Adapted from episode 62 of The Perfect Stool podcast and edited for readability.
When we think about diarrhea, we think that it’s just the intestinal flu, gastroenteritis, or just something we ate or drank that had gone bad. However, it’s not always the case. We will take a look at diarrhea and loose stool and the causes and solutions for common functional digestive problems, the connection between diarrhea, loose stool and IBS, SIBO, Candida, IBD, celiac disease, gluten intolerance, lactose intolerance, and supplements you can take to address some common problems.
What is diarrhea essentially?
Most people end up with diarrhea at least once a year. However, we usually chalk it up to eating or drinking something bad or a bout of intestinal flu or gastroenteritis. So we take some over the counter diarrhea medication and usually it goes away. But that’s not always the end of it. There are two types of diarrhea: short-term, acute type diarrhea and longer-term, chronic type diarrhea with loose stool.
The official definition of diarrhea is a condition of gastrointestinal upset or inflammation in which you have at least 2 – 3 or more than loose or watery bowel movements a day. Acute diarrhea is diarrhea that lasts up to a week, but if it goes on for two to three weeks, it can be considered chronic. In most cases, it’s happening because your body is trying to get rid of infections and toxins, so rather than slowing down your stool, it’s better to drink water and electrolytes and let your body do its job. It will remove the offending bacteria or parasites, but in the process it will rob you of important fluids, which you need to replace or risk dehydration.
If your diarrhea is frequent and lasts more than a couple of days, you should either buy a rehydration solution, make your own homemade one, or better yet, consume lots of liquids like homemade vegetable and fruit juices and smoothies, herbal teas, bone broth or other types of broth, water with lemon or lime and raw honey, or sparkling water with fruit slices.
What are the causes of acute diarrhea?
Acute diarrhea is usually caused by a parasitic protozoa of some sort, such as Cryptosporidium, Giardia or Entamoeba Histolytica or worms like roundworm, whipworm, tapeworm or hookworms. Protozoan infections are either treated with prescription antiparasitics or herbal antiparasitics. Two of my favorites herbal ones are Cell Core Biosciences* Para 1 and Para 2* (you’ll need my patient direct code: I0rdLMOm to purchase).
Diarrhea can also come from viruses such as Norovirus or Rotavirus. Viral diarrhea is usually accompanied by nausea, vomiting and fever as well and stomach cramps. These will typically pass on their own and don’t require any special treatment other than staying hydrated and keeping up with your electrolytes. Another virus that may cause diarrhea is Cytomegalovirus, which can include symptoms such as fatigue, fever, muscle aches and sore throat. There are some good antiviral herbs that you can take to speed up your healing if you have a viral infection. I especially like the Biocidin line of products for this, in particular Biocidin LSF and Olivirex (found in Fullscript*).
Diarrhea can also come from certain types of bacteria, like Salmonella, E. coli, Shigella, Campylobacter and Clostridium difficile. Most bacterial infections come from contaminated food or water and can be treated with antibiotics. Clostridium difficile or C Difficile, in contrast is often caught in hospital settings after heavy antibiotic usage. It exists in many of our healthy gut ecosystems, but when completing and balancing bacteria are decimated by antibiotics, it can become pathogenic. It will typically cause cramping and watery diarrhea many times a day, and can be quite serious. About 15,000 people die of it per year in the US, because it can lead to dehydration, severe intestinal inflammation, an enlarged colon and sepsis. The first and second line treatments are antibiotics, but if those fail, in the US you can now get a fecal microbiota transplant (aka, FMT or a poop transplant) sourced from a healthy donor either in the form of capsules or inserted rectally with a retention enema. With 2-3 treatments over the course of 2-3 days, depending on the modality, there’s a greater than 90% success rate for FMT curing C Diff.
If you have ongoing diarrhea and you’re not sure if it could be a parasite or bacterial infection, you can ask your doctor for an ova and parasites test. If that comes up empty, which is often the case, but you still suspect a parasite or bacterial infection, which is of course a more likely scenario if you live in or have recently traveled to a developing country, a stool test like the GI Map* by Diagnostic Solutions or one of Genova’s stool tests like the GI Effects or the Comprehensive Digestive Stool Analysis or Doctor’s Data’s GI 360 will tell you whether that’s the case. Unfortunately, those tests are not typically covered by insurance.
