Diarrhea, Acute

What Is Acute Diarrhea?

[dropcap]A[/dropcap]cute diarrhea is a small intestinal motility disorder characterized by excessively rapid movement of intestinal contents through the small intestine with excessive loss of fluid and electrolytes that leads rapidly to a life threatening hypokalemia (low potassium blood level) and acidosis.

Q: What is hypokalemia?

A: Hypokalemia is characterized by dehydration that may result in vascular collapse, muscular malfunction that may result in paralytic ileus (bowels do not move), paralysis (cannot stand), and respiratory hypoventilation (shallow breathing) or failure, metabolic acidosis resulting from diarrhea, and impaired nerve conduction.¹

While diarrhea may be a common symptom of small bowel mucosal disease, the consequent malabsorption can lead to substantial malnutrition and nutrient deficiencies. The small intestine, unlike the colon, has been relatively inaccessible, and systematic evaluation is often necessary to identify and treat small intestinal mucosal diseases that lead to diarrhea. All patients with severe diarrhea or diarrhea associated with features suggestive of malabsorption may have a disease of the small intestinal mucosa that requires careful evaluation and targeted management.²

What Is Acute Diarrhea In Celiac Disease and/or Gluten Sensitivity?

• Acute diarrhea in celiac disease is called celiac crisis. It is a life-threatening syndrome in which patients with untreated celiac disease have profuse diarrhea and severe metabolic disturbances.³
• Celiac crisis has an acute onset or rapid progression of diarrhea that are attributed to celiac disease and require hospitalization and/or parenteral nutrition, along with signs or symptoms of dehydration or malnutrition.⁴
• Acute diarrhea that resists medical treatment must evoke the hypothesis of celiac disease and lead to gastroscopy with duodenal biopsies not only to obtain rapid disappearance of the clinical signs after introduction of a gluten free diet, but also to avoid an increased risk of small bowel malignancies.⁵
• Celiac crisis, described mainly in children younger than two years of age, has become very rare due to earlier diagnosis and effective therapy of the disease. Nevertheless, it should be considered in the differential diagnosis, even in adults suffering from acute diarrhea and acidosis.⁶

How Prevalent is Acute Diarrhea In Celiac Disease and/or Gluten Sensitivity?

Acute diarrhea as the presenting symptom of celiac disease is more common in infants and young children than adults.

Acute severe onset of celiac disease is very uncommon in adults.³

What Are The Symptoms Of Acute Diarrhea?

Acute diarrhea in celiac disease is marked by  these symptoms:

• Passage of fluid or unformed non-bloody stools.
• Profound weakness.
• Inability to stand.
• Low blood pressure.
• Dizziness.
• Anorexia.
• Thirst.
• Vomiting.
• Tremor.
• Muscle spasm.
• Drowsiness.
• Anxiety.
• Confusion.
• Personality changes.
• Premature ventricular and atrial contractions.⁵

How Does Acute Diarrhea Develop In Celiac Disease and/or Gluten Sensitivity?

• Acute diarrhea in celiac disease results from these mechanisms:

• Osmotic action of undigested solutes (dissolved substances) in the intestine which draw large quantities of fluid into the intestine.
• Excessive fermentation of undigested matter.
• Dysbiosis.
• Altered motility that passes the food matter through too rapidly.

• Zinc deficiency aggravates diarrhea.

Does Acute Diarrhea Respond To Gluten-Free Diet?

Yes. Celiac disease-related acute diarrhea disappears on gluten free diet.⁵ Fluids need to be restored quickly by intravenous infusion, potassium deficiency needs to be corrected, and corticosteroids may need to be administered.⁷

In a review study of 12 patients with acute severe diarrhea, all patients required hospitalization and intravenous fluids, 6 required corticosteroids, and 5 required parenteral nutrition.⁸

Nutritional support often is required in the short term but most patients ultimately respond to gluten avoidance.⁴

6 Steps To Improve Acute Diarrhea In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both diarrhea and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁹
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹⁰
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹⁰
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹⁰.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹⁰
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹⁰
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹⁰[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

• [dropcap]4[/dropcap] Manage Your Medications Safely:

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Certain prescription drugs cause zinc deficiency, which aggravates acute diarrhea, and potassium deficiency, which rapidly develops from diarrhea.  Since both deficiencies need to be corrected to treat acute diarrhea, the doctor needs to know if you are taking any of these drugs because of their additive effects. Ask your doctor or pharmacist about this possible adverse effect. Do not stop prescribed medications without supervision.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Zinc, Potassium.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Zinc,  Potassium.
• Alka Seltzer®, Baking Soda deplete Potassium.

ANTIBIOTICS disrupt intestinal permeability.

•  Tetracyclines deplete Zinc.
• Cipro depletes Zinc.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Zinc.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Zinc.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Zinc.
• Foscanet depletes Potassium. 

