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Diarrhea, Gas and Bloating

Diarrhea, gas and bloating can be inconvenient and embarrassing. They can also be painful and dangerous for your health. Don’t be afraid to talk to your healthcare providers about these conditions. It is almost always possible to control them with a comprehensive approach.

No laughing matter

Diarrhea is an increase in the frequency of bowel movements and a decrease in the consistency of stools (poo). It is a side effect that can arise when starting a new treatment, and often goes away after a few weeks. However, for some people, diarrhea remains an issue for years. Abdominal gas and bloating are also common in people living with HIV, sometimes to an uncomfortable extent. 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 or onset is unpredictable. These conditions can make people unwilling to leave home because they don’t want to risk an 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 (a serious health condition that leads to unwanted weight loss).

There are many benefits to addressing 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 reduce the pain that accompanies bloating from gas.
  • normalize your daily life since you don’t have the constant interruptions and embarrassment
  • of these conditions.
  • improve your sleep since you aren’t running to the bathroom in the night.
  • improve your body’s nutrient status since you are no longer flushing away unabsorbed nutrients that maintain weight and immune function.
  • ensure that your HIV drugs will be absorbed at the levels needed for effective viral control.
  • 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.

Figuring out the cause

It is important to report to your healthcare provider any diarrhea that is frequent, watery, lasts for more than a couple of days or contains blood. Also report any ongoing 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. Some people experience temporary and mild diarrhea, gas and bloating when starting a new HIV regimen, particularly one that contains protease inhibitors. However, these issues can also have causes unrelated to HIV, 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 healthcare provider 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. More often than not, these will be short-term side effects that 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 living 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 a medication, then that medication is a likely suspect. It is usually worth waiting for a few weeks to see if the problem clears up, especially if your HIV viral load is undetectable. If these side effects continue, however, it is important to discuss this with your healthcare provider.

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

Medications and natural therapies

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. Pepto-Bismol should only be taken for a short period of time. Consult your pharmacist or healthcare provider before taking them. This consultation should include possible interactions with your medicines and side effects of anti-diarrhea remedies.

Crofelemer (Mytesi) is a prescription drug derived from the extract of a tropical plant. Clinical trials have found it useful in cases of HIV-related diarrhea that is not caused by another infection. Check with your healthcare provider or pharmacist if this is an option for you.

Other natural therapy options for diarrhea include:

  • the amino acid L-glutamine can help to 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 healthcare provider to make sure it will not interfere with other medications you are taking, and that you are not taking too much calcium.

Dietary considerations

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 without added sugar, herbal teas, broth, fruit and smoothies that do not contain added sugar. You should consume at least 1.5 litres of healthy fluids every day, 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), and whole grains (such as oatmeal and white rice and psyllium-containing supplements like Metamucil), can help with diarrhea. These foods absorb water and expand to bind together the intestinal contents, bulk up the stool and slow its passage out of the body. Fibre intake should be increased slowly because it can cause gas. Bananas and avocados contain fibre and potassium, which can help to replenish electrolytes. 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. 

Replenishing electrolytes

It is important to rebalance the body’s electrolytes, including sodium, potassium and chloride if you experience diarrhea. Drinking juices or broths, diluted with water to enhance absorption, can help. Avoid Gatorade and other sports drinks, which contain a lot of sugar and 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.