Diarrhea affects most people living with HIV at one time or another.
While some individuals have found the right combination of food or medications to make diarrhea manageable, for others it is a living nightmare, putting limitations on their daily activities and significantly impacting their quality of life.
Acute (severe and serious, but for a short time) or chronic (long-term, constant) diarrhea can cause vitamin and mineral loss, weight loss and eventual wasting without adequate food compensation. Therefore, body weight and composition needs to be monitored on a regular basis. If fluid and electrolyte balance are not returned to normal, severe diarrhea can lead to dehydration and death.
Causes and Treatments
HIV infection, medications, malabsorption, lactose or food intolerance, small bowel bacterial overgrowth, irritable bowel syndrome and pathogen sources (bacterial, viral, mycobacterial, protozoal and fungal) can all cause diarrhea. More severely immunosuppressed individuals may suffer from diarrhea more frequently and for longer periods of time than others.
Highly active antiretroviral therapy (HAART) has resulted in fewer incidences of the more serious and infectious kinds of diarrhea, such as microsporidia and cryptosporidia. Individuals with T-cells above 200/mm3 are less likely to have CMV or MAC, and can usually spontaneously clear infections caused by cryptosporidium with T-cell counts between 200 and 300 and higher. However, diarrhea related to protease inhibitors is frequently reported and can be persistent.
While symptoms of diarrhea can be treated with some degree of success, determining the cause of the diarrhea is important. Dr. Michael Poles, a gastroenterologist attending at UCLA Medical Center says that if he has a patient with diarrhea of uncertain cause, he repeats the gastrointestinal workup every six months just to be sure nothing has been missed. Contact your physician if diarrhea persists more than a few days or if you notice any change in stool frequency, consistency, color or smell.
Evaluating the Cause
An exam and review of an individual's medical history is where the search for a cause for the diarrhea should begin, says Dr. Poles.
Questions about diet, recent travel, new medications, and usual stool patterns are important bits of information. Some topics that might be covered include:
Number of stools a day
What time of day
Element of urgency
Consistency: loose, watery, food particles (looks like lunch)
Smell: different, foul-smelling
Appearance: greasy, oily, color, any visible blood
Volume: large or small amount
Consumption of dairy products
Any fever, chills, pain, or vomiting
Change in appetite
Any weight loss
Review the Diet
Keeping a diary of food and medication is a good idea, advises Dr. Poles.
A daily record of your food and drug intake is an easy, non-invasive, fact-finding method that may provide clues to the cause of the diarrhea or what's making it worse.
Dr. Poles cautions his clients against self-diagnosing the cause of diarrhea, however. If stopping dairy products and cutting back on fat does not stop the diarrhea, one should seek medical advice.
In keeping a diary, write down the time you eat, what you eat and drink, plus any medications taken during the day. Write down the time of the diarrhea or other symptoms like gas, bloating, belching or nausea. Discuss information with your physician and dietitian. Eliminating some food items from your diet for awhile may be necessary to find out if certain foods are making the diarrhea worse.
Try to notice if milk or dairy products cause bloating and gas. Do French fries or donuts lead to diarrhea? Does that morning cup of coffee set off the diarrhea? These are foods/beverages that frequently cause diarrhea or make it worse. Avoid dairy items that contain lactose like milk, ice cream, frozen yogurt, cream soups, chocolate and soft cheeses. Yogurt with live cultures may be OK to eat.
Lactose can also be found in medications. For those who are very sensitive, taking a lactaid tablet or two with medications that contain lactose may be helpful. Ask your pharmacist if any of the medications you are taking contain lactose.
Too much fat in the diet might be a problem. Cut back on butter, sour cream, greasy foods, fried foods, donuts and French fries. Foods high in insoluble fiber such as bran muffins, bran cereals, whole wheat products, brown rice, salads and berries are usually a good idea, but may be too much fiber at this time.
Caffeine, which can be found in coffee, tea, colas, and chocolate, can cause diarrhea or make it worse. One cup of coffee can be enough to cause diarrhea in some individuals. Try skipping coffee or substitute decaffeinated beverages.
Caffeine can also be found in aspirin or other pain medication. Know whether your medications need to be taken with food. Will you need a little snack, or a full meal for best absorption and to reduce the risk of drug resistance. Norvir and Fortovase require a substantial meal to maximize absorption, but the full meal can help minimize the drug's side effects.
There are many foods that you can eat every day that can help firm up the stool. The bottom line is to eat several of these foods daily while avoiding the problematic foods and beverages.
