Chronic Diarrhea Due to Surreptitious Use of Bisacodyl: Case Reports and Methods for Detection

Abstract

Surreptitious abuse of laxatives is a common cause of severe chronic diarrhea. Standard laboratory screening studies of urine and stool specimens may identify phenolphthalein, diuretics, and magnesium-containing agents. An assay for bisacodyl, a commonly used over-the-counter laxative, however, is not included in routine screening tests. Herein we describe two patients with chronic watery diarrhea of large volume; analysis of stool and urine samples revealed that surreptitious use of bisacodyl was the cause. In one patient, nonspecific inflammatory changes of the colonic mucosa were noted on biopsy, and fecal leukocytes were detected in both patients. In a prospective study of eight patients who received bisacodyl as part of a preparation for colonoscopy, we analyzed serial urine samples for bisacodyl diphenol during a 48-hour period. This metabolite was found in seven of eight hydrolyzed urine samples obtained 12 hours after oral administration of bisacodyl but not in samples obtained 24 and 48 hours after ingestion of the laxative. We recommend that urinalysis and, in some cases, stool analysis for bisacodyl should be considered in the diagnostic assessment for surreptitious use of laxatives.

Bisacodyl Induced Severe Rectal Ulcer with Proctitis

“…Bisacodyl has been reported to damage the rectal mucosa when taken in the form of suppositories [6][7][8][9].…”

Approach to the Patient with Diarrhea

“…They have 10-20 bowel movements per day, with 24-h stool volumes in the range of 300 to 3000 mL, and may have nocturnal diarrhea as well. The most common drug causing this syndrome in the United States is probably bisacodyl [358]. Anthraquinones, which include senna, cascara, aloe, rhubarb, frangula, and danthron, are other abused laxatives [357][358][359].…”

“…The most common drug causing this syndrome in the United States is probably bisacodyl [358]. Anthraquinones, which include senna, cascara, aloe, rhubarb, frangula, and danthron, are other abused laxatives [357][358][359]. Osmotic laxatives such as Na 2 SO 4 , Na 2 PO 4 , MgSO 4 , and magnesium citrate are occasionally used [356,357].…”

“…To screen for laxative abuse in factitious diarrhea, it is necessary to send stool or urine to specific reference laboratories for qualitative tests for emetine (a component of ipecac), bisacodyl, castor oil, or anthraquinone [199,[356][357][358][359][360]. Screening is not available for the docusate salts (dioctyl sodium sulfosuccinate), which are present in many of the over-the-counter cathartics.…”

Factitious Diarrhea Induced by Stimulant Laxatives: Accuracy of Diagnosis by a Clinical Reference Laboratory Using Thin Layer Chromatography

“…Some individuals participated in more than one arm of this experiment. The interval between such experiments was always Ͼ1 week, much longer than the time required for complete elimination of bisacodyl metabolites (24 h) or senna metabolites (32 h) from the urine (19,31 ).…”