes of diarrhea, and it can all be a little confusing. Joining us to help sort through all these options are two experts.
First is Dr. Lucy Harris, a gastroenterologist at Cornell Medical Center. Welcome.
LUCINDA HARRIS, MS, MD: Thank you.
DAVID MARKS, MD: And her colleague from Cornell Medical Center is Dr. Mark Pochapin. He's also a gastroenterologist. Welcome.
MARK POCHAPIN, MD: Thanks.
DAVID MARKS, MD: There are a lot of options out there. How does someone know which one to choose?
LUCINDA HARRIS, MS, MD: I think it depends upon the cause of their diarrhea, to start with. If they are having an acute infectious diarrhea, it might not be unreasonable to try something like Pepto-Bismol. Some of the other things out there may not be as helpful, and certainly they want to use some of the agents that really stop the intestine, like Imodium and Lomotil, with great caution.
MARK POCHAPIN, MD: It's a difficult question, because very often diarrhea that occurs from the start, that is new and not something that a patient generally has, if they take medication for it, it could actually make the symptoms of cramping and bloating worse. Although it might stop the diarrhea, it might make them actually feel worse.
So if they're not doing too badly having the diarrhea, it's better for them just to drink plenty of fluids, especially fluids that have sugar and electrolytes to keep them hydrated, like Gatorade, and not try and stop things up so much.
DAVID MARKS, MD: There's something called the BRAT diet. What is that?
LUCINDA HARRIS, MS, MD: The BRAT diet is something that pediatricians often teach their patients, and that is to have, it stands for bananas, rice, apples, applesauce, tea and toast. Those are the things that are safe to eat when you have an acute diarrhea, and actually may help your symptoms.
DAVID MARKS, MD: Are there certain things that people should avoid at all costs when they have diarrhea?
MARK POCHAPIN, MD: Definitely. Without a doubt, milk and milk products. You know, when a baby gets diarrhea, most people who take care of little infants, children of their own, will know not to give that baby milk. They'll change the formula to some soy-containing formula. But as adults, we forget that.
Milk is very poorly absorbed when the intestine is inflamed or infected. So milk products, also fatty and greasy foods, and foods that contain a lot of sugar, usually in the form of fructose or sorbitol.
DAVID MARKS, MD: There are some malabsorption conditions that can also result in diarrhea. First tell us what they are, what the most common ones are, and then how to treat them.
LUCINDA HARRIS, MS, MD: I think some of the common symptoms or common things that cause diarrhea may be lactose intolerance. That can be a malabsorption. There is a disease called celiac sprue, which is an actual, patient has a problem with wheat and wheat products. And sometimes inflammatory bowel disease, especially ulcerative colitis, can appear to be somewhat of a malabsorptive symptom, particularly when they're having profuse, watery diarrhea.
There are lots of other rare causes of diarrhea, such as endocrine tumors and a disease that occurs primarily in men called Whipple's disease. These are things that would probably have to be worked up by a physician.
MARK POCHAPIN, MD: But they're very rare. The most common things people are going to have are usually infections or food-related. I think it's important just to try and let it pass on its own, and not try and treat it. People should not try and treat themselves, thinking that they know what's causing the diarrhea, because it could make things worse. And if it doesn't resolve within a day or two, they should seek medical help.
DAVID MARKS, MD: What are some of the medications that people can, doctors can prescribe. Forget about the over-the-counter for right now. How about prescription drugs?
MARK POCHAPIN, MD: It's so varied depending on the type of diarrhea. You mentioned, for example, some inflammatory conditions like Crohn's disease and ulcerative colitis. The drugs that you would give patients with inflammation would be anti-inflammatory medications, things that contain something called mesalamine in it, Pentasa, Asacol, Dipentum, sulfasalazine.
DAVID MARKS, MD: These are specific for the conditions that the person has?