Some symptoms that may help you differentiate a parasite from another type of problem is having trouble falling asleep or waking frequently during the night; grinding your teeth at night; becoming more symptomatic during the full moon; skin issues like rash, hives, rosacea or eczema; pain or aching in joints and muscles; fatigue; iron-deficiency anemia or not feeling full or satisfied after eating.
Could a food sensitivity be causing my diarrhea or loose stool?
A food sensitivity such as lactose intolerance or gluten intolerance or celiac disease, which is an autoimmune disease in which gluten causes an autoimmune attack on your intestines, could also be at the root of your diarrhea or loose stool. Often it’s hard to determine if this is the case by simply stopping the food for a short period of time and reintroducing it because there may be damage and inflammation that has to be repaired over time to see symptoms fade completely. For example, in celiac disease, the villi lining your small intestine which absorb nutrients may be blunted or worn down, which will impact your ability to absorb nutrients other than gluten, and in particular dairy, which may cloud your ability to determine the root cause. Celiac disease testing is an easy test to ask for from your doctor, however. Other common symptoms of celiac disease include bloating, gas, fatigue, anemia, malnutrition and osteoporosis.
Gluten sensitivity is tougher to test for and is best determined following a negative celiac test with a one-month elimination diet followed by a reintroduction over the course of several days. You can also be tested for lactose intolerance by your doctor, but the easiest way to find out, especially if you’re very gassy or have painful or burning, mushy stool when you drink milk, or to eat soft cheeses or large quantities of cheese in particular, is to purchase a Dairy digestant or lactase enzyme pill and take it when you eat dairy products. If it helps, lactose intolerance is likely, and it’s pretty common for adults to suffer from this problem.
Of course an unhealthy diet lacking in fiber and high in sugar, processed foods, alcohol and caffeine can also lead to loose stool. Because this type of diet creates inflammation, dysregulates your blood sugar and feeds pathogenic bacteria, it can lead to dysbiosis, which can create loose stool. If you suspect your diet may be at the root of your issues, try a whole foods, anti-inflammatory diet, with healthy fats like avocados and olives and their oils, grass fed butter or ghee, coconut oil and products, organic and grass fed meats, whole grains, root vegetables, beans and legumes, and plenty of fruits, vegetables and herbs. I have had clients whose digestive issues cleared up once they fixed their diet and their blood sugar became more balanced. Also, be aware that a diet that is completely lacking in grains or starchy or root vegetables but not a ketogenic diet can also lead to loose stool, so sometimes what seems to be a healthy diet may be a root cause.
Could my diarrhea be from SIBO or IBS?
Longer-term diarrhea or soft stool, especially when accompanied by bloating soon after you eat, is more likely to be caused by SIBO, or Small Intestine Bacterial Overgrowth. This is often diagnosed by gastroenterologists as IBS or Irritable Bowel Syndrome or IBS-D with the D standing for diarrhea. SIBO can also be at play when you have long-term constipation or a pattern of constipation mixed with diarrhea, which usually is caused by what’s called breakthrough diarrhea, where diarrhea is all that can get by the hard stool blocking your colon. SIBO, ironically, is often the result of food poisoning, which may have triggered the original diarrhea.
The research of Dr. Marc Pimentel at Cedars-Sinai Medical Center has revealed that some people end up having an autoimmune attack on the cells that move food along the small intestine as a result of molecular mimicry following food poisoning. When your body attacks the invader, it produces antibodies to common bacterial pathogens, which are called anti-CDTB or anti-Cytolethal Distending Toxin B antibodies. Because a protein called vinculin in the gut looks similar to CDTB, your body may also produce antibodies to vinculin, which is an important protein for helping your small intestine motility. The antibodies can stay elevated for many years following an attack of food poisoning. For example, my last bad attack of food poisoning that I recall was 25 years ago during my honeymoon, and I recently had my vinculin antibodies tested and they’re still elevated. This autoimmune attack on the vinculin protein impacts your Migrating Motor Complex, which clears food out of your small intestine every 1.5-2 hours. When your migrating motor complex is impacted, it results in stagnation and bacterial overgrowth.
So in addition to diarrhea or loose stool, you’ll often have bloating, heartburn, nausea, vomiting, and will feel full quickly when eating when SIBO is your root cause. If you recall a bout of food poisoning that may have kicked off your issues, the ibs-smart test can tell you whether you have elevated antibodies. If it’s positive, then you know there’s likely bacteria that needs to be killed in your small intestine, which can be done through an antibiotic called Rifaximin, or through herbal antimicrobials. It’s also good to take ½ tbsp. of partially hydrolyzed guar gum, also known as Sun Fiber (found at Fullscript) in 8 oz. of water with each dose of either Rifaximin or bota antimicrobials, for maximum success. SIBO breath testing may be recommended through a gastroenterologist, naturopath or functional medicine practitioner, but I tend to shy away from that as it’s not a terribly useful or reliable tool compared to other stool tests, in my opinion.
