Diarrhoea

Published on 05/05/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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225 Diarrhoea

Patient 1

Instruction

This patient has diarrhoea; would you like to ask him a few questions?

Salient features

History

• Ask about the following:

• Onset
• Duration of diarrhoea
• Frequency
• Whether or not it is nocturnal
• Blood (seen in ulcerative colitis, shigellosis, diverticulitis, carcinoma of the colon) and mucus in the stools; blood on the toilet paper
• Nature of the stools (pale and bulky and difficult to flush away in steatorrhoea)
• Associated pain in the abdomen
• Appetite (increased in thyrotoxicosis)
• Weight loss (marked in chronic diarrhoea)
• Associated nausea and vomiting
• Drug ingestion (including antibiotics and laxatives)
• Foreign travel.

Patient 2

Instruction

This patient has diarrhoea, would you like to examine her?

Salient features

Examination

• Look for the following signs:

• Anaemia
• Clubbing
• Aphthous ulcers
• Abdominal tenderness, abdominal masses.

• Tell the examiner that you would like to do a rectal examination and check for faecal occult blood.

Diagnosis

This patient has chronic diarrhoea with aphthous ulcers and abdominal tenderness indicating that she has inflammatory bowel disease (aetiology).

Questions

What do you understand by the term diarrhoea?

It implies passing of increased amounts of loose stool (stool weights >250 g/day).

How would you investigate a patient with diarrhoea?

• FBC, ESR

• Serum albumin

• Sigmoidoscopy

• Stool chart, stool cultures, faecal cultures

• Barium enema, small bowel barium studies.

Advanced-level questions

What are the mechanisms of diarrhoea?

• Osmotic diarrhoea: the mucosa of the gut acts as a semipermeable membrane; the diarrhoea stops when the patient fasts (e.g. diarrhoea from magnesium sulfate, lactulose, malabsorptive states)

• Secretory diarrhoea: there is active secretion of intestinal fluid (e.g. Escherichia coli diarrhoea)

• Inflammatory diarrhoea: there is mucosal damage (e.g. shigellosis, ulcerative colitis)

• Increased gut motility (e.g. irritable bowel syndrome).

What are the poor prognostic factors in ulcerative colitis?

Anaemia (haemoglobin <100 g/l), raised ESR (30 mm/h), fever (37.5°C), increased frequency of stools (>6/day), tachycardia (>90 beats/min) and hypoalbuminaemia (<30 g/l).

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