Diarrhea

Chronic, Noninfectious Diarrhea A Review

Nathan Hinkle — Mon, 20 Apr 2026 20:01:38 +0000

Date Added:

April 20, 2026

Journal/Publication:

Journal of the American Medical Association

Publisher:

The American Medical Association

Publication Date:

March 2, 2026

Issue:

Volume:

335

Pages:

1250-1262

URL:

Chronic, Noninfectious Diarrhea A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi:10.1001/jama.2026.0872

Keywords

Diarrhea

Irritable Bowel Syndrome

MeSH

celiac disease

Irritable Bowel Syndrome

Defecation

diarrhea

RPR Commentary: A review of the diagnosis and treatment of patients with chronic non-infectious diarrhea. Remember to always consider the side effects of current medications and supplements first before thinking of other causes. James W. Mold, MD, MPH

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Chronic diarrhea is defined as loose or watery stools lasting longer than 4 weeks and affects approximately 6% to 7% of adults in the US. More than 90% of patients with chronic diarrhea have a noninfectious etiology.

Observations The most common causes of chronic, noninfectious diarrhea are irritable bowel syndrome with diarrhea (IBS-D) and functional diarrhea. IBS-D typically presents with recurrent abdominal pain relieved or worsened after defecation. Functional diarrhea is a condition in which more than 25% of bowel movements in the preceding 3 months are loose or watery, but it is not associated with significant abdominal pain. Chronic diarrhea due to a small-bowel source, such as celiac disease or small intestinal bacterial overgrowth, is typically associated with large-volume diarrhea and weight loss, with or without steatorrhea. Celiac disease is an autoimmune condition defined by enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals, and small intestinal bacterial overgrowth is characterized by excessive bacteria in the small bowel. Chronic diarrhea due to colon pathology, such as bile acid diarrhea and microscopic colitis, typically presents with frequent, low-volume stools, with or without urgency and excess mucus. Bile acid diarrhea is characterized by excess bile acids in the colon, and microscopic colitis is characterized by chronic inflammation on colon biopsies despite normal endoscopic appearance. Evaluation of chronic diarrhea includes serological testing for celiac disease (tissue transglutaminase immunoglobulin A, along with total immunoglobulin A) and stool testing for fecal calprotectin to evaluate for inflammatory bowel disease. Patients with gastrointestinal bleeding, unexplained weight loss, 45 years or older, nocturnal diarrhea, steatorrhea, and/or iron deficiency anemia should undergo colonoscopy to evaluate for colorectal cancer as well as upper endoscopy. During colonoscopy, random biopsies are recommended to evaluate for microscopic colitis, which affects 13% of patients with chronic diarrhea. If evaluation does not identify a cause of chronic diarrhea, likely diagnoses are IBS-D or functional diarrhea and the patient should be treated with lifestyle modification, such as regularly scheduled meals, exercise, intake of at least 8 cups of noncaffeinated fluids daily, limiting caffeine to 3 cups or fewer daily, and avoiding alcohol and carbonated beverages. For general treatment of chronic diarrhea, dietary modifications, such as consuming a diet low in fermentable oligosaccharides (legumes, wheat, onions, garlic), disaccharides (lactose), and monosaccharides (fructose), and polyols (sorbitol, mannitol), or medications, such as opiate agonists (loperamide), anticholinergics (hyoscyamine, dicyclomine), or 5-hydroxytryptamine 3 receptor (5-HT3) antagonists (ondansetron), can be prescribed. These therapies typically improve diarrhea in 50% to 80% of patients.

Conclusions and Relevance The most common causes of chronic, noninfectious diarrhea include IBS-D and functional diarrhea. Diagnostic testing should include consideration of celiac disease, inflammatory bowel disease, and microscopic colitis. Empiric therapies for chronic diarrhea include lifestyle and dietary modifications and medications, including opiate agonists, anticholinergics, and 5-HT3 antagonists.

Author/s:

Prashant Singh, Allen Lee, Neil M Sheth, William D Chey

Chronic, Noninfectious Diarrhea: A Review

Megan George — Wed, 04 Mar 2026 18:21:26 +0000

Date Added:

March 4, 2026

Journal/Publication:

JAMA

Publication Date:

March 2, 2026

URL:

Chronic, Noninfectious Diarrhea: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2026.0872

Keywords

Diarrhea

infectious diarrhea

Irritable Bowel Syndrome

abdominal pain

Defecation

Steatorrhea

PMID (1):

41770539

MeSH

diarrhea

Irritable Bowel Syndrome

abdominal pain

Defecation

Steatorrhea

An in-depth review of the evaluation and management of chronic non-infectious diarrhea. James W. Mold, MD, MPH

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Importance: Chronic diarrhea is defined as loose or watery stools lasting longer than 4 weeks and affects approximately 6% to 7% of adults in the US. More than 90% of patients with chronic diarrhea have a noninfectious etiology.

