What does the patient mean by diarrhoea? (frequency and consistency of stool versus normal bowel pattern, nocturnal diarrhoea?)
Timing questions:
Since when
Sudden or gradual onset
All the time/come and go
Getting better/worse
Previous episodes
Aggravating/mitigating factors
Features of stool:
Colour, consistency e.g. watery, blood (mixed, on stool, in bowl), mucus, smell, volume, greasy stools that float and are hard to flush
Abdo questions:
- Appetite/weight
- Dysphagia
- Nausea, vomiting, haematemesis
- Indigestion/heartburn
- Jaundice
- Abdominal pain + SOCRATES e.g. diverticular disease
- Bowels: change/constipation/diarrhoea/stool/blood/mucus/flatus
- Bloating, tenesmus, urgency, soiling/incontinence
Systemic symptoms: fever, night sweats, weight loss, lymph nodes
Ask questions relating to possible causes:
Infectious Diarrhoea – Fever, nausea and vomiting, Diet e.g. Takeaways, restaurants /Travel history including food and water consumption/Contacts/sexual risk including risk factors for HIV infection (intravenous drug use, men who have sex with men, sex with a sex worker, sex with HIV positive person)
Medications- laxatives N.B could be laxative abuse, antibiotics (C diff), metformin, digoxin, statin, radiotherapy/chemo, erythromycin, domperidone, PPI, magnesium containing products, NSAIDs
IBD- rashes, eye symptoms, joint/back pains, ulcers, weight loss
IBS – Constipation, bloating
Overflow diarrhoea- constipation with overflow
Bowel cancer- Weight loss (quantify) and appetite, Change in bowel habit, Tenesmus, urgency, incontinence
Microscopic colitis (histological diagnosis)
Thyroid – tremor, palps, heat intolerance, goitre, eye, periods. Other endocrine: Addisons. VIPoma. DM. Carcinoid. Gastrinoma. Parathyroid disease.
Malabsorption (pale, greasy, voluminous, foul-smelling stools, weight loss, flatulence, distension):
Coeliac disease or lactose intolerance- food history e.g. bread, cakes, oats, dairy
Diabetes- ask re. thirst and polyuria (pancreatic insufficiency) NB: autonomic neuropathy in diabetics can also cause diarrhoea. Ask re. alcohol as a cause of pancreatic insufficiency. Ask re. previous pancreatic disease
Surgical history- e.g. Cholecystectomy causing bile acid malabsorption, ileal resection, colonic resection, gastric bypass
Bacterial Overgrowth of the small intestine e.g. in systemic sclerosis
Whipples disease: weight loss, joint pains
Impact:
Dehydration. E.g. Dizziness/light-headedness, urine output
Eating and drinking?
Dx: thorough medication history including all prescription and OTC medications and supplements
Fx: bowel problems e.g. IBD, coeliac, MEN, cancer
Sx: alcohol abuse commonly causes diarrhoea, diet history including use of sorbitol-containing products in sugar-free foods, occupation e.g. food handler
ICE
Systems review
Investigations:
Routine bloods including FBC, U+E, LFT, CRP, Ca, P, Mg, clotting
TFTs, Coeliac serology, amylase, iron, ferritin, B12, folate, glucose, vitamin D
Stool m,c,s, C diff, virology, ova, cysts, parasites e.g. cryptosporidium, giardia lamblia
Blood cultures
CXR, AXR
Flexi sigi/OGD/colonoscopy/CT/MRI/barium studies
HIV test
Specialist tests e.g. Faecal elastase or chymotrypsin, pancreolauryl test, calprotectin, Gastrin, calcitonin, VIP, somatostatin, Urine 5-HIAA, synacthen test, immunoglobulins, serum electrophoresis, secretin test, 72-hour faecal fat collection, hydrogen breath testing, laxative screen, stool osmolality, osmotic gap, the75Se-HCAT) test.