MARK POCHAPIN, MD: Exactly. But you wouldn't use those in diarrhea conditions that are infectious in nature. Those would get antibiotics. So the treatment is so varied, based on what you think the cause is. And that usually breaks down to something that's occurring, new, acute, versus something that's been long-standing, chronic.
The medications over-the-counter just stop everything up. And that's why it can be dangerous if you don't really understand the cause of it.
DAVID MARKS, MD: What are some of those?
MARK POCHAPIN, MD: The most common one is Imodium. That was really a very powerful medication. Basically paralyzes the intestine. And, sure, it will clearly slow down bowel movements, but it could cause bloating, cramping, and sometimes even very severe distention.
Pepto-Bismol is another one. It uses bismuth, and people don't quite understand why that works well. It may actually have an antibiotic, antimicrobial action to it. And that also turns the stool black, so you have to understand that if you take that, the stool changing color might alarm physicians, because black stool might also be indicative of blood in the stomach.
LUCINDA HARRIS, MS, MD: Even the Pepto-Bismol can even turn the tongue black if people take enough of it. So if they are taking it, they should know that turning the stool black and turning their tongue black are signs of taking the medication, and not signs of bleeding.
The other point that I think that I would make is that there is medication called Kaopectate, and for most people that has a very minimal effect and is usually not very helpful.
DAVID MARKS, MD: How about just taking supplemental fiber? Does that work?
LUCINDA HARRIS, MS, MD: If they have, it can somewhat take up some of the water in the stool, but even for irritable bowel syndrome, it's not felt to be an effective treatment for diarrhea-predominant irritable bowel syndrome, but more for constipation-predominant irritable bowel syndrome.
DAVID MARKS, MD: When people talk about irritable bowel syndrome, a lot of people think it's stress related or psychological. Is that the case, number one, I guess? And then, will stress reduction methods work?
LUCINDA HARRIS, MS, MD: Food and stress don't cause irritable bowel syndrome, but they can make the symptoms worse. We now understand a little bit more about irritable bowel syndrome, and it's actually probably a natural substance that the body produces called serotonin that actually causes irritable bowel syndrome.
MARK POCHAPIN, MD: There's a brain of the intestine that's very complex, and we're just beginning to understand it. I sort of look at irritable bowel as a dysregulation, almost a depression, in certain cases, of the brain of the intestine. And you treat that just like you might treat a depression of the mind or central nervous system.
LUCINDA HARRIS, MS, MD: Right. There are new medications that are available and there are companies working on new drugs, as well as for constipation-predominant irritable bowel syndrome. There's one that's going to be coming on the market soon called Zelmac or tegaserod.
MARK POCHAPIN, MD: It's not that the patient's crazy, it's not that they're reacting inappropriately or neurotic. I think that's a label that gets put on these patients, especially because many of them are women, and they get labeled in a very, I think, detrimental way. The patient has a real problem. It's a real disease. It's just that we don't understand it that well now, but with all these new studies and medications coming out, it's really a very exciting time to try and treat this disorder.
DAVID MARKS, MD: Is there a time when it's not appropriate to take medications, over-the-counter medications for diarrhea?
LUCINDA HARRIS, MS, MD: I believe so, yes. If a patient has a high fever, severe abdominal pain and is having bloody diarrhea, they really need to consult their physician.
MARK POCHAPIN, MD: Yeah, and if they're having abdominal pain, nausea and vomiting, absolutely should not take any medication.
DAVID MARKS, MD: Back to the question about stress management. Does that ever help people with diarrhea?
LUCINDA HARRIS, MS, MD: I think that if you have an exacerbation of your symptoms by stress, then certainly yes. Exercise, maybe cognitive therapy, short-term therapy. Those things may be helpful in managing the stress, and therefore they're going to help the diarrhea that's related to stress.
MARK POCHAPIN, MD: They just help overall good health, and dealing with the situation that a patient finds themselves in with their symptoms.
DAVID MARKS, MD: Thank you both for a very non-stressful segment. And thank you for joining our webcast. I'm Dr. David Marks, and I'll see you next time.