Observations: The most common causes of chronic, noninfectious diarrhea are irritable bowel syndrome with diarrhea (IBS-D) and functional diarrhea. IBS-D typically presents with recurrent abdominal pain relieved or worsened after defecation. Functional diarrhea is a condition in which more than 25% of bowel movements in the preceding 3 months are loose or watery, but it is not associated with significant abdominal pain. Chronic diarrhea due to a small-bowel source, such as celiac disease or small intestinal bacterial overgrowth, is typically associated with large-volume diarrhea and weight loss, with or without steatorrhea. Celiac disease is an autoimmune condition defined by enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals, and small intestinal bacterial overgrowth is characterized by excessive bacteria in the small bowel. Chronic diarrhea due to colon pathology, such as bile acid diarrhea and microscopic colitis, typically presents with frequent, low-volume stools, with or without urgency and excess mucus. Bile acid diarrhea is characterized by excess bile acids in the colon, and microscopic colitis is characterized by chronic inflammation on colon biopsies despite normal endoscopic appearance. Evaluation of chronic diarrhea includes serological testing for celiac disease (tissue transglutaminase immunoglobulin A, along with total immunoglobulin A) and stool testing for fecal calprotectin to evaluate for inflammatory bowel disease. Patients with gastrointestinal bleeding, unexplained weight loss, 45 years or older, nocturnal diarrhea, steatorrhea, and/or iron deficiency anemia should undergo colonoscopy to evaluate for colorectal cancer as well as upper endoscopy. During colonoscopy, random biopsies are recommended to evaluate for microscopic colitis, which affects 13% of patients with chronic diarrhea. If evaluation does not identify a cause of chronic diarrhea, likely diagnoses are IBS-D or functional diarrhea and the patient should be treated with lifestyle modification, such as regularly scheduled meals, exercise, intake of at least 8 cups of noncaffeinated fluids daily, limiting caffeine to 3 cups or fewer daily, and avoiding alcohol and carbonated beverages. For general treatment of chronic diarrhea, dietary modifications, such as consuming a diet low in fermentable oligosaccharides (legumes, wheat, onions, garlic), disaccharides (lactose), and monosaccharides (fructose), and polyols (sorbitol, mannitol), or medications, such as opiate agonists (loperamide), anticholinergics (hyoscyamine, dicyclomine), or 5-hydroxytryptamine 3 receptor (5-HT3) antagonists (ondansetron), can be prescribed. These therapies typically improve diarrhea in 50% to 80% of patients.

Conclusions and relevance: The most common causes of chronic, noninfectious diarrhea include IBS-D and functional diarrhea. Diagnostic testing should include consideration of celiac disease, inflammatory bowel disease, and microscopic colitis. Empiric therapies for chronic diarrhea include lifestyle and dietary modifications and medications, including opiate agonists, anticholinergics, and 5-HT3 antagonists.

Author/s:

Prashant Singh, Allen Lee, Neil M. Sheth

What Is Ulcerative Colitis?

Erin Blanchette — Mon, 12 Feb 2024 16:55:58 +0000

Date Added:

February 12, 2024

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

February 2, 2024

Issue:

Volume:

330

Pages:

951-965

URL:

What Is Ulcerative Colitis?

Type:

Patient Education Materials

Format:

Article

DOI (1):

10.1001/jama.2023.23814

Keywords

ulcerative colitis

Diarrhea

Gastroenterology

Inflammatory Bowel Disease

PMID (1):

38306113

MeSH

Information for patients about ulcerative colitis. James W. Mold, MD, MPH

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This JAMA Patient Page describes the condition of ulcerative colitis and its symptoms, diagnosis, and treatment options.

Author/s:

Rebecca Voelker

Treatment of Clostridioides difficile Infection

Aubrey Delammermore — Sat, 10 Sep 2022 05:00:00 +0000

Date Added:

September 10, 2022

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

September 6, 2022

Issue:

Volume:

328

Pages:

881-882

URL:

Treatment of Clostridioides difficile Infection

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.12251

Keywords

PMID (1):

35939317

MeSH

Clostridioides difficile*

Clostridium infections* / drug therapy

Cross infection

diarrhea

Clostridium Infections

An evidence-based summary of the treatment of Clostridium difficile infections. James W. Mold, MD, MPH

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Clostridioides difficile infection is a common nosocomial and community-acquired cause of diarrhea, with an estimated 453 000 cases per year in the United States.1 Treatment of CDI is based on severity and recurrence risk.

Author/s:

Sehgal, K., Cifu, A. S., Khanna, S.