Q. What could be the reason behind chronic diarrhea if endoscopy results are normal?

Answered by
Dr. Ajeet Kumar
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Jul 22, 2022

Hello doctor,

I am a 52-year-old male with type 1 diabetes. I have had constant diarrhea, and lower left abdominal discomfort, and nausea for the last year. I had an upper and lower abdomen endoscopy; the lower was clear, but the upper showed a shallow ulcer. I have had constant pain and diarrhea immediately after eating. My entire body is sore and smells very strange. I started on Imodium, which has reduced it, but stool is still always fluid and light brown. I am tired and sore constantly, which I assume is from a lack of water and nutrients. Kindly advise.



Welcome to

You are having chronic diarrhea, the cause of which can be various. However, in blood tests and the endoscopy reports (attachments removed to protect the patient's identity), I did not find a reason for it. The proper approach should be doing blood and stool tests and then endoscopy only to take biopsies of the upper gastrointestinal and lower gastrointestinal tract. However, I do not see that the endoscopist who performed the endoscopies took biopsies of the large or small bowel. Since both these sites are the potential site for the disease, particularly those that cause diarrhea, namely celiac disease, food allergies, parasitic infections, microscopic colitis, and irritable bowel syndrome. For a better understanding of your problem, please tell me the following.

1) Is the amount of stool you pass more than 200 ml or approximately amounts to a glass of water?

2) Are the stools firm, watery, or just loose?

3) Do you feel a constant urge to pass stool just after passing stools already?

4) Did you go to the toilet mid-night due to the urge to pass stools?

5) Do you experience any weight loss?

6) Have you ever noticed blood in stools?

7) Do you have any family history of gut-related disorders such as celiac disease, inflammatory bowel disease, or cancers?

8) Did you notice any food trigger for diarrhea?

9) Have you ever noticed that diarrhea gets resolved on itself?

10) Do you take medications besides Imodium, which has helped you?

11) How is your sleep?

12) Do you have anxiety or any mood disorder such as depression?

13) Do you take any medications besides what you mentioned in the query?

Please share with me any other investigations you did last year.

Thank you.

Hello doctor,

It is hard to say, but the amount of stool does feel like a large glass of water. The stool is watery with small soft bits. I feel an urge to pass the stool immediately after eating. They have a strange strong smell. I feel constant mild nausea, body aches, fatigue, and a mild feeling like I have to pass stool continuously, and it feels more like abdominal discomfort. I have not gone to the toilet mid-night due to the urge to pass stool. I had a rapid weight gain two months ago and lost around 10 pounds in the last week or two. A couple of times, a few months back, I noticed blood in my stool and hence scheduled an endoscopy. I do not have a family history of gut-related disorders. I did not notice any food triggers for diarrhea. Diarrhea has been consistent for almost a year. It normally only gets more solid with anti-diarrhea over-the-counter medicine. This all has gotten significantly worse in the last month. For the last couple of weeks, it has been out of control. I have not tried any medication other than Imodium. I started on Omeprazole for the shallow ulcers found in the upper gastrointestinal tract, but there is no change in nausea and diarrhea. I have been sleeping fine lately. I have suffered from chronic depression since the loss of my children five years ago. I am not on any medications for the same. I have improved since I started on testosterone after taking a test and found it almost zero. I will share the reports of any other investigations performed last year. I have had multiple CBCs, and all show normal results across the board except for low iron. I started on Iron supplements a while back. I stopped those about a week ago in case it was contributing to diarrhea. CRP was very high, around 220 mg/L last year for a few months, and I finally got it down to 1.67 with heavy antibiotics.



Welcome back to

Looking at the overall picture, there seem to be two possibilities-

1) Tropical sprue

2) Irritable bowel syndrome (IBS) or functional diarrhea.

The former is because you started all these symptoms after visiting a tropical country, and it is not uncommon to have a gut infection that would remain even after you return to your own country. The latter is possible if the former is not true, and it is possible because you did not lose weight and have some depression issues, which can make a human gut more sensitive and cause diarrhea-like symptoms. Also, IBS is a possibility because your blood workup is absolutely normal. If it were some pathological problem within your gut, you would also have abnormal blood tests. Now I suggest you consult a specialist, take the medications mentioned below with their consent, and follow up with me in two weeks' time to see whether the prescribed medications improved the symptoms. Unfortunately, your endoscopist did not take the small bowel biopsies, which would have given us a clue regarding tropical sprue, celiac disease, food allergies, and parasitic infections. Take the following medications.

1) Tablet Rifaximin 200 mg thrice daily for two weeks.

2) Tablet Tinidazole 500 mg thrice daily for three days.

3) Tablet Nitazoxanide 500 mg twice daily for three days.

Use oral rehydration solution (ORS) 1 to 2 liters per day. Let me know in two weeks; if it improves your diarrhea, we might start some anti-secretory agents, which would decrease the amount of stools formed in the gut and help in diarrhea- this while considering that you have irritable bowel disease or functional diarrhea.

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