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Diarrhea

The IBS-D Subtype
What Causes the "D" in IBS-D?
IBS-D vs Functional Diarrhea
Is It Just IBS-D?
Create Your Diarrhea Game Plan
How Do You Experience Diarrhea?
Rescue Strategies
Proactive Strategies
Menstrual Cycle and Perimenopause
Aging and Diarrhea

If diarrhea is the IBS symptom you'd like to tackle, then this section is for you.

Find out more about IBS-D, it's relationship to other subtypes and other conditions it may be linked to.

Get lots of tips for creating your own diarrhea game plan, including rescue strategies to relieve diarrhea right now and proactive strategies that give you a better chance of not having diarrhea at all!

At the end you'll find some info about diarrhea in different stages of life.

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Video Transcript

The IBS-D Subtype

If more than 25% of your bowel movements are Bristol Stool Form types 6 or 7 (loose/watery) and fewer than 25% are types 1 or 2 (hard/lumpy), then you probably fall into the IBS with Diarrhea (IBS-D) subtype.

Keep in mind that these are guidelines and you can have other types of stools and even some normal stools and still be considered as an IBS-D subtype.

Diarrhea that wakes you up at night is not normal if you have IBS-D. The gut naturally slows down and rests during sleep, so IBS-D typically causes symptoms during the day that are triggered by meals or stress.

Diarrhea at night is usually considered to be a red flag and you should tell your doctor.

Some other symptoms of IBS-D include:

Sudden or urgent need to use the bathroom
Abdominal discomfort, cramping and pain
Bloating, distension and excess gas
Nausea, heartburn, reflux, belching

Diarrhea and Constipation?

Yes, it's possible to have both.

Long-term constipation can lead to fecal impaction, which means that poo has built up in the rectum. The main symptom is diarrhea, which leaks through the build-up of solid poo and is known as overflow diarrhea. Please see your doctor if you think this may be the case.

IBS-M (Irritable Bowel Syndrome with Mixed bowel habits), is another subtype of IBS that alternates between constipation and diarrhea.

What Causes the "D" in IBS-D?

There are many factors and body systems that could be involved in your diarrhea if you have IBS-D.

Keep in mind that not all of them are well understood and research is ongoing. In time, this subtype may be further subdivided as we learn more about the underlying drivers of IBS.

Although the exact combination can vary from person to person, IBS-D is thought to be primarily caused by the following factors. But everything is connected, so go to What Causes IBS? for more info.

Accelerated GI Motility

Things move too quickly through the entire GI tract, which means there isn't enough time for water to be absorbed. As a high volume of watery fluid moves downstream, it can overstimulate the colon and cause powerful contractions that rush waste to the rectum.

Some components of foods and other metabolites can draw water into the GI tract, making things worse.

Gut-Brain Miscommunication

This can disrupt normal motility (movement) in your GI tract.

Dysbiosis

Some people with IBS-D have an imbalance in the communities of microorganisms living in their gut. This can affect motility in many ways.

These physiological issues are often worsened by external triggers like mismanaged stress, poor diet, common triggers, FODMAPs, meal hygiene, poor sleep, lack of movement and dehydration.

IBS-D vs Functional Diarrhea

There are a lot of similarities between IBS-D and a diarrhea subtype known as functional diarrhea (FD). FD is diarrhea with no obvious underlying cause.

The big difference between the two subtypes of diarrhea is pain and discomfort. If they are regularly associated with your symptoms, then you probably have IBS-D. IBS-D pain is associated with visceral hypersensitivity (VH), which causes the threshold for pain in the GI tract to be lower than normal. Bothersome bloating is also not included in a diagnosis of FD.

Treatment strategies differ, so it's important to know which subtype you have. If you're on this site be sure to have your IBS diagnosis.

Is It Just IBS-D?

There are a number of conditions that present with chronic diarrhea that are not IBS-D and should have been ruled out before you received your IBS-D diagnosis. These include conditions like celiac disease, diverticulitis, lactose intolerance, microscopic colitis, IBD, pancreatic insufficiency, hyperthyroidism and GI infections.

But there are also conditions that are a bit sneakier and may not have been caught during your initial diagnosis. Conditions that are sneaky because they can more easily masquerade as IBS-D or they can occur alongside IBS-D, often making symptoms worse.

Don't go looking for trouble!

If you've been diagnosed with IBS-D, first try management strategies for IBS.

If nothing works for you, then consider talking to your doctor or dietitian about other conditions.

