According to the U.S. Centers for Disease Control & Prevention, diarrhea is the second leading cause of death worldwide among children under five, and even adults can experience bouts from time to time. Experts at Baptist Health discuss the different types of diarrhea – yes, there are more than one – and their causes. They also share tips on how you can self-treat diarrhea at home and when you should see your doctor.
Host:
Jonathan Fialkow, M.D., Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health.
Guest:
Joel Calafell, M.D., General Surgeon at Baptist Health Medical Group specializing in colon and rectal surgery.
According to the U.S. Centers for Disease Control & Prevention, diarrhea is the second leading cause of death worldwide among children under five, and even adults can experience bouts from time to time. Experts at Baptist Health discuss the different types of diarrhea – yes, there are more than one – and their causes. They also share tips on how you can self-treat diarrhea at home and when you should see your doctor.
Host:
Jonathan Fialkow, M.D., Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health.
Guest:
Joel Calafell, M.D., General Surgeon at Baptist Health Medical Group specializing in colon and rectal surgery.
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Dr. Jonathan Fialkow:
Here's a scary fact. Odds are you've had and will have again, something that kills 1.5 million people a year. Can you imagine? More than suicide, homicide and terrorism combined. For centuries, dysentery was a death sentence to many. And if the word dysentery doesn't ring a bell, how about the runs or the troths or even the ever-present term diarrhea? Yep. 90% of deaths were due to it at one time. Men and women have lived with this as far back as recorded time allows, and yet it still plagues us. I'm your host, Dr. Jonathan Fialkow, a preventative cardiologist and leader at Baptist Health South Florida. And joining us today to explore this is Dr. Joel Calafell, a general and colorectal surgeon at Baptist Health Medical Group. Welcome to the podcast, Joel.
Dr. Joel Calafell:
Hi. Good morning John. Very nice to see you. Very nice to be here. I'm happy to talk about this somewhat embarrassing topic, but it's very important. And like you said, it was a big deal and it still is a big deal.
Dr. Jonathan Fialkow:
I guess people do tend to be embarrassed during the throes of it and whatnot, but it is a significant medical condition and I think you're here to help guide us as to what are the more simple common reasons people have diarrhea and what to do about it. But more importantly, when should we be concerned it's a medical problem, and what are the scenarios where it really can take one's life?
So let's kick it off, Joel, which is some basic concepts. So how do we define diarrhea? Maybe different things to different people. What would be the medical definition for diarrhea?
Dr. Joel Calafell:
That's a good one. And that's actually where I talk to a lot of patients in the office and also the hospital where they have one episode or maybe two episodes. The term diarrhea by the World Health Organization is actually three loose bowel movements in 24 hours. So if you've had less than that, technically it's not diarrhea. You just had a loose bowel movement; which can be caused by a number of things. You had a lot of water that day, you didn't have a lot of substance, so you had a runny or loose bowel movement. But if you're going to the bathroom 4, 5, 6 times a day and it is very running, very loose, then you, by definition, have diarrhea. And you... Go ahead John.
Dr. Jonathan Fialkow:
No, no, please go ahead.
Dr. Joel Calafell:
No, I was going to say, I always ask them, it's embarrassing questions, but it's my job as a colorectal surgeon, Well, what does the diarrhea look like? And people look at me like I have two heads.
Dr. Jonathan Fialkow:
Right, right.
Dr. Joel Calafell:
Like, Well what are you talking about? What do you mean? Well, it's important to know because there's actually three types of diarrhea. There's watery diarrhea, there's inflammatory diarrhea, and there's malabsorptive or slash fatty diarrhea. And they all have different looks and also different indications of when you have to go see a doctor or what's actually really going on in the body.
Dr. Jonathan Fialkow:
So that's actually interesting. As you described it, I'm thinking in different terms. For example, the difference between elevated blood pressure and hypertension. Hypertension is a different cause. It's when the blood pressure's elevated chronically in a resting state, but people can get frightened or scared and the blood pressure's up. And that's a kind of interesting way you put it as well, which is a loose bowel movement, which most of us will say, I just had diarrhea. It's not by the medical definition, it has to be more chronic for it to be considered diarrhea. So from the diarrhea standpoint of the [inaudible 00:03:31], three loose bowel movements, 24 hours, and you mentioned many different causes, what would be the more common causes and/or presentations of the less dangerous types? One of the more common reasons people would have that, but it's not necessarily a long-term problem. And feel free to get into whatever you want to get into, including what's in the toilet when you actually have the diarrhea.
