Digestive Wellness Protocol for Soft Stools: A Resource for Practitioners


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by Fullscript’s Integrative Medical Advisory Team

Diarrhea, defined as three or more watery or loose stools per day, occurs as a result of reduced water absorption in the bowel and increased water secretion. (15)(16) The condition is typically characterized as acute, persistent, or chronic based on the duration of symptoms. Diarrheal symptoms lasting less than two weeks is characterized as acute, symptoms lasting two to four weeks is characterized as persistent, and symptoms lasting longer than four weeks is characterized as chronic. (15)

With approximately 179 million cases occurring each year, acute diarrhea is one of the most common illnesses in the United States. (1)(15) Diarrhea is also the leading cause of death in children under four years old, particularly in developing countries. (1)

Did you know?
Diarrhea is defined as three or more watery or loose stools per day.

Causes of acute diarrhea

The most common cause of acute diarrhea is viral infection (e.g., norovirus, rotavirus, viral gastroenteritis). (1)(15)(16) Acute diarrhea may also be a result of:

  • Bacterial infections, commonly responsible for Traveler’s diarrhea (4) (e.g., E. coli, Campylobacter, Salmonella, Shigella) (1)(15)
  • Parasitic infections (e.g., Entamoeba histolytica, Cryptosporidium enteritis, Giardia lamblia)
  • Certain medications (e.g., antibiotics, magnesium-containing antacids, certain cancer medications) (15)

Infectious diarrhea results from injury to the intestinal epithelium, leading to increased intestinal permeability and impaired absorption of water from the intestine. (16)

Causes of chronic diarrhea

While certain infections, particularly those caused by parasites, may result in chronic diarrhea, (1) the condition is caused primarily by non-infectious agents, (16) including:

  • Digestive tract dysfunction (e.g., Celiac disease, irritable bowel syndrome, small intestinal bacterial overgrowth, ulcerative colitis, Crohn’s disease)
  • Abdominal surgery (15)
  • Food allergies and intolerances (e.g., dairy, eggs, soy, cereal grains, seafood, fructose)
  • Long-term use of certain medications (e.g., antibiotics leading to C. difficile infection, NSAIDs, antacids, antihypertensives, antiarrhythmics ) (1)(15)
  • Ischemia of the gut
  • Radiation therapy
  • Polyps
  • Colon cancer
  • Diabetes mellitus (1)
woman measuring her temperature with a thermometer

Individuals with diarrhea may experience fatigue, fever, and chills.

Signs, symptoms, and complications

In addition to passing three or more watery or loose stools per day, individuals with diarrhea may experience:

  • Abdominal pain, cramps
  • Urgency to use the bathroom
  • Nausea
  • Vomiting
  • Fever and chills (1)(15)
  • Loss of control of bowel movements
  • Bloody stools
  • Light-headedness, dizziness (15)
  • Fatigue (1)

In cases of diarrhea, it is important to recognize certain serious complications, including dehydration and malabsorption. (15) Symptoms of dehydration in adults include:

  • Thirst, dry mouth
  • Fatigue
  • Fainting, lightheadedness
  • Urinating less and dark-colored urine
  • Sunken eyes or cheeks
  • Decreased skin turgor (when skin is pinched and released, it does not return to normal immediately) (15)

Symptoms of malabsorption in adults include:

  • Changes in appetite
  • Bloating, gas
  • Weight loss
  • Loose, greasy, foul-smelling bowel movements (15)

Integrative protocol for soft stools

While acute diarrhea typically resolves within a few days, (15) anti-diarrheal medications, such as loperamide and bismuth subsalicylate, are commonly used to address severe symptoms. (1)(15) The treatment of chronic diarrhea typically depends on the underlying cause. For example, antibiotics are often used to treat bacterial or parasitic infections, while specific medications may be used in cases of Crohn’s disease, irritable bowel syndrome, or ulcerative colitis. (15) In cases of both acute and chronic diarrhea, replenishing fluid and electrolytes is essential for preventing dehydration and its symptoms. (1)(16)

The dietary supplements included in the following protocol have also demonstrated effectiveness in supporting the treatment of diarrhea.

practitioner giving patient pills

Probiotics may be recommended to address a number of health conditions, including diarrheal diseases.