Bile Acid Malabsorption (BAM)

Bile acids are squirted from your gall bladder into your intestine to help your body digest and absorb dietary fats. Normally they're reabsorbed near the end of your small intestine. BAM allows too many bile acids to make it through to your large intestine, where they can cause diarrhea.

BAM diarrhea is generally watery and loose, pale or yellow coloured because of the unabsorbed bile and very bad smelling and frothy. There is often urgency, especially after eating.

It's estimated that BAM occurs in 25-30% of people with IBS-D. If first line IBS-D treatment strategies aren't working as well as they should, some people with IBS-D may experience diarrhea relief from medications for BAM.

Small Intestinal Bacterial Overgrowth (SIBO)

SIBO occurs when there are excess bacteria in the small intestine, where bacterial counts are normally low. As food passes through, those bacteria ferment it and produce gas, triggering symptoms similar to IBS-D. Not everyone who has SIBO will experience symptoms.

It's possible to have both SIBO and IBS. SIBO is often diagnosed using breath testing, however these tests are not always reliable.

Endometriosis

This is a condition in which tissue similar to the lining of the uterus grows outside the uterus. Many symptoms overlap with IBS. Symptoms can be very different from person to person, just like IBS, and it might not be easily diagnosed. It's also possible to have endometriosis and IBS.

Tell you doctor if you also have any of the following symptoms which are not symptoms of IBS: severe pain during periods, sex, bowel movements or peeing, chronic pain in your pelvis (all the time), heavy bleeding during or between periods, irregular periods, trouble getting pregnant.

Histamine Intolerance (HIT)

HIT occurs when a person has a low level of DAO, an enzyme that breaks down histamines. When they eat histamines or histamine-producing foods, the chemical can build-up in the body and cause GI symptoms similar to IBS. Histamine is a link between the gut's immune system, nervous system and microbiome and is considered to be a key mediator in IBS.

This is a developing area of research, but there is evidence that some people with IBS have lower levels of the DAO enzyme. Unfortunately, there are not yet tests that can confirm a diagnosis of HIT. A reduction in IBS symptoms after following a histamine-reduced diet is currently the only way to tell if HIT is an issue.

Genetic Sucrase Isomaltase Deficiency (GSID)

GSID is caused by a gene mutation that impairs the ability to digest sucrose and certain starches. In the past it was considered a rare condition, affecting infants who had chronic diarrhea when sucrose was added to their diet. But growing evidence is suggesting that some genetic variants may present later in life, with symptoms similar to those of IBS-D. Damage to the membrane of the intestine could also affect the production of the SI enzyme.

People with IBS-D may also have GSID, although the genetic defect is a good mimic of IBS symptoms and could also lead to a misdiagnosis of IBS-D. If you've tried the FODMAP diet and it didn't work for you (making sure it was followed correctly), then it may be worth exploring a diet for GSID. Keep in mind this is a very restrictive diet, so talk to your doctor or dietitian before you consider it.

Pelvic Floor Dysfunction

The muscles in your pelvic floor need to be coordinated for normal bowel movements. They should tighten at the right time to hold stool, allowing you to get to the toilet in time. If the muscles in your pelvic floor lack strength or control, you may suffer from involuntary loss of stool—known as fecal incontinence—or bowel urgency.

It's possible this could be making your IBS-D symptoms worse. Check out the Pelvic Floor Therapy section for more info.

Create Your Diarrhea Game Plan

Just like any game plan, different situations require different plays.

People experience diarrhea in different ways and for different reasons. The first step in creating your own diarrhea game plan is to understand how you experience diarrhea. Check out the following section How Do You Experience Diarrhea? for some advice about playing digestive detective.

Your personal diarrhea game plan should also be two-fold. Check out Rescue Strategies for things you can try if you're already experiencing diarrhea and Proactive Management Strategies for building habits that will help prevent you from having diarrhea in the first place.

Read on for some game plan tips!

Don't Panic!

Regular bowel moments are considered 3 times per day to every 3 days and it's normal to have fluctuations in bowel habits. Getting stressed about pooping will only make things worse.

Once you've created your game plan, use your short and long term strategies to get back on track.

Be Proactive

The longer you live with the unpredictability of diarrhea, the more stressful it becomes and stress can make diarrhea worse. So don't wait until your diarrhea is really bad before you do something about it. Figure out which rescue strategies work for you.