First is Dr. Lucy Harris, a gastroenterologist at Cornell Medical Center. Welcome.
LUCINDA HARRIS, MS, MD: Thank you.
DAVID MARKS, MD: And her colleague from Cornell Medical Center is Dr. Mark Pochapin. He's also a gastroenterologist. Welcome.
MARK POCHAPIN, MD: Thanks.
DAVID MARKS, MD: There are a lot of options out there. How does someone know which one to choose?
LUCINDA HARRIS, MS, MD: I think it depends upon the cause of their diarrhea, to start with. If they are having an acute infectious diarrhea, it might not be unreasonable to try something like Pepto-Bismol. Some of the other things out there may not be as helpful, and certainly they want to use some of the agents that really stop the intestine, like Imodium and Lomotil, with great caution.
MARK POCHAPIN, MD: It's a difficult question, because very often diarrhea that occurs from the start, that is new and not something that a patient generally has, if they take medication for it, it could actually make the symptoms of cramping and bloating worse. Although it might stop the diarrhea, it might make them actually feel worse.
So if they're not doing too badly having the diarrhea, it's better for them just to drink plenty of fluids, especially fluids that have sugar and electrolytes to keep them hydrated, like Gatorade, and not try and stop things up so much.
DAVID MARKS, MD: There's something called the BRAT diet. What is that?
LUCINDA HARRIS, MS, MD: The BRAT diet is something that pediatricians often teach their patients, and that is to have, it stands for bananas, rice, apples, applesauce, tea and toast. Those are the things that are safe to eat when you have an acute diarrhea, and actually may help your symptoms.
DAVID MARKS, MD: Are there certain things that people should avoid at all costs when they have diarrhea?
MARK POCHAPIN, MD: Definitely. Without a doubt, milk and milk products. You know, when a baby gets diarrhea, most people who take care of little infants, children of their own, will know not to give that baby milk. They'll change the formula to some soy-containing formula. But as adults, we forget that.
Milk is very poorly absorbed when the intestine is inflamed or infected. So milk products, also fatty and greasy foods, and foods that contain a lot of sugar, usually in the form of fructose or sorbitol.
DAVID MARKS, MD: There are some malabsorption conditions that can also result in diarrhea. First tell us what they are, what the most common ones are, and then how to treat them.
LUCINDA HARRIS, MS, MD: I think some of the common symptoms or common things that cause diarrhea may be lactose intolerance. That can be a malabsorption. There is a disease called celiac sprue, which is an actual, patient has a problem with wheat and wheat products. And sometimes inflammatory bowel disease, especially ulcerative colitis, can appear to be somewhat of a malabsorptive symptom, particularly when they're having profuse, watery diarrhea.
There are lots of other rare causes of diarrhea, such as endocrine tumors and a disease that occurs primarily in men called Whipple's disease. These are things that would probably have to be worked up by a physician.
MARK POCHAPIN, MD: But they're very rare. The most common things people are going to have are usually infections or food-related. I think it's important just to try and let it pass on its own, and not try and treat it. People should not try and treat themselves, thinking that they know what's causing the diarrhea, because it could make things worse. And if it doesn't resolve within a day or two, they should seek medical help.
DAVID MARKS, MD: What are some of the medications that people can, doctors can prescribe. Forget about the over-the-counter for right now. How about prescription drugs?
MARK POCHAPIN, MD: It's so varied depending on the type of diarrhea. You mentioned, for example, some inflammatory conditions like Crohn's disease and ulcerative colitis. The drugs that you would give patients with inflammation would be anti-inflammatory medications, things that contain something called mesalamine in it, Pentasa, Asacol, Dipentum, sulfasalazine.
DAVID MARKS, MD: These are specific for the conditions that the person has?
MARK POCHAPIN, MD: Exactly. But you wouldn't use those in diarrhea conditions that are infectious in nature. Those would get antibiotics. So the treatment is so varied, based on what you think the cause is. And that usually breaks down to something that's occurring, new, acute, versus something that's been long-standing, chronic.