Dr. Joel Calafell:
No, no problem. No, by far it's going to be the diarrhea that we experience from GI bugs, viral etiologies. We all hear about the runs that people have of these bad rhino viruses, rotoviruses on the cruise ships, things like that. Montezuma's revenge; when you go to Mexico and you drink the water. Typically it is bacterial and viral, by far, viral is the most common type of cause of gastroenteritis, which can lead to diarrhea. What caused dysentery, what you were talking about before, to be so deadly, is that people got infected. The problem was they would get reinfected, reinfected because they didn't have any access to clean filtered water. And that's where dysentery came from. It was from the water. So people would get over it, get a little bit better, drink the water and then have it again. And subjects succumb to dehydration, kidney failure and eventually pass away.
Now in the modern world, in the western world, in developed countries, you don't see as much dysentery anymore. However, you still see these viral etiologies come in and just cause havoc on our colons and our small intestines in the realm of diarrhea. Thankfully, most of the time, I'd say about 99% of the time you can get better on your own with good fluid hydration. I tell people all the time, I know the old, especially coming from a Cuban heritage, Drink soda and Gatorade, you'll be fine, no problem. Not always the best advice because sugar acts as an osmotic, could actually worsen the diarrhea. So actually Pedialyte is the best thing because Pedialyte has all the electrolytes you're going to lose without the high load of sugar. So that's the most important thing to do when you're having these episodes.
Dr. Jonathan Fialkow:
So most common viral, very prevalent in our society, generally self-limiting, not necessarily something that becomes a chronic problem, important to stay hydrated, which is what you're expressing. And not use concentrated sugar drinks; Pedialyte's in that formulation, otherwise water to stay hydrated from that standpoint.
By definition, do you need to have a fever with viral diarrhea? Or any other symptoms that would be associated with it? Or can people just have watery bowel movements on a regular basis?
Dr. Joel Calafell:
Typically the watery bowel movements is what comes. Fever is kind of rare. If you do spike a fever and it's a chronic fever, it's probably time to seek medical attention. You could be having a bacterial type of gastroenteritis, which again, sometimes can be self-limiting, but sometimes if you have one, like a bad strain of E.coli or shigella or things like that, you could need antibiotics. So I would then at that time, especially if your diarrhea turns from watery to bloody, that's something to be really alerted. And that's why I tell patients, if you see that time to start thinking about calling your PCP or even heading to the emergency room.
Dr. Jonathan Fialkow:
So that's kind of leading into a question I was going to ask, which is when should someone feel comfortable that, Hey let me just let this run its course, no pun intended, or actually seek medical attention? What should it look like? So you alluded to fevers not usually common with just a viral, you may have a low grade fever that's persistent or high. If it turns bloody from watery, I think we just elaborated that that was one of the components you might want because that may... And the reason is that might be bacterial, in which case antibiotics would be worthwhile. Whereas with a viral, antibiotics would've no function, right?
Dr. Joel Calafell:
No antibiotics will not be a function. And that's something that a lot of people have a big issue with that we deal with, is that people will get a little bout of diarrhea and they grab some antibiotic that they had from a leftover ear infection or a family member's antibiotic. Then you end up possibly getting something called C. diff, which is Clostridioides difficile infection, which essentially, I tell patients that we actually naturally have this bacteria in our colon. The problem is you take an antibiotic unadvised, and it kills all the good bacteria and now this bacteria is allowed to overrun your colon and produce toxins and give you very, very bad diarrhea. And if it gets out of control, it can be fatal and to a point where before it hits your mortality, it can kill off your colon and you have to come see me in the emergency room and I potentially have to take your colon out.
Dr. Jonathan Fialkow:
We actually just did a podcast with a prominent clinical pharmacist about super infections, antibiotics, stewardship, and I think your take home point is, you don't take antibiotics unless you need them. You should only take them under the discretion and supervision of a physician.
Dr. Joel Calafell:
Yeah. Any antibiotics or narcotics you have leftover in the house, take them back to the pharmacy. Don't keep them in the house.
Dr. Jonathan Fialkow:
So you mentioned different cause of diarrhea, or different presentation of diarrhea. Can you have blood in your diarrhea or in your stool, or let's say in the diarrheal illness, and it's still benign? Is that a pathognomonic of something that's more serious?
Dr. Joel Calafell:
Usually if you're having blood in the stools from diarrhea, it's time to speak to a PCP or get ahold of a medical professional. Granted, there are some patients that I have that have a history of, whether it be an anal fissure or a hemorrhoid, where a hard or a loose bowel movement will aggravate it and you'll see a little bit of blood. So you have to take that into effect as well. But when you're seeing blood in your stool with diarrhea, it's time to seek the help of a medical professional. Because could it be a bacterial diarrhea? Yes. But could it be also something a little bit more serious? Could it be an inflammatory diarrhea, which usually comes from Crohn's disease or ulcerative colitis. Usually about 30, 40% of the presenting symptom of those inflammatory bowel disorders is bloody diarrhea.