Proactive management is even better. Building healthy habits that support digestion and discovering your IBS-D triggers means you won't have to rely as heavily on rescue strategies in the first place.

Get Help from the Pros

Poo is a taboo subject for a lot of people, but it shouldn't be. Everybody does it and it's a necessary bodily function.

So talk to your doctor and, if you can afford it or get access, a registered dietitian (preferably one that specializes in gut health).

How Do You Experience Diarrhea?

Understanding your own diarrhea experience can help you discover strategies that work for you. Having IBS, of course, presents its own challenges and you may have to try additional strategies that are not standard for other types of diarrhea.

Everybody is different, but there are a few common characteristics of IBS-D diarrhea. If you experience symptoms associated with other types of diarrhea, you may want to talk to your doctor.

The timing of your diarrhea could give you some clues about management strategies that may work for you.

IBS-D Diarrhea

IBS-D diarrhea is characterized by frequent loose and watery stools and urgency.

Altered motility (hyper-motility) in the gut is the primary underlying cause of IBS-D. Muscles in the gut tend to contract too fast or have strong spasms. Waste moves through the system too quickly and the large intestine doesn't have enough time to absorb water from the stool.

Osmotic mechanisms can act as a trigger or make things worse. Osmotic diarrhea occurs when poorly absorbed substances stay in the bowel and pull water into the intestines by osmosis. In IBS-D, these substances are often FODMAPs and could also be bile acids. The water, combined with the rapid fermentation by gut bacteria in the case of FODMAPs, creates gas and distension. This can trigger the already hyperactive motility reflexes of an IBS gut.

Bloody diarrhea or greasy, pale, foul-smelling stools that often float are not typical of IBS-D and could point to an inflammatory condition or fat malabsorption.

Waking during the night because of diarrhea or unexpected weight loss are also not normal IBS-D symptoms.

Talk to your doctor if you experience any of these warning signs.

Timing of Diarrhea

The timing of your diarrhea may give you some clues about strategies you can try.

When people experience diarrhea, they often thing about what they ate most recently to try and figure out what triggered their symptoms. But it can actually take somewhere between 12 and 48 hours for things to move between the mouth and the anus. There are also other factors besides food and drink that can lead to diarrhea if you have IBS-D.

Shortly After Eating

Studies show that some people with IBS-D have an exaggerated gastrocolic reflex. This reflex triggers strong colon contractions shortly after eating to make room in your colon when your body senses food entering your stomach. If urgency or diarrhea strike within 30 minutes of a meal, this may be an issue for you.

Try: Smaller, more frequent meals and lower fat meals, mindful eating, gut-directed calming techniques like breath work or gut directed meditations before a meal, anti-spasmodic medications or supplements like peppermint oil.

Since digestion can take many hours or even days, the intestines always contain things from previous meals. When you eat, they are moved along by your gastrocolic reflex. If they contain FODMAPs or other trigger foods, the diarrhea you experience shortly after eating may have nothing to do with the meal you just ate. This can be confusing and lead to unnecessary food restrictions.

Try: Keeping a food diary and looking at the last 48 hours before experiencing diarrhea, considering other factors like unmanaged stress or disordered eating that could affect your gut.

In the Morning

Your gastrocolic reflex and colon activity are generally strongest in the morning, mainly due to your body's circadian rhythms. Your master brain clock and peripheral gut clocks work together to start ramping up bowel motility right after you wake up. If your gut is already moving too quickly, this could make matters worse.

Try: Avoiding high-fat, spicy and late night dinners, limiting alcohol in the evening, not having coffee or artificial sweeteners first thing in the morning, protecting time first thing in the morning for stress management strategies like yoga or meditation.

Before Stressful Events

If your diarrhea flares up before potentially stressful events like presentations, travel or first dates, then it's probably due to the effect of anxiety and unmanaged stress on the body systems involved in the gut-brain axis.

Try: Stress management strategies, planning ahead to reduce stress, pre-emptive scheduling of anti-diarrheals

Rescue Strategies

The ultimate goal of long term IBS management is to reduce symptoms, including diarrhea. Because the truth is it's impossible to control every aspect of your life at all times and sometimes diarrhea happens. It may also take some time to figure out the IBS strategies that work for you and to establish helpful habits, so you may need some SOS type help as you're starting your IBS journey.

This section focuses on more immediate solutions for diarrhea, although you may add some of them to your proactive IBS management routine. Always keep in mind that what works for someone else may not work for you, so put your detective hat on.

