Sacral Wounds and Diarrhea Don’t Mix, Part 1

Published on September 12, 2018 by Nancy Collins, PhD, RDN, LD, NWCC, FAND

Frequent bouts of diarrhea make it difficult to care for wounds on the sacrum or coccyx, and healing often is impeded because of fecal contamination.

Dr Nancy Collins

Nancy Collins, PhD, RDN, LD, NWCC, FAND

Many patients, particularly those with mobility issues, have pressure injuries on the sacrum or coccyx. Frequent bouts of diarrhea make it difficult to care for these wounds, which affects healing. If frequent, loose, and watery stools contaminate the wound, it can make the healing process more challenging. The first step is to identify the cause of the diarrhea in order to begin the appropriate nutritional, medical, and pharmaceutical treatment plan.

Causes of Diarrhea

Diarrhea is a symptom of many diseases and disorders. Here are just a few to consider.


Food intolerance/allergies: These include lactose and gluten intolerance or excessive intake of sorbitol, mannitol, or xylitol.

Protein energy malnutrition: Hypoproteinemia (albumin levels < 2.6 g/dL) is associated with intestinal edema, which negatively affects luminal absorption and may result in diarrhea.

Bacterial contamination: Contaminated food or water may lead to Campylobacter, Salmonella, Shigella, Clostridium difficile, or Escherichia coli.

Viral infections: Rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, or viral hepatitis may all cause diarrhea.

Enteral tube feedings: Hypertonic formulas, refeeding syndrome, contamination, bolus feedings into the small intestine, and lack of fiber in the formula are all reasons that some patients may experience diarrhea.

Parasites: Giardia lamblia, Entamoeba histolytica, or Cryptosporidium can enter the body through food or water and settle in the digestive tract.

Drug reactions: Laxatives, diuretics, cholinergic drugs, antibiotics, prostaglandins, liquid medications containing sugar alcohols, warfarin, thyroid preparations, anti-epileptics, and many other drugs can cause diarrhea.

Gastrointestinal disease: Inflammatory bowel disease, short gut syndrome, HIV/AIDS, Crohn’s disease, chronic ulcerative colitis, bowel resection, and malabsorption syndrome all have diarrhea as a symptom of the disease.

Fecal impaction: Impacted feces prevent the passage of normal stool. Only watery stool is able to pass the point of impaction.

Types of Diarrhea

The list of possible causes of diarrhea is lengthy, and it sometimes is difficult to pinpoint the cause. It may help to classify the diarrhea in one of the three common categories—watery, fatty, or small volume.

Watery diarrhea occurs when the amount of water and electrolytes moving into the intestinal mucosa exceeds the amount absorbed into the bloodstream. Watery diarrhea is further classified into two subtypes—osmotic or secretory. Osmotic diarrhea abates with fasting, while secretory does not. Watery osmotic diarrhea usually accompanies lactose intolerance, dumping syndromes, and enteral feeding intolerances. Watery secretory diarrhea is often a sign of bacterial enterotoxins and viruses.

Fatty diarrhea, or steatorrhea, usually accompanies conditions associated with malabsorption, such as chronic pancreatitis or short bowel syndrome.

Small volume diarrhea may accompany diverticulitis of the colon.

Bloody or Black Tarry Stool

Bloody or black tarry stools may indicate a more serious condition—this is not common diarrhea. Black tarry stools, or melena, usually indicates that blood is coming from the upper part of the gastrointestinal tract. Maroon or red, bloody stools, called hematochezia, usually suggests that blood is coming from the large intestine or rectum. These conditions warrant prompt medical attention and testing.

Occasionally, the ingestion of black licorice, lead, iron supplements, or even blueberries can cause black stools or false melena. A fecal occult blood test can rule our false melena.

Medical Record Documentation

Always document diarrhea, including the frequency, odor, color, presence of blood, abdominal pain, bloating, and fever. Also document what you suspect are the possible causes and type of diarrhea because this information will form the basis for the treatment plan.

Detailed records describing what is occurring with the patient provide essential information to the entire care team. These types of wounds may take longer to heal or present challenges. Therefore, thorough documentation also is needed in case any future legal or care questions arise.

Next month, in part 2, I will examine the detailed treatment plan.


National Institute of Diabetes and Digestive and Kidney Diseases. Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases website. Accessed September 11, 2018.


About the Author: Nancy Collins, PhD, RDN, LD, NWCC, FAND, is a wound care-certified, registered dietitian nutritionist with expertise in wound care, malnutrition, and medico-legal issues. Dr. Collins strives to improve patient outcomes and patient satisfaction through better communication. To contact her, visit her website,

Related Topics:

Wound Care Education Institute® provides online and onsite courses in Skin & WoundDiabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC®, OMS and NWCC™ national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

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