Dr. Jonathan Fialkow:
Just as a side note, what would be the other presenting illness signs of an inflammatory bowel disorder in addition to or besides diarrhea? Just again, I think the goal is if someone has a diarrheal episode, we want them to not panic and not run to the emergency room, [inaudible 00:09:31]. So where will be the other things that may make someone say, Hey, I better get checked out because I've got to [inaudible 00:09:37]
Dr. Joel Calafell:
If it's inflammatory bowel disease like Crohn's or ulcerative colitis, you could be having a lot of nausea as well, a lot of abdominal pain. And not just crampy abdominal pain, kind of more severe abdominal pain. The other thing, especially for Crohn's disease, let's say you had an abscess in that area that somebody like me had to cut and it's coming back or you're having more, that could also be a sign of Crohn's disease as well.
But when it comes to the diarrhea as well, most of the time when people have these gastroenteritis or bouts of the viral diarrhea, they don't have a lot of abdominal pain, they kind of just feel a little crampy. Once they get hydrated, they feel much better. Really, inflammatory bowel disease, they don't get better. They usually have to be seen pretty quickly.
Dr. Jonathan Fialkow:
So a couple other questions that I think are the kind of things that I get asked in my cardiovascular space, it shows you how prevalent this is. So just a side note, are diarrhea illnesses more likely in one age or the other? Or it can strike anyone at any time?
Dr. Joel Calafell:
It could strike anybody at any time, but definitely we see it more common in children, especially once the toddlers get out the daycare. And schools and daycares are just giant Petri dishes. And the thing is, the kids will drag it home and give it to everybody. So I mean, it's a good thing because it builds up their defense, their immunity to it so that they don't get it again. Or if they do, it's a less severe episode. But definitely the younger generation, the kids.
And then also the elderly generation. I think more for the elderly, I think it's just a dampen immune response is what really carries it to a more aggressive episode. I think that's the issue. Because obviously when you get older, seventy, eighties, even the 90-year-olds, we're seeing the grandparents and the great-grandparents, their immune system is not as robust. So a 1-2 day issue of diarrhea for a three-year-old is no big deal, but for an 85-year-old they can get dehydrated very quickly.
Dr. Jonathan Fialkow:
So once again, you've answered one of my upcoming questions. And the question was going to be, what kind of medical conditions or populations might be at a higher risk should they get diarrhea? And again, we're not talking about a loose bowel movement, but the three over 24 hours or more, which can obviously cause a lot of dehydration and electrolyte loss. You said, elderly, obviously? Any other medical conditions? If you have this medical condition and you have diarrhea, hey, get checked sooner than you might otherwise. Are there any other conditions that you would think off the top of your head?
Dr. Joel Calafell:
Definitely in terms of the age for inflammatory bowel disease, Crohn's disease and ulcerative colitis start young. Usually they start in the teens, early twenties. So if you're experiencing bouts of diarrhea that are just kind of unexplained, a little bit of blood in them as well, definitely probably tend to seek the attention from a medical professional. You probably need a colonoscopy to be evaluated.
Crohn's disease does have a bimodal peak. We do see a spike in the population around 60 to 70 years old. It's not nowhere near the size of the spike in the younger generation, but you do see it. So something to keep in mind of when you're dealing with an elderly patient that has these bouts of diarrhea.
Another one we get that's less common, it's called microscopic colitis, where it's typically a patient that has just bouts of non-bloody diarrhea, they've tried hydration, they've tried Imodium, it just doesn't get better. And it's not really severe, it's just more of annoyance. And usually I treat them with a colonoscopy, take a biopsy of the colon, and lo and behold the lining, the submucosal lining is inflamed. You don't grossly see it, you only see it under the microscope. And usually they require a treatment of steroids, and they do much better.
Dr. Jonathan Fialkow:
What can one do if they have diarrhea? And again, I'm going to say it every time, not a loose bowel movement, which hopefully is a one time or self-limiting thing. But if someone has diarrheal illness, what can one do? First place, are there over to counter therapies or, again, certain foods to avoid or eat? Can anyone do anything other than just wait it out?
Dr. Joel Calafell:
Yeah, no. So what you can do is obviously hydration. We talked about Pedialyte, water. The good one now is Gatorade Zero. If you don't like Pedialyte, Gatorade Zero is a great option.
Dr. Jonathan Fialkow:
And again, the premises avoid the sugar, right?
