Diarrhoea

Student info: Mr LG is 28 and has been referred to hospital by his

GP with a history of diarrhoea. You are the FY1 doctor who is seeing
him on the assessment unit
Patient info: You are a 28-year-old man with no PMH. You started
having diarrhoea 5 months ago with loose stool on average 3 times/
day. There is no blood PR. You went to India 4 months ago, and
returned last week. You are now passing watery stool up to 5 times/
day. There is some associated weight loss and you had a couple ofepisodes of probable gastroenteritis while away. You smoke
10/day but
no alcohol. You are heterosexual with no HIV risk factors, no associated systemic symptoms and no FH of note
Hints and tips
• Ascertain the patient’s understanding of the reason the GP has
referred him to hospital
• Ascertain the patient’s meaning of diarrhoea (i.e. loose motions,
increased frequency or both)
• Take an accurate history of the symptoms (frequency, colour, blood,
mucus, flushability, volume, consistency)
• Establish the start of the diarrhoea was actually prior to the trip
• Ask about the weight loss; any other associated systemic
symptoms?
• Ask about dietary intake and activities while in India
• Ask about close contacts (points to infection)
• Ask about nocturnal diarrhoea (presence usually indicates significant disease)
• Determine the impact of symptoms on quality of life
• Elicit any concerns the patient may have
• Offer a diagnosis and agree a management plan
Discussion points
• What investigations would you request?
• What are the causes of diarrhoea?
Causes
Acute
• Infective: bacterial, viral, amoebic
• Drugs, e.g. antibiotics
Chronic
• Inflammatory bowel disease (IBD)
• Parasite infections, e.g. giardiasis
• Malabsorption, e.g. coeliac disease
• Drugs, e.g. proton pump inhibitors
• Neoplasia
• Faecal impaction (with overflow diarrhoea)
• Endocrine, e.g. hyperthyroidism, carcinoid
• Ischaemic bowel
• Irritable bowel syndrome (IBS)
Bloody
• Infective, e.g. Campylobacter, Salmonella
• IBD
• Neoplasia
• Colitis, e.g. ischaemic

Malabsorption, IBD, infective

ΔΔ
neoplasia, IBS
FBC, U&E, LFT, haematinics, coeliac
Ix Bloods
serology
Micro Stool culture
Consider an abdominal X-ray (AXR)
Imaging if colitis
is suspected
Other Small bowel enema, colonoscopy