Symptoms and history go a lot further in my opinion to figuring out whether bloating and loose stool could be from SIBO. Food poisoning isn’t the only root cause, however, of diarrhea or loose stool caused by SIBO. Many other conditions can slow or inhibit small intestine motility, including traumatic brain injuries, hypothyroidism, diabetes, mold toxicity, adhesions following abdominal surgery, endometriosis, Ehlers-Danlos Syndrome and dysfunction of the ileocecal valve, the valve that separates the small and large intestines. Medications like proton pump inhibitors, opiates, narcotics, antispasmodics, tricyclic antidepressants, and cholestyramine can also be at the root of SIBO. And of course many functional digestive disorders relating to your basic digestive organs can also impact your body’s ability to kill entering bacteria or adequately digest food so that there’s not too much left over for bacteria to reproduce on, such as hypochlorhydria or low stomach acid, low pancreatic enzymes, poor bile flow, low brush border enzymes, or low secretory IgA, which is often the result of finding yourself in chronic fight or flight mode due to stress. I’ve also noticed in clients with H. Pylori, the bacteria that can cause ulcers and stomach cancer if it has certain what’s called virulence factors, that after a while their secretory IgA will go low, and then you see a good amount of dysbiosis and overgrowth of opportunistic bacteria like Streptococcus or Klebsiella, which then cause loose stool.
The long and short of it is, if you determine that SIBO is likely your root cause, you will probably want to do something to kill the overgrown bacteria. While you’re working on that, you may want to use a diet called low FODMAPs (that’s FODMAPS) for symptom relief, although I’m less set on recommending that these days since it’s so impractical, as it eliminates onions and garlic, which can be so limiting given our food culture.
In addition, if you determine that your SIBO is from elevated vinculin antibodies, then you’ll need to think about taking something called a prokinetic before bed, most likely in the long-term if not for life, which is something that keeps your small intestines moving. Two over-the-counter prokinetics that I’ve tried and have worked well for me are Iberogast* and GI Motility Complex by Enzyme Science (found at Fullscript*). Other options include MotilPro by Pure Encapsulations, SIBO-MCC by Priority One and Motility Activator by Integrative Therapeutics (find all at Fullscript*). Common ingredients for these types of formulations include ginger and artichoke extracts, various herbs and 5-HTP, or 5-hydroxytryptophan, which is a precursor to serotonin, which is involved in blood flow and motility in your gut. There are also prescription options but to access those you’d need a SIBO-literate doctor (and some do exist) and if you have one of those, they can help you out with those. Just one final note about prokinetics – if you’re used to using something to slow your motility in your colon, the idea of taking something to increase motility may be counterintuitive. But the thing is, prokinetics are meant to work on the small intestine to prevent stagnation upstream, which is causing symptoms downstream. So don’t let that scare you off.
Can Candida cause diarrhea?
So another potential source of diarrhea is Candida overgrowth in the intestines, also known as SIFO, or Small Intestine Fungal Overgrowth. This often follows the use of heavy antibiotics in a clinical setting, but can also happen to immune-suppressed individuals or people eating high-sugar or high-simple carbohydrate diets who take broad-spectrum or many courses of antibiotics. Various species of candida, which are yeasts, are normal residents of our gut but can overgrow when all of the competing bacteria are decimated. Diarrhea or soft stool accompanied by sugar cravings, bloating, gas, burping, abdominal pain, nausea, yeast infections in women and urinary tract infections can point to SIFO as a possible root cause. The only sure way to know if you have invasive candidiasis is to take an Organic Acids Test and see if a marker called Arabinose is elevated. If that is the case, it is often accompanied by SIBO, and there are herbal antimicrobials that will take care of both. If it’s just candida, there are more candida specific natural treatments using fatty acids like undecenoic acid, caprylic acid, horopito (sold as Kolorex) or black cumin seed oil, although I usually recommend those in conjunction with botanical antifungals. There are also various candida diets out there but people I really respect in the functional medicine field contend that going to extremes isn’t necessary, and just the basics of removing added sugars and simple carbs while going through treatment is necessary. I tend to agree because it can take several rounds (with a round lasting 6-8 weeks) of antifungals to get candida in check, and it can be pretty tough to stick with even the simplest changes over the long term, not to mention a really extreme diet.
