Diarrhoea

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.