Diarrhea, commonly known as diarrhea, is not only frequent trips to the toilet, but also unformed stools, some of which are like water. Diarrhea is mostly accompanied by bloating and abdominal pain. As we talked about constipation earlier, the general impression is that constipation and diarrhea are antonyms, and that some medications for diarrhea do produce side effects of constipation. But impressions are not equal to science. The etiology, mechanism of occurrence and management of diarrhea and constipation cannot be explained by a yin-yang relationship. Diarrhea is much more complex than constipation.
How diarrhea arises
In terms of the manifestations of diarrhea, any condition that makes the stool more, thinner, and with more frequent bowel movements can produce diarrhea. So diarrhea is first and foremost an increase in the amount of water in the stool. It is rare to find a stool to analyze its water content in order to clarify diarrhea, but it can be distinguished in a simple way because the typology was developed by experts from the University of Bristol in the UK, hence the name Bristol typology. There are seven types: Type I, nut-like lumpy stool, difficult to expel; Type II, sausage-shaped but hard; Type III, sausage-shaped but with cracks on the surface; Type IV, sausage or snake-like, smooth and soft; Type V, soft and flaky, with clear edges, easy to expel; Type VI, fluffy paste-like stool, with unclear edges; Type VII, watery stool without solid components. Normal is types three to five, with types one and two being constipation and types six and seven being diarrhea. Diarrhea is acute if it is only a few days to two weeks, and chronic if it is more than four weeks.
When there is more water in the stool, the stool is not formed. So how is water regulated under normal conditions? Actually, after the food has just passed through the stomach, all the way to the cecum, the nearest section of the large intestine, it is paste-like and liquid-like. The reason for this is, first, the chewing of the teeth, the mechanical agitation of the intestinal peristalsis, and second, the large amount of fluid secreted by the digestive tract. After these paste-like things reach the large intestine, the water inside will be reabsorbed, the water in the human intestine, including the intake from the mouth and intestinal secretion of as much as 9 liters, but the final stool discharge of only a few hundred milliliters, most of them are reabsorbed, only the large intestine to absorb 3-5 liters. Most of it is reabsorbed, and the large intestine alone absorbs 3-5 liters.
How the water in the stool is increased begins with the separation between the intestinal cavity and the interior of the body. Although the intestine is located in the innermost part of the body, the intestinal cavity is essentially connected to the outside world. Between this open cavity and the complex internal environment inside the body, there must be a sophisticated barrier that ensures that harmful foreign substances cannot just enter, nor can internal nutrients just be discharged. This barrier consists of several layers, excluding the outermost layer of non-cellular mucus, and a thin layer of mucous membrane composed of epithelial cells in direct contact with the intestinal lumen. If the mucosa is the Great Wall, then the epithelial cells are the bricks of the wall. Beneath the mucosa is a relatively loose connective tissue with patrolling and alert leukocytes and macrophages, as well as capillaries, lymphatic vessels and nerve endings.
The simplest cause of diarrhea may only be a physical reaction, as talked about in “What’s going on with edema” about osmotic pressure, and how much water in the intestinal lumen is also affected by osmotic pressure. If there is a sudden increase in the intestinal lumen with many small molecules that cannot be absorbed, the osmotic pressure increases and attracts water from the mucosa into the intestinal lumen. This type of diarrhea is called osmotic diarrhea. This type of diarrhea is usually associated with the ingestion of a substance that is not easily digestible, such as milk for lactose intolerant patients, where the lactose in the milk cannot be broken down and reaches the colon to produce osmotic diarrhea. Avoid eating the food in question and the symptoms will disappear quickly. There is also no damage to the intestinal mucosa and no sequelae are left behind.
In addition to osmotic diarrhea, there is also exudative diarrhea and secretory diarrhea. Although there is only one word difference between exudation and infiltration, exudation occurs on the basis of damage, and in some cases, only white blood cells are highly alert and turn into various inflammatory cells, secreting many components that promote inflammation; in some cases, a large shedding of epithelial cells occurs. The shedding becomes more and more visible to the naked eye, and erosions and ulcers are formed. Secretory diarrhea is not a passive leakage of water, but also an active discharge of water into the intestinal cavity. For example, the toxins released by cholera bacteria will activate the secretion mechanism of epithelial cells, which will secrete water and electrolytes outward regardless of death, and the person will not stop being dehydrated. If it is acute, it is usually related to some kind of germs, and most people will get better without treatment, and there are no after-effects. In a few cases, the germs linger and the inflammation becomes chronic. And among the chronic ones, there are many people who cannot find the pathogenic bacteria. These people may have a specific inflammatory bowel disease, and the ulcers and erosions in the intestine are often difficult to heal without treatment, and most of them will relapse after treatment has improved.