Probiotics

Probiotics are defined as “live microorganisms which, when administered in adequate amounts, confer a health benefit to the host”. (13)(14) Probiotics are typically recommended to help support immune function and/or to address a number of health conditions (14), such as hypercholesterolemia, immunoinflammatory disorders, nosocomial and respiratory tract infections, and diarrheal diseases. (13)

While the exact mechanism of action of probiotics has not been confirmed, a number of possible mechanisms have been suggested, such as:

  • Modulation of immune activity and inflammatory mechanisms
  • Displacement and inhibition of pathogenic bacteria
  • Alteration of microbiota composition
  • Enhancement of epithelial lining function
  • Induction of intestinal epithelial cell µ-opioid and cannabinoid receptors
  • Modulation of the stress response and reduction of visceral hypersensitivity and spinal afferent traffic (22)

While there are a wide variety of commercial probiotic products available, when prescribing probiotics for specific conditions, it’s important to consider that the benefits of probiotics appear to be strain-specific. (13)(14)

Research findings:

  • Probiotics have been shown to decrease diarrhea in conditions like traveler’s diarrhea and antibiotic-associated diarrhea (2)(8)(14)
  • Bacillus coagulans decreased stool frequency in diarrhea-associated irritable bowel syndrome (IBS-D) (13)
  • A blend of probiotics including Lactobacillus acidophilus and Bifidobacterium bifidum, has shown to decrease daily stool frequency (9)(17)

US: Search for Probiotics in the Fullscript catalog.
CAN: Search for Probiotics in the Fullscript catalog.

Prebiotics

Prebiotics are defined as “a nondigestible compound that, through its metabolization by microorganisms in the gut, modulates composition and/or activity of the gut microbiota, thus conferring a beneficial physiologic effect on the host”. (3) Prebiotics are essentially carbohydrate compounds that meets the following unique criteria:

  • Resistance to gastric acidity, enzyme hydrolysis, and absorption in the gastrointestinal tract
  • Fermentation by intestinal microbes
  • Selective stimulation of growth and/or activity of intestinal microbes conferring health benefits to the host (19)(20)

Prebiotic intake may be beneficial in a number of health conditions, particularly those related to gastrointestinal health, such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), constipation, and diarrhea. (12) They can be obtained in supplement form or through a number of dietary sources, such as asparagus, chicory, garlic, Jerusalem artichokes, leeks, soybeans, oats, onions, and wheat. (20)

Learn more about prebiotics and their clinical applications.

Research findings:

  • Galacto-oligosaccharide was shown to prevent the incidence of traveler’s diarrhea (6)
  • Prebiotics, specifically oligofructose, were shown to reduce relapse of diarrhea in C-difficile patients (11)

US: Search for Prebiotics in the Fullscript catalog.
CAN: Search for Prebiotics in the Fullscript catalog.

Pectin in a jar with apple pomaces

Pectin derived from apple pomace is commonly used as a gelling-agent and stabilizer in commercial food products.

Pectin

Pectin, a soluble dietary fiber with prebiotic properties, is a mixture of polysaccharides that constitutes approximately 35% of fruit cell walls. (7) Pectin is found naturally in certain foods, including fruits, vegetables, legumes, potatoes, and sugar beets. (5) Commercially, pectin, derived primarily from citrus peel and apple pomace, is commonly used as a gelling-agent in jams and jellies and as a stabilizer in milk beverages and fruit juices. (21) Pectin has been shown to promote a favorable anti-inflammatory microbiota profile (7) and delay gastric emptying. (23)

Research findings:

  • Fibers reduce diarrhea when patients are receiving enteral nutrition (10)
  • Pectin reduced stool frequency, diarrheal duration, frequency in vomiting, oral rehydration and intravenous fluid in children (18)
  • Pectin has shown to improve diarrhea-associated irritable bowel syndrome (IBS-D) by balancing the microflora and decreasing systemic inflammation (24)

US: Search for Pectin in the Fullscript catalog.
CAN: Search for Pectin in the Fullscript catalog.

The bottom line

Supplementation with probiotics, prebiotics, and pectin has been shown to be effective in preventing and addressing symptoms of diarrhea. A protocol using natural supplements can be used therapeutically on its own or as an adjunct to existing treatment. When recommending nutrients or botanicals as an adjunct to treatment, be sure to check for possible interactions with pharmaceutical medications to prevent possible negative health outcomes in patients. If you are not an integrative healthcare provider, we recommend speaking with one to find out whether these supplements are right for your wellness plan.

If you are a practitioner, consider signing up to Fullscript. If you are a patient, talk to your healthcare practitioner about Fullscript!