Dr. Joel Calafell:
Yes, avoid the sodas, avoid the high Powerade, Gatorade. Granted, they may make you feel a little bit better, but in the long run you may make your diarrhea worse. The things over the counter that you can get Imodium Lomotil, are things you can get. I usually tell people, be careful with those medications. They can easily cause the other issue, they can cause constipation. So in terms of turning on the dam, you may shut off the dam completely.
Dr. Jonathan Fialkow:
Yeah, yeah.
Dr. Joel Calafell:
So I usually tell people start with one to two pills and that's it. Don't take any more than that. It usually works very well. If the diarrhea is lasting more than three to four days, I would give a call to your PCP.
Dr. Jonathan Fialkow:
Okay, great advice.
And my last question would be, anything one could do to avoid diarrhea? Well, obviously hygiene's important. But what about things like any supplements, probiotics? Maybe you could talk about any things that can help create a healthier microbiome. What really works, what doesn't work.
Dr. Joel Calafell:
And that's becoming a hot topic in the colorectal world. And even the gastroenterology world is like, what is this microbiome. Is it not only good for the intestinal system, but is it all good for our overall health, our mental health? There's been a lot of studies out there that if you treat somebody's chronic constipation, they're a much happier person. I would be too.
Dr. Jonathan Fialkow:
Fantastic
Dr. Joel Calafell:
Same thing can go with diarrhea. But a well-balanced diet is the key. Probiotics I think are helpful. I don't think they're your all-in-one magical potion. Because you can get those healthy bacteria in a well-balanced diet, especially fiber and yogurt and dairy that have those bacteria in it naturally, especially fiber. Fiber's huge. If you don't have enough fiber in your diet one, the probiotic doesn't work because what happens is, fiber works in two ways to keep your colon healthy. One, the sugars that are in the fiber, your body, your colon, digest them, and that creates bacteria. And that actually causes motility in your colon to have a healthy bowel movement. And that's the importance of it.
Obviously stay away from water that you know is not clean. So when you're on a hike, don't drink the water from the spring. You don't know where it's coming from. You don't know what animal did its business.
Dr. Jonathan Fialkow:
Yeah.
Dr. Joel Calafell:
Just upstream. Those are things you have to be worried about. Really clean water. If you're around pikes and things like that, that you're just drinking unfiltered, healthy water, you're putting yourself at risk for one of these diseases.
Dr. Jonathan Fialkow:
Great advice. Again, healthy, balanced diet. Lots of fiber, fermented foods. You say yogurt, kimchi, sauerkraut. They sound silly, but they do have health benefits for your bowel. They like them.
Dr. Joel Calafell:
Veggies and your fruits are huge. Always have your veggies and fruits. And especially, I get this one a lot. People will come to me, they're like, Oh, I eat fruits all the time, why don't I have enough fiber? Not all fruits have fiber.
Dr. Jonathan Fialkow:
Correct.
Dr. Joel Calafell:
You got to go for the fruits that have skin on them. The apples, the pears, the plums, all those stuff. I have one patient that says, Oh, I have six bananas a day.
Dr. Jonathan Fialkow:
No, no.
Dr. Joel Calafell:
Bananas actually plug you up more than anything.
Dr. Jonathan Fialkow:
Yeah, yeah. I say you squeeze an apple, you get water and juice. You squeeze a banana, you get nothing. You get mush in your hand. So yeah, you want the fruits where you're eating the skin, not while you're peeling the skin. Just eating the sugar.
Dr. Joel Calafell:
Yes, eat the skin. That's important.
Dr. Jonathan Fialkow:
Great advice. Great, great, great information. Again, I always love podcast guests that I learned from as well.
So any final comments or anything we missed that you want the listeners to know or anything you just want to emphasize?
Dr. Joel Calafell:
No. Just diarrhea, it's a very real thing. It's something we don't like to talk about a lot, but it can cause a lot of issues, especially if it's a very chronic thing that can lead to more serious things like Crohn's disease, ulcerative colitis. But if you're just at home and not hydrating yourself, I mean you can go into kidney failure, you can put yourself into a lot of medical issues. So definitely, if you see the warning signs, I tell people, if you're having a lot of abdominal pain, you see blood in your stool, get some help. There's something going on.
Dr. Jonathan Fialkow:
Awesome.
Dr. Joel Calafell, who's general and colorectal surgeon at the Baptist Health Medical Group, appreciate your insights, your time, and obviously your passion and expertise in this difficult sometimes to discuss subject. To our listeners, if you have a comment or a suggestion for a future topic, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. We'd love to hear from you, and thanks for listening.