Other diarrhea has nothing to do with osmotic pressure and no inflammation, but because the intestinal peristalsis is really fast and the water is expelled before it can be absorbed. This type of diarrhea is called kinetic diarrhea. It can be acute, such as shitting your pants when you are overly frightened, or it can be chronic, as the so-called “lazy donkeys on the ground” is not a one-time performance evaluation.
In brief, diarrhea is divided into acute diarrhea and chronic diarrhea according to the urgency and duration of its occurrence, and into osmotic, exudative, secretory and kinetic diarrhea according to the mechanism of its occurrence.
What are the diseases of diarrhea
To treat diarrhea, it should first be clear which diarrhea needs to be treated and which diarrhea does not. The progress of modern medicine is not only shown in how to deal with diseases and symptoms, but also in telling us when they do not need to be treated. In general, acute diarrhea, like colds, is mostly caused by viruses and, to a lesser extent, by bacteria, and usually resolves itself. Only when significant abdominal pain, blood in the stool, dehydration, and fever occur does it need to be treated; otherwise, most cases heal in about two days. The most common cause of diarrhea that needs to be treated is a gastrointestinal infection. If diarrhea occurs in many people during the same period of time, the possibility of food poisoning or infectious disease should also be considered.
Chronic diarrhea usually requires colonoscopy to clarify the cause. Many diseases have obvious changes under colonoscopy, such as edema, erosion, and ulcers, and most of them can be clearly diagnosed by combining medical history and clinical manifestations. There are a few enteritis that cannot be seen as changes under the naked eye, but have characteristic changes under the microscope. This enteritis is called microscopic enteritis, and there are two main types: collagenous enteritis and lymphocytic enteritis. If neither colonoscopy nor microscopy reveals abnormalities, one should also pay attention to diarrhea caused by some systemic diseases, such as hyperthyroidism, some pancreatic tumors, intestinal dysfunction caused by diabetes, etc. However, for many patients with chronic diarrhea, these related tests may not reveal abnormal findings, because most of them belong to a functional bowel disease called irritable bowel syndrome, or functional diarrhea if they only have diarrhea without abdominal pain and discomfort. The cause of irritable bowel syndrome diarrhea is generally believed to be mainly related to intestinal dynamics, i.e., the intestinal peristalsis is too fast for water to be absorbed. In fact, the cause of irritable bowel syndrome is much more complex than that, and it is possible that these patients have a brain that is a little more overstimulated than others when it comes to the intestines. In general, stimulation is only transmitted to the brain during intestinal inflammation, and the brain instructs the release of hormones that promote secretion and intestinal peristalsis to facilitate the elimination of toxins from the intestine. The reason why the irritable bowel syndrome is treated is that
In addition to classifying diarrhea according to its etiology and pathogenesis, it is also traditionally customary to classify diarrhea into dysentery and watery diarrhea, and there are some old textbooks and experts who still use this method. The characteristics of both are: large amount of dysentery, small amount of watery diarrhea; dysentery paste, watery diarrhea pure liquid; dysentery with a sense of urgency, but not watery diarrhea; dysentery with blood in the stool, but not watery diarrhea; dysentery is mostly inflammatory; watery diarrhea is mostly osmotic, secretory and dynamic; dysentery lesions in the large intestine, watery diarrhea in the small intestine. Although this classification is simple, some people believe that dysentery, especially those with blood in the stool, should not be called diarrhea. And this classification is far less scientific than the pathogenesis, so many new textbooks no longer mention this classification.
How to treat diarrhea
The treatment of diarrhea is a selective choice of treatment according to the etiology and pathogenesis of the disease: those with acute onset and mild disease do not need treatment. Those that can identify the disease are treated for the disease, such as: food caused by avoiding troublesome food; bacterial infection caused by antibiotics; inflammatory with anti-inflammatory drugs; other chronic diseases caused by treating the original disease; peristalsis caused by excessive peristalsis with drugs that slow down intestinal peristalsis …… sometimes combined with some adjuvant supportive treatment, such as diarrhea water The treatment of diarrhea is mostly based on the treatment of the disease.