Could My Diarrhea be Inflammatory Bowel Disease?
One of the remaining most common causes of chronic diarrhea is inflammatory bowel disease, or IBD, which can be broken into colitis, of which there are various forms, including ulcerative colitis and microscopic colitis and Crohn’s Disease. This is especially likely if you see blood in your stool, have unintended weight loss, abdominal pain and cramping, a reduced appetite or fatigue. Usually they are diagnosed using a colonoscopy or endoscopy, but there are also markers from stool that are indicative of IBD, which are lactoferrin and calprotectin. Calprotectin is on the GI Map*, which I often use with clients. Either are good markers for differentiating IBD from IBS or SIBO, although keep in mind that many people present with both at the same time. I’ve got other podcasts that go into much more detail on IBD, so if you want more info on that, check out episodes 15, 35 and 54 in particular.
What other issues can cause diarrhea or loose stool?
There are of course other potential causes of diarrhea or loose stool, such as liver and gallbladder issues, which can be supported through digestive enzymes and Ox bile supplements, or liver detoxification supplements like NAC. Hyperthyroidism is another potential cause, which would be suspect if you have a rapid or irregular heartbeat, nervousness, anxiety or irritability, or unintentional weight loss. And then certain medications and supplements can cause loose stool. In terms of supplements, the most common that will loosen your stool are large doses of vitamin C or certain forms of magnesium like mag oxide or mag citrate. For prescription medications, you can check the inserts or online for side effects.
What natural supplements can help with diarrhea or soft stool?
No matter what the cause of your diarrhea or soft stool, one supplement that I’m currently enamored with to help solve this problem is butyrate. Older forms are called sodium or magnesium butyrate, and tend to be really smelly and not as effective. Never forms including tributyrin and pro butyrate don’t have the issue with smell and are released further on in the intestines, which helps slow motility in the large intestine, resulting in firmer stool. I have a few forms I recommend, including Pro Butyrate (which is capsules) or AuRx (which is powder) (find at Fullscript*) or Tributyrin-X*. When you first start these you sometimes have to take a bunch (like 3 two or three times a day of the Tributyrin-X or a couple scoops of AuRx 2-3 times a day or 3 or 4 Pro Butyrate 2-3 times/day) to get your stool to firm up. After that you usually can start tapering down to a good maintenance dose.
Now of course I would be remiss not to mention that butyrate is produced by bacteria when they ferment fiber, so of course eating a higher fiber diet (meaning more beans, legumes, whole grains, root vegetables, and other fruits and veggies) could produce the same effect. Fiber supplements are also an option. Psyllium husk fiber is an old favorite for me although it’s just kind of gross to take, no matter how you mix it in. But 1 tbsp. 2x/day in 8 oz. of water or juice will very likely bulk and firm up your stool and will certainly be less expensive than butyrate.
Will probiotics help with diarrhea?
If dysbiosis is at the root of your loose stool, probiotics may be helpful, either from your food or in supplement format. Generally, if you’re looking to try a probiotic consisting of lactobacilli or bifidobacteria, you should look at something in the 50 billion CFU range and up to correct minor dysbiosis. Visbiome* has been validated in the research for this in particular, and can be purchased in super high dose packets of 450 billion CFU or in lower dose capsules. Spore-based or soil based strains from the Bacillus family are also known for their ability to help reshape a dysbiotic microbiome. S. Boulardii, a beneficial yeast sold as a probiotic, is particularly known for its ability to help prevent traveler’s diarrhea. And or course eating fermented foods like sauerkraut, kim chee, yogurt, kefir and kombucha can help bring a dysbiotic microbiome into balance over time, as well as help stabilize your immune system, provide vitamins, regulate your metabolism, decrease obesity and chances of inflammatory diseases such as IBD.
So obviously if you’re suffering from long standing diarrhea or soft stool and don’t know why, that’s the kind of thing I specialize in. If you’re struggling with your gut health, you’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my gut health coaching 5-appointment program in which I recommend lab tests, educate you on what the results mean and the protocols used by doctors to fix the problems revealed. Or if you’re ready to jump in right away or can just afford one appointment at a time, you can set up an 1-hour consultation with me.
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