Chronic Diarrhoea

Question 1

A 59 year old woman presents with six-week history of diarrhoea. What is your management plan?

Answer 1

Impression
Chronic diarrhoea (given >3 per day, >4 weeks sx), could be due to a number of underlying pathologies. 

Provisionally, consider autoimmune causes such as IBD (crohns, UC),
- malabsorptive (coeliac disease, pancreatic insufficiency). Common causes include IBS, medication adverse effect. Others to rule out include chronic infection (C. Diff, parasite - Giardia lamblia), diverticulitis. Rule out malignancy, strictures (structural changes to bowel)

Question 2

Chronic diarrhoea - History

Answer 2

History

• sx: nature of diarrhoea, bloody, mucus, Malena, weight loss, fevers, night sweats, constipation alternating with diarrhoea (faecal impaction, IBS), incontinence, relief post-voiding
• HPI: duration, number per day, night time sx (less likely functional cause), travel history
• PMHx: radiation, recent cholecystectomy
• Meds: ABX (c.diff), supplements, laxatives, unprescribed
• Psychosocial, dietary hx, sick contacts, travel

Question 3

Chronic diarrhoea - Examination

Answer 3

Examination

• general observation, vitals
• Thyroid examination (hypothyroidism)
• Gastrointestinal examination: tenderness, bowel sounds, organomegaly, masses, PR exam (assess sphincter strength)
• systemic: skin rashes (extra-GI manifestations of IBD), lymphadenopathy,

Question 4

Chronic diarrhoea - Investigations

Answer 4

Investigations
- Key/diagnostic: endoscopy +/- biopsy

• bedside: vitals, PR, urine sample, stool sample - MCS + OCP + faecal calprotectin
• bloods: FBC, UEC, LFT, Lipase, CRP/ESR, coeliac serology, ANCA/ASCA, nutritional screening
• imaging: abdo ultrasound, CT abdo oral/IV contrast, MRI abdo
• other: endoscopy, FOBT?

Question 5

Chronic diarrhoea - Management

Answer 5

Management
- Investigate for and rule-out underlying pathology

Supportive:

• increase fibre in diet
• consider medication: loperamide (opioid agonist targeting opioid receptors in GIT to reduce gastric motility) or cholestyramine (anticholinergic)
• fluid replacement, electrolyte replacement

Definitive:

• IBD: induction and maintenance therapy
• Coeliac: gluten free diet
• Infective: empirical and targeted Abx
• Malignancy: MDT and specific treatments

Dispositioning:

• gastro consult
• gen surg if structural