Simply put, diarrhea is mostly treated for certain diseases, and as the disease heals, the diarrhea will naturally disappear. Antidiarrheal drugs alone are generally not necessary. Unlike constipation treatment medications, there are fewer types of simple antidiarrheal medications, and there are three general types: water adsorption, secretion inhibition, and peristaltic inhibition. Many of these medications are over-the-counter and can be conveniently purchased at pharmacies. They can generally only be used for a short period of time, and the medication is discontinued when the diarrhea stops.
The most difficult diarrhea to treat is functional diarrhea, represented by irritable bowel syndrome. Other diarrheas either have a single cause or, although the cause of the disease causing the diarrhea is unclear, the mechanism causing the diarrhea is clearer, such as inflammatory bowel disease. Even if the treatment is not effective, the doctor is still able to take the patient’s bloody colonoscopy picture and explain to them: it is not that I am incompetent, but your intestines are already like a sieve. However, no single cause can be found for functional diarrhea, and the mechanisms of its occurrence are all very different, and all of them are quite reliable, but the treatments offered according to these mechanisms are not effective, at least not for most people. The most distressing thing is that when you can’t cure a patient’s diarrhea for a long time and you can’t find any abnormality, the patient and his family will look at you differently.
In the end, functional diarrhea is the most confusing diarrhea of all. Not only for the patient, but for the doctor as well. The most reliable current explanation for this disease is that it is the result of a combination of several factors. The patient himself has psychological, social and genetic factors that predispose him to functional diarrhea, such as having been abused as a child, parents being overly concerned about their small children being sick, and under certain stimuli, such as acute gastroenteritis, major life events, initiating a series of abnormal reactions, such as abnormal dynamics, increased visceral sensitivity This leads to symptoms of diarrhea and abdominal pain. None of these factors is missing, but it is not possible to determine which is the root cause, as in the case of computer repair. Since the disease itself does not have any physical abnormality and does not affect life expectancy, it is considered a successful treatment even if it does not make the symptoms disappear and the patient gradually accepts it and does not treat it as a serious condition. Therefore, education is far more important than medication for functional gastrointestinal disorders, including irritable bowel syndrome.
Traditional Chinese medicine and diarrhea
Like constipation, TCM is claimed to be effective for many diarrheas. Also like constipation, no matter how it is treated, it must first be diagnosed clearly. The diagnosis of diarrhea in TCM has similarities to modern medicine, but is largely different. In TCM terminology, diarrhea is called cathartic diarrhea. It is not the same as diarrhea, and its characteristics are somewhat similar to the distinction between dysentery and watery diarrhea that was once used in Western medicine, but is now less common. In the Internal Medicine of Chinese Medicine, it is said that “those who have little fecal matter and have a slow tendency to leak are cathartic; those who have a large amount of fecal matter and have a straight and unobstructed tendency to pour out are diarrhea”.
As mentioned earlier, to treat diarrhea, we must first distinguish between acute diarrhea and chronic diarrhea. It seems that ancient Chinese medicine does not have the distinction between acute diarrhea and chronic diarrhea, but only modern published textbooks of Chinese medicine have such a classification. Perhaps most of the ancient people with acute diarrhea would not seek medical attention, one is that acute diarrhea generally lasts about two days, even the rich and famous would not just diarrhea for two days to find a doctor, not to mention the general public; two is that acute diarrhea is mostly accompanied by more pronounced nausea, vomiting, eating is not possible, not to mention the Chinese medicine. Even today, few TCM practitioners dare to prescribe medicine for people with acute diarrhea. Although there is a lack of medication, there are countless folk remedies for acute diarrhea, mostly dietary, with no less than dozens of types, mainly low-fat porridge, as well as acupuncture, moxibustion, tui na, ear acupuncture, and so on. Some of these methods are personal experiences, some are handed down from previous generations, and some are created by themselves according to the theory of Chinese medicine. It seems to be the “valuable experience of the working people”, but in fact, most of the acute diarrhea would have been cured quickly by itself, so these experiences are not mostly valuable, but only play a role of psychological comfort. But if it is a virulent diarrhea, such as cholera, typhoid and other virulent infectious diseases, the ancient people, including Chinese medicine, are helpless. The number of deaths from infectious diseases that have manifested themselves as diarrhea on a large scale in Chinese history is not low, but the reason why they did not die out is because of the characteristics of infectious diseases, as even the most powerful infectious diseases will gradually end. The so-called Chinese medicine to protect the Chinese people did not extinct is just an illusion. In conclusion, for acute diarrhea, except for infectious diseases and bacterial infections where modern medicine has a clear advantage, the role of Chinese and Western medicine is largely comparable and basically does not affect the natural course of the disease in most patients.
