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Clinical assessment of chronic diarrhoea

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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).


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