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Fullscript Protocol for Digestive Wellness

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Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

  1. American College of Gastroenterology. (2012). Diarrheal diseases: Acute and chronic. Retrieved from https://gi.org/topics/diarrhea-acute-and-chronic/
  2. Bae J. M. (2018). Prophylactic efficacy of probiotics on travelers’ diarrhea: An adaptive meta-analysis of randomized controlled trials. Epidemiology and Health, 40, e2018043.
  3. Carlson, J. L., Erickson, J. M., Lloyd, B. B., & Slavin, J. L. (2018). Health effects and sources of prebiotic dietary fiber. Current Developments in Nutrition, 2(3), nzy005.
  4. de la Cabada Bauche, J., & Dupont, H. L. (2011). New developments in traveler’s diarrhea. Gastroenterology & Hepatology, 7(2), 88–95.
  5. Dhingra, D., Michael, M., Rajput, H., & Patil, R. T. (2012). Dietary fibre in foods: A review. Journal of Food Science and Technology, 49(3), 255–266.
  6. Drakoularakou, A., Tzortzis, G., Rastall, R.A., & Gibson, G.R. (2010). A double-blind, placebo-controlled, randomized human study assessing the capacity of a novel galacto-oligosaccharide mixture in reducing travellers’ diarrhoea. European Journal of Clinical Nutrition, 64(2), 146-52.
  7. Dreher M. L. (2018). Whole fruits and fruit fiber emerging health effects. Nutrients, 10(12), 1833.
  8. Hempel, S., Newberry, S.J., Maher, A.R., Wang, Z., Miles, J.N., Shanman, R., … Shekelle, P.G. (2012). Probiotics for the prevention and treatment of antibiotic-associated diarrhea: A systematic review and meta-analysis. JAMA, 307(18), 1959-69.
  9. Ishaque, S. M., Khosruzzaman, S. M., Ahmed, D. S., & Sah, M. P. (2018). A randomized placebo-controlled clinical trial of a multi-strain probiotic formulation (Bio-Kult®) in the management of diarrhea-predominant irritable bowel syndrome. BMC Gastroenterology, 18(1), 71.
  10. Kamarul Zaman, M., Chin, K. F., Rai, V., & Majid, H. A. (2015). Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis. World Journal of Gastroenterology, 21(17), 5372–5381.
  11. Lewis, S., Burmeister, S., & Brazier, J. (2005). Effect of the prebiotic oligofructose on relapse of Clostridium difficile-associated diarrhea: a randomized, controlled study. Clinical Gastroenterology and Hepatology, 3(5), 442-8.
  12. Macfarlane, S., Macfarlane, G.T., & Cummings, J.H. (2006). Review article: Prebiotics in the gastrointestinal tract. Alimentary Pharmacology and Therapeutics, 24(5), 701-714.
  13. Majeed, M., Nagabhushanam, K., Natarajan, S., Sivakumar, A., Ali, F., Pande, A., … Karri, S. K. (2016). Bacillus coagulans MTCC 5856 supplementation in the management of diarrhea predominant irritable bowel syndrome: A double blind randomized placebo controlled pilot clinical study. Nutrition Journal, 15, 21.
  14. McFarland L. V. (2010). Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World Journal of Gastroenterology, 16(18), 2202–2222.
  15. National Institute of Diabetes and Digestive and Kidney Diseases. (2016). Definition & facts for diarrhea. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea/definition-facts
  16. Nemeth, V., Zulfiqar, H., & Pfleghaar, N. (2019). Diarrhea. StatPearls. Treasure Island (FL): StatPearls Publishing.
  17. Preston, K., Krumian, R., Hattner, J., de Montigny, D., Stewart, M., & Gaddam, S. (2018). Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R and Lactobacillus rhamnosus CLR2 improve quality-of-life and IBS symptoms: A double-blind, randomised, placebo-controlled study. Beneficial Microbes, 9(5), 697-706.
  18. Rabbani, G.H., Teka, T., Zaman, B., Majid, N., Khatun, M., & Fuchs, G.J. (2001). Clinical studies in persistent diarrhea: Dietary management with green banana or pectin in Bangladeshi children. Gastroenterology, 121, 554-560.
  19. Roberfroid, M. (2007). Prebiotics: The concept revisited. The Journal of Nutrition, 137(3), 830S–837S.
  20. Slavin, J. (2013). Fiber and prebiotics: Mechanisms and health benefits. Nutrients, 5(4), 1417-1435.
  21. Srivastava, P., & Malviya, R. (2011). Sources of pectin, extraction and its application in pharmaceutical industry: An overview. Indian Journal of Natural Products and Resources, 2(1), 10-18.
  22. Verna, E. C., & Lucak, S. (2010). Use of probiotics in gastrointestinal disorders: What to recommend?. Therapeutic Advances in Gastroenterology, 3(5), 307–319.
  23. Wikiera, A., Irla, M., & Mika, M. (2014). Health-promoting properties of pectin. Postepy Higieny I Medycyny Doswiadczalnej, 68, 590-6.
  24. Xu, L., Yu, W., Jiang, J., Feng, X., & Li, N. (2015). Efficacy of pectin in the treatment of diarrhea predominant irritable bowel syndrome. Zhonghua Wei Chang Wai Ke Za Zhi, 18(3), 267-71.