So the goal of TCM for diarrhea is primarily chronic, and chronic diarrhea is the treatment for the primary causes for which TCM is not recognized for its efficacy. What does it mean to be recognized? For medical professionals, it means that they can be found in authoritative guidelines and textbooks, especially international guidelines and textbooks. Guidelines and textbooks are not the golden rule, but are based on current evidence. If the evidence is faulty, the recommendations in the guidelines and textbooks will be faulty as well. The good thing is that the recommendations that go wrong are often tested in practice and corrected in the next edition. So reference guides and textbooks are generally based on the most recent edition. Like many things in this world, there are guidelines and Chinese guidelines, and one of the biggest differences is the TCM content in the guidelines. Some people may fantasize that one day the TCM content of Chinese guidelines will be included in international guidelines, but it is just a fantasy. First, there is no evidence of high-quality Chinese medicine; second, even in Chinese guidelines and textbooks, the figure of Chinese medicine is gradually disappearing. The author has summarized the contents of the 7th edition of Internal Medicine and the previous edition of Internal Medicine of the People’s Health Publishing House, and not only is there less space, but the power of TCM is also weakening.
In chronic diarrhea of organic origin, such as bacterial infection and inflammatory bowel disease, the etiology and pathogenesis are relatively clear, and not only is the treatment effective, but there are also very objective indicators of efficacy, such as endoscopy and serum component testing. In contrast, the evidence of TCM seems to be abundant, but it is not practical, as the so-called dietary disorders, emotional disorders, summer dampness and heat, weakness of the spleen and stomach, loss of liver drainage, deficiency of kidney yang, etc. cannot be quantified at all. Strangely enough, most of the identification of diarrhea in Chinese medicine has neglected the large intestine, which is most relevant to diarrhea. Since most of the organic chronic diarrhea has a chronic disease that does not heal itself, or even progresses, there is a risk of serious irreversible consequences if the diagnosis is delayed. The author has seen more than one patient with ulcerative colitis who, because of adherence to TCM treatment, waited until the basic structure of the large intestinal mucosa was completely destroyed by the time the symptoms worsened, and even if the inflammation was controlled and the blood in the stool ceased, the reabsorption function could not be restored and the diarrhea would continue.
Since organic diarrhea is risky, what about functional diarrhea in which organic pathology has been ruled out after modern medical examination? It is entirely possible that patients who have added TCM will be treated better than those who do not, because the symptoms of functional gastrointestinal disease are inherently subjective, and it is now almost impossible to find a commonly accepted better indicator of judgment that is unrelated to the patient’s competent sensation. For such patients, any additional attention can cause changes in the patient’s subjective sensations, not to mention additional medications and default trust in TCM. However, the safety of TCM cannot be ignored. Among the Chinese medicines commonly used to treat diarrhea: Radix et Rhizoma has cardiotoxicity, Yanhuzo has cardiac and renal toxicity, Huang Lian can develop hemolytic jaundice when taken by children, Hou Pao has nephrotoxicity, etc. Side effects can also be found in western medicines, but they are used in a trade-off. For example, for leukemia arsenic, which is toxic to humans, can be used because the risk of leukemia is comparable or even greater than the toxicity of arsenic. But if the treatment of diarrhea causes serious damage to other organ systems, it will not be worth the cost. In fact, the FDA has banned many effective drugs for diarrhea, albeit only a few per thousand, because their side effects are more harmful than the health effects of diarrhea, so even one case is not allowed to be used again.
In conclusion, diarrhea can be divided into acute diarrhea and chronic diarrhea according to duration; diarrhea is divided into osmotic diarrhea, exudative diarrhea, secretory diarrhea, and motility diarrhea according to pathogenesis; acute diarrhea mostly requires no treatment; chronic diarrhea caused by organic disease requires this treatment for etiology and pathogenesis; functional chronic diarrhea is more educational than pharmacological; the use of herbal medicine is not recommended for any type of diarrhea Treatment.