The medications over-the-counter just stop everything up. And that's why it can be dangerous if you don't really understand the cause of it.
DAVID MARKS, MD: What are some of those?
MARK POCHAPIN, MD: The most common one is Imodium. That was really a very powerful medication. Basically paralyzes the intestine. And, sure, it will clearly slow down bowel movements, but it could cause bloating, cramping, and sometimes even very severe distention.
Pepto-Bismol is another one. It uses bismuth, and people don't quite understand why that works well. It may actually have an antibiotic, antimicrobial action to it. And that also turns the stool black, so you have to understand that if you take that, the stool changing color might alarm physicians, because black stool might also be indicative of blood in the stomach.
LUCINDA HARRIS, MS, MD: Even the Pepto-Bismol can even turn the tongue black if people take enough of it. So if they are taking it, they should know that turning the stool black and turning their tongue black are signs of taking the medication, and not signs of bleeding.
The other point that I think that I would make is that there is medication called Kaopectate, and for most people that has a very minimal effect and is usually not very helpful.
DAVID MARKS, MD: How about just taking supplemental fiber? Does that work?
LUCINDA HARRIS, MS, MD: If they have, it can somewhat take up some of the water in the stool, but even for irritable bowel syndrome, it's not felt to be an effective treatment for diarrhea-predominant irritable bowel syndrome, but more for constipation-predominant irritable bowel syndrome.
DAVID MARKS, MD: When people talk about irritable bowel syndrome, a lot of people think it's stress related or psychological. Is that the case, number one, I guess? And then, will stress reduction methods work?
LUCINDA HARRIS, MS, MD: Food and stress don't cause irritable bowel syndrome, but they can make the symptoms worse. We now understand a little bit more about irritable bowel syndrome, and it's actually probably a natural substance that the body produces called serotonin that actually causes irritable bowel syndrome.
MARK POCHAPIN, MD: There's a brain of the intestine that's very complex, and we're just beginning to understand it. I sort of look at irritable bowel as a dysregulation, almost a depression, in certain cases, of the brain of the intestine. And you treat that just like you might treat a depression of the mind or central nervous system.
LUCINDA HARRIS, MS, MD: Right. There are new medications that are available and there are companies working on new drugs, as well as for constipation-predominant irritable bowel syndrome. There's one that's going to be coming on the market soon called Zelmac or tegaserod.
MARK POCHAPIN, MD: It's not that the patient's crazy, it's not that they're reacting inappropriately or neurotic. I think that's a label that gets put on these patients, especially because many of them are women, and they get labeled in a very, I think, detrimental way. The patient has a real problem. It's a real disease. It's just that we don't understand it that well now, but with all these new studies and medications coming out, it's really a very exciting time to try and treat this disorder.
DAVID MARKS, MD: Is there a time when it's not appropriate to take medications, over-the-counter medications for diarrhea?
LUCINDA HARRIS, MS, MD: I believe so, yes. If a patient has a high fever, severe abdominal pain and is having bloody diarrhea, they really need to consult their physician.
MARK POCHAPIN, MD: Yeah, and if they're having abdominal pain, nausea and vomiting, absolutely should not take any medication.
DAVID MARKS, MD: Back to the question about stress management. Does that ever help people with diarrhea?
LUCINDA HARRIS, MS, MD: I think that if you have an exacerbation of your symptoms by stress, then certainly yes. Exercise, maybe cognitive therapy, short-term therapy. Those things may be helpful in managing the stress, and therefore they're going to help the diarrhea that's related to stress.
MARK POCHAPIN, MD: They just help overall good health, and dealing with the situation that a patient finds themselves in with their symptoms.
DAVID MARKS, MD: Thank you both for a very non-stressful segment. And thank you for joining our webcast. I'm Dr. David Marks, and I'll see you next time.