CARDIOVASCULAR DRUGS

• Antihypertensives (Catapres®, Aldomet) deplete Zinc.
• ACE Inhibitors (Capotenv, Vasotec®, Monopril® and others) deplete Zinc.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete  Zinc.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Potassium. Zinc.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Potassium, Zinc.

FEMALE HORMONES disrupt intestinal permeability.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete  Zinc.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Zinc.[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Chelated zinc as prescribed for deficiency, but do not take at same time as calcium because they compete for absorption.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Acute Diarrhea In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Celiac crisis is a rare but serious complication of celiac disease in adults.” Celiac crisis is rare among adults and not well documented. This study aiming to improve awareness of celiac crisis and to facilitate diagnosis, reviewed cases of celiac crisis to identify presenting features, formulate diagnostic criteria, and develop treatment strategies. Celiac crisis was defined as acute onset or rapid progression of gastrointestinal symptoms that could be attributed to celiac disease and required hospitalization and/or parenteral nutrition, along with signs or symptoms of dehydration or malnutrition.

Twelve patients met preset criteria for celiac crisis; 11 developed celiac crisis before they were diagnosed with celiac disease. Eleven patients had increased levels of transglutaminase antibodies and 1 had immunoglobulin A deficiency. Results of biopsy analyses of duodenum samples from all patients were consistent with a Marsh 3 score (33% with total villous atrophy). Patients presented with severe dehydration, renal dysfunction, and electrolyte disturbances. All patients required hospitalization and intravenous fluids, 6 required corticosteroids, and 5 required parenteral nutrition. All patients eventually had a full response to a gluten-free diet.

Conclusions: Celiac crisis has a high morbidity and, although rarely described, occurs in adults and often has a clear precipitating factor. Patients who present with severe unexplained diarrhea and malabsorption should be tested for celiac disease; treatment with systemic steroids or oral budesonide should be considered. Nutritional support often is required in the short term but most patients ultimately respond to gluten avoidance.⁴

CASE REPORT SUMMARIES

“Quadriplegia due to celiac crisis with hypokalemia as initial presentation of celiac disease: a case report.” Celiac crisis is a rare, life-threatening complication of celiac disease characterized by worsening of clinical symptoms, multiple metabolic derangements and shock. We report an 8-year-old girl with previously undiagnosed celiac disease who presented with flaccid quadriparesis secondary to severe hypokalemia associated with celiac crisis. Diagnosis was expedited by an elevated anti-tissue transglutaminase antibody titer. The patient improved with correction of hypokalemia, corticosteroids and gluten-free diet. In tropical countries such as India, where both acute flaccid paresis and diarrhea are usually of infective etiologies, this rare clinical condition should also be considered in the differential diagnosis of both.¹¹

“Celiac crisis with quadriplegia due to potassium depletion as presenting feature of celiac disease.” This case report describes undiagnosed celiac disease revealed by quadriplegia due to potassium depletion in a 26-year-old woman who presented with a suddenly developed weakness of all four limbs and a severe diarrhea. Authors emphasize celiac crisis, which is a presenting feature of celiac disease, characterized by acute diarrhea with life-threatening acid base and electrolyte abnormalities. The patient improved with correction of hypokalemia and gluten-free diet.

“A severe acute diarrhea with metabolic and systemic complications, the so-called coeliac crisis, is a possible presenting clinical feature of a previously undiagnosed adult celiac disease.”¹²

Sources:

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5. Mennecier D, Rimlinger H, Rapp C, Bredin C, Corberand D, Vergeau B. Acute diarrhoea revealing a coeliac disease. La Presse Medicale. Apr 24, 2004;33(8):530-2. [↩] [↩] [↩]
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7. Bhattacharya M, Kapoor S. Quadriplegia due to celiac crisis with hypokalemia as initial presentation of celiac disease: a case report. J Trop Pediatr. 2012 Feb;58(1):74-6. doi: 10.1093/tropej/fmr034. Epub 2011 Apr 27. [↩]
8. Jamma S, Rubio-Tapia A, Kelly CP, Murray J, Najarian R, Sheth S, Schuppan D, Dennis M, Leffler DA. Celiac crisis is a rare but serious complication of celiac disease in adults. Clin Gastroenterol Hepatol. 2010 Jul;8(7):587-90. doi: 10.1016/j.cgh.2010.04.009. Epub 2010 Apr 24. [↩]
9. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
10. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
11. Bhattacharya M, Kapoor S. Quadriplegia due to celiac crisis with hypokalemia as initial presentation of celiac disease: a case report. 2012 Feb;58(1):74-6. doi: 10.1093/tropej/fmr034. Epub 2011 Apr 27. [↩]
12. Atikou A, Rabhi M, Hidani H, El Alaoui Faris M, Toloune F. Celiac crisis with quadriplegia due to potassium depletion as presenting feature of celiac disease. Rev Med Interne. 2009 Jun;30(6):516-8. doi: 10.1016/j.revmed.2008.11.012. [↩]