Management of Chronic Diarrhea in Inflammatory Bowel Disease Patients

Initial Assessment and Pharmacologic Management

The American Gastroenterological Association recommends optimizing IBD-directed therapy first if inflammation is active, rather than treating diarrhea symptomatically 1
For patients with disease in remission, symptomatic management with loperamide as the primary agent for diarrhea control is recommended, with a dosing of 2-4 mg up to four times daily as needed 2, 1, 4
The use of bile acid sequestrants is recommended when bile acid malabsorption is suspected, particularly in Crohn's disease patients with ileal disease or resection 2, 5, 1

Rifaximin may be considered for presumed small intestinal bacterial overgrowth (SIBO), with evidence showing benefit in active Crohn's disease for both induction and maintenance of remission 8, 9, 10
Pancreatic enzyme replacement may be used when pancreatic exocrine insufficiency (PEI) is suspected, particularly in patients with prior pancreatic surgery or chronic pancreatitis 6, 7, 9

A low FODMAP diet shows evidence of benefit in Crohn's disease for functional symptoms, and must be supervised by a dietitian to ensure nutritional adequacy 2, 5, 1
Cognitive behavioral therapy, gut-directed hypnotherapy, or mindfulness therapy are clinically valuable options when symptoms impair quality of life 2, 3, 5, 1
Physical exercise is beneficial in quiescent or mild IBD and associated with decreased risk of active disease 2, 5, 1

Opiates should never be used for chronic diarrhea management in IBD patients, as they increase risk of dependence, overdose, and worsen GI symptoms long-term 6, 7, 9, 10
It is essential to confirm disease remission before initiating symptomatic treatment, as up to 30-40% of IBD patients in remission have functional symptoms that mimic active disease 2, 3