Fibre

Fibre can be tricky business during an IBS-D flare up and will depend on the severity and duration of your symptoms and what works for you. Adding some fibre may help, but overall fibre needs be increased gradually and can be considered more of a proactive strategy. Find out more about fibre for diarrhea in the next section and check out Fibre and IBS in the Healthy Eating section.

Soluble vs. Insoluble Fibre

The type of fibre is important when you're having a diarrhea flare up. Soluble fibre is like a sponge, sopping up water in your intestines and making your stool firmer. It can be especially helpful if you have watery or malabsorptive diarrhea. You could try adding a small amount (2-3 g) during a flare up.

Insoluble fibre, often called roughage, can actually speed up transit time. You could try temporarily reducing foods high in insoluble fibre to see if that helps.

The GI Society has a great list of foods to consider (follow link and scroll to the bottom of the page).

Avoid Large Fibre Input

Too much fibre at one time could be overwhelming for a gut struggling with diarrhea, possibly pulling more water into the gut and increasing motility. Resistant starch, found in foods like cooked and cooled pasta, rice and whole grains, can have the same effect.

Try temporarily reducing the serving size of fibre rich foods (make sure to replace them with something else). Eating smaller, more frequent meals is a good way to do this as well.

Low Fibre Diet

If your flare up is more severe and you just can't seem to get back on track, you might consider a low fibre diet or a low residue diet (low fibre plus other restrictions). These are both very temporary measures and foods should be gradually introduced as symptoms normalize.

The diets also include eating more cooked foods, increasing liquids and eating smaller meals.

The BRAT Diet

For years the BRAT diet (bananas, rice, applesauce and toast) was the go to for diarrhea and Dr. Google will often still recommend it. However, it's no longer recommended by experts because it's too restrictive and doesn't provide essential nutrients.

Foods to Limit

Everybody is different, so the following are just suggestions of things you can look out for that may be making your diarrhea worse. The goal is to restrict your diet as little as possible, so it's important to try and figure out your personal triggers. Even if you have to be somewhat restrictive during an IBS-D flare up, think of it as a temporary solution. Add foods back slowly until symptoms are managed.

Gut Irritants

Certain food and drink can irritate the gut lining and increase motility. Watch out for fatty foods, spicy foods, alcohol, caffeine and coffee (even decaf).

Osmotic Agents

Some food and drink pull water into your intestines. Watch out for high sugar (especially fructose), lactose and sugar alcohols like sorbitol, xylitol and mannitol that are often used as artificial sweeteners

Natural Laxatives

Prunes, prune juice, papaya, rhubarb and kiwis may not be the best thing to choose during a diarrhea flare up. Certain types of magnesium supplements can also have laxative properties at higher dosages.

Meal Hygiene

How you eat is also important and could help during a diarrhea flare up. Try eating smaller and more frequent meals (5-6 a day). Calm yourself before a meal and practice deep breathing. Eat slowly and chew your food well.

Check out the Mindful Eating section for a deeper dive.

Hydration and Electrolytes

Hydration may not actually improve your diarrhea, but it's key to managing it. Your body loses water and electrolytes, like salt, potassium and magnesium, with every loose bowel movement. It's important to replace them.

Try drinking a cup of water after each loose bowel movement and sipping on it throughout the day. Add clear liquids like non-caffeinated teas, coconut water or broth. Eat foods that contain electrolytes like bananas, boiled potatoes or simple salted crackers. Consider oral rehydration solutions or sports drinks with electrolytes (be sure there's not artificial sweeteners).

Stress Management

Unmanaged stress can speed up digestion and intestinal movement. In yet another IBS feedback loop, loose stools cause urgency, which causes stress that can make things worse! Relaxing your mind helps switch your nervous system back to "rest-and-digest" mode. Having go to stress management techniques may be especially helpful for for IBS diarrhea.

It may take time to find things that work for you, but once you do you can use them as part of your rescue strategy for diarrhea. For some ideas go to the Stress Management section.

Medications

There are a few common go to over the counter emergency medications for acute diarrhea.

There's nothing wrong with taking them if you have an important situation coming up, like an airplane flight or a big meeting. However, there can be side effects, especially if used frequently or in larger doses.

Proactive Strategies

The IBS Management Strategies section is full of information and tips on proactively managing your IBS and reducing symptoms like diarrhea.

In this section I wanted to highlight some things that might be particularly helpful for diarrhea. For the most part they are habits that take time to build and may help to keep you from having diarrhea in the first place.