clinical assessment of chronic diarrhoea

Last reviewed 01/2018

A detailed history together with a thoughtful physical examination will help to direct the diagnostic work-up and limit the number (and cost) of tests needed and increase the efficiency of the evaluation (1).

History should be able to

• establish the likelihood that the symptoms are organic (as opposed to functional)
• presence of the following symptoms suggest an organic disease
• history of diarrhoea of less than three months' duration,
• predominantly nocturnal or continuous diarrhoea (as opposed to intermittent diarrhoea)
• significant weight loss
  
  
• distinguish malabsorptive from colonic/inflammatory forms of diarrhoea
• steatorrhoea and the passage of bulky malodorous pale stools is associated with malabsorption
• colonic/inflammatory forms of diarrhoea typically presents with liquid loose stools with blood or mucous discharge
  
  
• assess for specific causes of diarrhoea which increase the likelihood of organic diarrhoea or point to potential lines of investigation
• family history of neoplastic, inflammatory bowel, or coeliac disease.
• previous surgery leading to malabsorption
• previous pancreatic diseases
• systemic illness - thyrotoxicosis and parathyroid disease, diabetes mellitus etc
• alcohol
• drugs
• recent overseas travel
• recent antibiotic therapy and Clostridium difficile infection
• change in diet - excessive fibre and misuse of laxatives will increase the frequency of stools. 
• lactase deficiency (1,2)

Physical examination may reveal underlying cause for diarrhoea:

• recent weight loss or lymphadenopathy -  chronic infection or malignancy. 
• episcleritis - inflammatory bowel disease (IBD)
• exophthalmia - hyperthyroidism
• Dermatitis herpetiformis - seen in 15-25% of patients with celiac disease
• abdominal examination
• scars - surgical cause of diarrhoea
• bowel sounds - hypermotility
• tenderness - infection and inflammation
• masses - neoplasia
• rectal examination - to exclude any induration or local  tenderness that might suggest crohns or an anal fissure (1,2).

Reference:

• (1) Schiller LR et al. Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis. J Gastroenterol Hepatol. 2014;29(1):6-25.  
• (2) Thomas PD et al. Guidelines for the investigation of chronic diarrhoea, 2nd edition. Gut. 2003;52 Suppl 5:v1-15.