History: Diarrhoea

Diarrhoea is a common symptom and can be the presenting complaint of a wide range of gastrointestinal and systemic disease.

The precise wording of any scenario can vary, and the questions below should be used if the patient reports diarrhoea, ‘loose stool’, or faecal urgency (loss of control of bowels).

History of Presenting Complaint
    OSCE-Aid Tips

    Time frame is critical in establishing the underlying cause of diarrhoea, allowing you to narrow the differential diagnosis (See table)

  • Establish a time frame
    • When did this start/How long has it been going on?
    • Where were they doing in the days before it came on (esp. any recent travel)
  • Describe the diarrhoea
    • When does it occur (bowels opening at night is always abnormal, and suggests organic pathology)
    • Constant, or intermittent diarrhoea and normal stool (constant more likely organic cause)
    • How many times per day (bowels opening >3x day considered abnormal)
    • Fever (infective likely)
    • Bloody?
      • More concerning if mixed in with stool (blood on the outside of stool or in the toilet pan suggests haemorrhoids)
      • Consider IBD or infective causes from certain organisms (Campylobacter, salmonella, E. coli, Entamoeba)
    • Oily pools around stool = steatorrhoea: suggests malabsorption (chronic pancreatitis, bile acid malabsorption, small intestinal bacterial overgrowth)
  • Precipitating factors
    • Any recent travel? Where to? For how long? Where did they stay? Did they eat local food? Any restaurants? Did they drink tap water?
    • Recent hospitalisation/antibiotic course (C. diff diarrhoea)
    • Any change in diet (artificial sweeteners, increased gluten, milk)
    • Establish normal bowel habit- e.g. if normally constipated think of overflow diarrhoea
    • Anxiety/depression (may be associated with thyroid disease, and also linked with IBS)
  • Features of systemic disease
    • Thyrotoxicosis: Anxiety, tremor, sweating, weight loss
    • Malignancy: Weight loss, fatigue, PR bleeding
    • Addison’s: Skin hyperpigmentation, fatigue
    • Chronic pancreatitis: Abdominal pain
    • Diabetes: Polydipsia/polyuria, weight loss, peripheral neuropathy
  • Red flags
    • Unintentional weight loss
    • Rectal bleeding
    • Family history of bowel cancer
    • Abdominal mass
    • Persistent diarrhoea (>6 weeks) if more than 60 years of age
    • Anaemia
    • Raised inflammatory markers with no other precipitating cause
    • New incontinence in context of cancer (rule out cord compression - see our back pain resource here

Past Medical History
  • IBD
  • Diabetes
  • Previous malignancy (radiation enteropathy/proctopathy if radiation was given to abdomen/pelvis)
  • Thyroid disease
  • AF (risk factor for bowel ischaemia)
  • Cystic fibrosis (pancreatic insufficiency)
  • Previous surgery
  • Anxiety/Depression

Drug History
  • Many drugs cause diarrhoea, common ones include:
    • Metformin
    • Laxatives
    • Antibiotics
    • NSAIDS
    • Digoxin
  • Allergies

Family History
  • Colorectal cancer
  • Inflammatory bowel disease
  • Coeliac disease

Social History
  • Alcohol intake (chronic pancreatitis)
  • Smoker (risk of cancer)
  • Social situation: Home setting, support network, occupation (important when considering the consequences of the symptoms on quality of life)
  • Functional impact of diarrhoea on life/mental state (especially if chronic)

Causes of Diarrhoea

Acute (<4 weeks)

Chronic (>4 weeks)

  • Infection
    • Gastroenteritis (Can be viral or bacterial, usually self limiting)
    • C. difficile (use of antibiotics)
  • Drugs
    • Metformin, laxatives, antibiotics, NSAIDS, digoxin, SSRIs, chemotherapy agents
  • Acute abdomen
    • Diverticulitis (often bloody), sometimes in appendicitis
  • Anxiety
  • Mesenteric ischaemia
  • Radiation enteritis (may be acute or chronic)
  • Constipation with overflow diarrhoea
  • Bile acid malabsorption
  • Pancreatic exocrine insufficiency (Usually due to chronic pancreatitis, alcohol)
  • Coeliac disease (gluten sensitive enteropathy)
  • Inflammatory bowel disease (UC/Crohns)
  • Irritable bowel syndrome
  • Food intolerance (Lactose, sorbitol)
  • Small bowel bacterial overgrowth (associated with previous bowel surgery, chemo/radiotherapy)
  • Previous surgery
    • small bowel resection: especially terminal ileum, gastrectomy, cholecystectomy
  • Factitious (e.g. laxative abuse)
  • Chronic tropical infections
  • Tropical sprue, Whipple’s, Entamoeba, Giardia, hookworm, Cryptosporidium.

written by: george_thornton, first posted on: 12/06/2016; 14:01

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