Types of Diarrhea
An episode of diarrhea may stem from problems in the small bowel and/or large bowel.
After food leaves the stomach it enters into the tube called the small bowel, small intestine, or gut. The small intestine is about 20 feet long and is divided into three parts; the duodenum, jejunum and ileum.
The small intestine is where most of the digestion (food broken down into smaller fragments/nutrients) and absorption (nutrients getting into the blood) of food takes place. Large stool volume, somewhat infrequent, diarrhea at night, possible mild cramping, bloating or gas, and weight loss suggests small bowel disease. Diarrhea of the small bowel can lead to weight loss and malnutrition more so than diarrhea stemming from the large bowel.
Large bowel problems are suggested by small stool volume but more frequent movement, abdominal pain and tenderness, stools with blood or mucous, feelings of urgency and rectal spasm, with or without fever. The large bowel or large intestine begins where the ileum segment of the small intestine ends. It is about five feet in length and is mainly concerned with transporting undigestible food to the rectum, and with absorption of water and minerals and certain vitamins. The large bowel ends at the anus.
Diarrhea can occur when the intestine is having trouble digesting foods and food remains in the small bowel causing excess water to be pulled into the area. This is sometimes called osmotic diarrhea. This can happen with lactose or other sugar intolerances, antacid use, or some laxatives. Eating foods containing sugar substitutes such as sorbitol or mannitol, which are common in diabetic candy, chewing gum, and breath mints can cause diarrhea. The diarrhea should stop once you are no longer eating these items if they were the cause of the diarrhea.
Secretory Diarrhea and Malabsorption
Diarrhea can occur because large amounts of water are pumped into the intestine. This is sometimes called secretory diarrhea. Viruses of the intestine, bacterial toxins, parasites, tumors, irritable bowel disease, unabsorbed dietary fat, castor oil, and bile acids (compounds that aid in digestion and absorption) can be the cause.
Foods not being absorbed normally (malabsorption), can produce either osmotic or secretory diarrhea. It may be due to the surface of the small intestine being damaged by infectious agents which then interferes with the digestion and absorption of fat, starch, other nutrients and medications. Fat malabsorption is a frequent cause of diarrhea.
One of the first stool studies Dr. Poles does is a 24-hour quantitation -- determining how much fat is in the stool. He will prescribe pancreatic enzyme replacement if 24-hour stool fat levels are high. In the body, pancreatic enzymes are released by the pancreas and help with food digestion. Pancreatic enzymes usually include lipase which helps with fat digestion, and amylase which helps with starch digestion.
Altered Intestinal Transit Time
After swallowing food, it usually travels through the stomach and intestines at a speed that allows time for digestion and absorption.
Some HIV medications, such as Videx (ddI), Norvir (ritonavir) and Viracept (nelfinavir) can cause food to pass more quickly through this area, causing undigested food to be rushed through and into the toilet bowl in less than one hour after eating. This is sometimes called altered intestinal transit time. Think of it as food now traveling at 20 miles per hour instead of 5 miles per hour.
This is a good place to increase those green light foods. The soluble fiber which they contain can help bind up the excess fluid and slow down the passage of the food, allowing for increased absorption and firmer stools. Anti-motility drugs such as Lomotil or Imodium may be prescribed. Both have been somewhat successful in slowing down the diarrhea, but an interesting thing is that Lomotil contains sorbitol, and Imodium contains lactose in the tablet or capsule formula.
When no obvious cause of diarrhea can be found, the physician may point the finger at medications or label the cause as HIV enteropathy.
HIV enteropathy means disease of the intestine. Even though this may be a diagnosis of exclusion, HIV can disrupt the protective surface of the intestine and allow the virus to cause trouble.
Regardless of the type of diarrhea, do not neglect the symptoms and discuss diarrhea with your doctor.
Free Community Education Forums on dealing with side effects, offered regularly at AIDS Project Los Angeles, include discussions on diarrhea. Call (323) 993-1612 for the next class date. Fact sheets on diarrhea and diet are also available in APLA's HIV Resource Center.
Etiology of Diarrhea in HIV-Infected Patients
|Mycobacterium avium complex (MAC)|
|Source: "HIV-Associated Diarrhea" by Edward Lew, M.D., Michael Poles, M.D. and Douglas T. Dieterich, M.D., PAACNOTES, October 1993.|
Janelle L'Heureuax, M.S., R.D., is a nutrition advocate in AIDS Project Los Angeles' Client Health Education and Advocacy Program. She can be reached by calling (323) 993-1556 or by e-mail at jlheureuax@APLA.org.