Diarrhea, Gas and Bloating

Diarrhea is an increase in the frequency and decrease in the consistency of stools. It is a side effect that can arise when starting treatment. It often goes away after a few weeks, though, for some people, it remains an issue for years. Gas and bloating, sometimes to an uncomfortable extent, are also common in people with HIV. Many of the causes of gas and bloating are similar to those that cause diarrhea.

Diarrhea, gas and bloating can cause pain and embarrassment, particularly when their timing is unpredictable. They can make people unwilling to leave home because they don’t want to risk a humiliating incident in public. Diarrhea can become life-threatening when it causes the body to lose too much fluid or too many electrolytes (normal chemical compounds in the blood) or it contributes to wasting (serious, unwanted weight loss).

There are many benefits to fully addressing the issues of diarrhea, gas and bloating, including an improvement in your quality of life. When you get rid of diarrhea or excessive gas:

• You reduce the painful irritation caused by diarrhea and you reduce the pain that accompanies bloating from gas.
• You normalize your daily life since you don’t have the constant interruptions and embarrassment of these conditions.
• Your sleep improves since you aren’t running to the bathroom in the night.
• You improve your body’s nutrient status since you are no longer flushing away unabsorbed nutrients that maintain weight and immune function.
• Your drugs work better since these medications will be absorbed at the levels needed for effective viral control.
• You can stay on your antiretroviral therapy longer since gastrointestinal problems, including diarrhea, gas and nausea, are some of the main reasons people stop or switch therapy.

It is important to report to your doctor any diarrhea that is frequent, watery, lasts for more than a couple of days or contains blood. Also report any on-going problems with gas or bloating.

These conditions have many causes and can be complex to address. HIV itself damages the gut by attacking immune cells there. Many HIV medications are a common cause of diarrhea, gas and bloating. However, they can also have causes unrelated to HIV disease, such as functional bowel disease (irritable bowel syndrome and inflammatory bowel disease), lactose intolerance or gluten sensitivity. Infections, including bacterial and parasitic infections, can also cause diarrhea. These causes can be dangerous and lead to severe health problems, such as wasting. The best approach is to see your doctor for a full workup to determine the specific cause or causes and to develop a comprehensive treatment strategy.

Many medications, including antiretroviral medications and other medications used in the treatment of HIV, list diarrhea, gas and bloating among their possible side effects. Often these will be short-term side effects that will disappear after a few days or weeks of treatment. In some cases, however, these side effects continue long-term.

The number of medications often taken by people with HIV can make it difficult to tease out the cause of gastrointestinal symptoms. If the onset or sudden worsening of diarrhea, gas or bloating is tied to starting or switching to a medication, it’s a likely suspect. It is usually worth waiting for a few weeks to see if the problem clears up, especially if you are on otherwise effective antiretroviral therapy. If these side effects continue, however, it is important to discuss this with your doctor.

Since diarrhea, gas and bloating have many causes, truly effective treatment requires thorough diagnosis. In addition to medications, these conditions can be the result of:

• infections and parasites that require treatment
• fat intolerance and malabsorption; can be improved by cutting back on dietary fat and taking lipase, the fat-digesting enzyme, with meals
• lactose intolerance; can be resolved by eliminating or decreasing the consumption of dairy products and by taking enzymes to break down lactose or casein when dairy products are eaten
• excessive sugar or caffeine, legumes (dried peas and beans) and raw broccoli or cauliflower
• recently taking antibiotics
• stress.

When the causes of diarrhea, gas and bloating cannot be entirely eliminated, an over-the-counter anti-diarrheal agent, such as Imodium (loperamide), Kaopectate or Pepto-Bismol, may help relieve symptoms. Check with your pharmacist and doctor to ensure they will not interfere with any other medications you are taking.

Crofelemer (Fulyzaq) is a prescription drug derived from the extract of a tropical plant. Clinical trials have found it useful in cases of HIV-related diarrhea not caused by another infection. At the time of publication, the drug had been approved for use in the United States and was available in Canada through a special access program. Check with your doctor or pharmacist for the most up-to-date information.

Other natural therapy options for diarrhea include:

• The amino acid L-glutamine can heal damaged intestines and reduce diarrhea by enhancing water and salt absorption across the wall of the small intestine.
• Gut-friendly bacteria, such as L. acidophilus or S. boulardii.
• Ground flax seeds sometimes help to relieve diarrhea and heal the intestines.
• Calcium may work to reduce or eliminate diarrhea caused by protease inhibitors, but check with your pharmacist or doctor to make sure it will not interfere with other medications you’re taking and that you are not taking too much calcium.

It is crucial to prevent dehydration when you are suffering from diarrhea. As long as diarrhea continues, consume plenty of calories and drink plenty of healthy fluids, such as water, juices, herbal teas, broth and fruit juice smoothies. You should consume at least 1.5 litres of fluids every day, and more if the diarrhea is ongoing and causing substantial fluid loss. Also, be sure to consume enough high-quality calories. Diarrhea causes food to move faster than normal through the digestive system, meaning all nutrients may not be absorbed.

Foods that contain soluble fibre, such as apples, peaches, pears and bananas, grains such as oatmeal and white rice and psyllium-containing supplements like Metamucil, can help with diarrhea. They absorb water, expand and bind together the intestinal contents, bulking up the stool and slowing its passage. Fibre intake should be increased slowly because it can cause gas. Bananas and avocados contain fibre and potassium, which can help to replenish electrolytes (see below). In some cases, cheese can also help bind loose stool and control diarrhea; however, if you are lactose intolerant, cheese could actually contribute to diarrhea.

Foods and liquids to avoid when you have diarrhea include coffee and other caffeinated beverages, alcohol, chocolate, fried and fatty foods, spicy foods and high-sugar foods or liquids. A registered dietitian can be a good source of advice on how to deal with diarrhea. Check www.dietitians.ca for a list of registered dietitians in your area.

With serious diarrhea, it is important to rebalance the body’s electrolytes, including sodium, potassium and chloride. Drinking juices or broths, diluted with water to enhance absorption, can help. Avoid Gatorade and other sports drinks, which contain a lot of sugar that can make diarrhea worse.

Concentrated sources of electrolyte minerals may be needed. Oral rehydration salts are one option that is available through many pharmacies at low cost. You can make your own rehydration solution. Start with one litre of orange juice and then add 5 ml (1 tsp) of light salt (which contains potassium mixed with sodium). Sweeten with 15 ml (1 tbsp) of pasteurized honey if desired. To add soluble fibre to this mix, add rice water to the juice. Make rice water by boiling four parts water and one part rice until the rice is tender, and then straining off the rice water. This rice water can also be drunk on its own as a source of both hydration and soluble fibre.