Pre referral checklists GASTROENTEROLOGY
CHRONIC DIARRHOEA
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Definition-DIARRHOEA > 4 weeks
Mechansisms: ( more than 1 may occur simultaneously)
1. Increased osmotic load-occurs when a soluble compound cannot be absorbed by the
small intestine, and thus draws fluid into the intestinal lumen eg osmotic laxatives
2. Increased secretion-Secretory diarrhoea results from active chloride secretion into
the bowel lumen. Water follows the chloride ions, leading to net loss of fluid eg
infections, certain drugs
3. Inflammation of intestinal lining
4. Increased intestinal motility
Are there any RED FLAGS?
 Possible 2ww Sx or signs
o Palpable right sided abdominal mass
o Rectal mass
o Unexplained IDA- see IDA guide
o Altered bowel habit
o Rectal bleeding
o Weight loss ( unintentional or unexplained)
 ONSET sx > 45
 FHx bowel or ovarian cancer
 Nocturnal Sx
 Raised inflammatory markers
y/n
see NICE cancer 2015- reference below
IF NO RED FLAGSHave possible causes been considered and treated where possible? Eg
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y/n
Infection – foreign travel (eg giardia), food-bourne, hospital acquired/
medication induced eg c. diff
Malignancy
Bowel conditions eg.
o Functional eg IBS, constipation with overflow
o Inflammatory bowel disease (including microscopic colitis)
o Malabsorption eg coeliac, chronic pancreatitis, CF
o Others eg Ischaemic colitis, Diverticulitis
Lifestyle eg alcohol Xs
Endocrine disorders eg hyperthyroidism
Drug induced – many- see appendix 1
Post intestinal resection
Does examination reveal any possible cause?
Including Digital rectal examination- if appropriate and acceptable to patient
y/n
1
Have investigations been done where appropriate? Eg
 FBC, LFTS
 Ferritin / b12/ folate/ calcium- check for malabsorbtion
 TFTs
 ESR/CRP
 Coeliac screen
 Stool C+S, Clostridium difficile
 Faecal calprotectin to differentiate? ibs/ibd- (off NSAIDs 4w to avoid false
+ve)
 USS abdomen/ pelvis
y/n
CONSIDER ROUTINE REFERRAL if no RED FLAGS:
y/n
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Diagnostic uncertainty
Investigations suggest secondary care management required eg positive
coeliac immunology, possible IBD
Urgent assessment if significantly systemically unwell
References
NICE IBS
http://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults
http://www.nice.org.uk/guidance/cg61
Suspected lower GI cancer
http://www.nice.org.uk/guidance/NG12/chapter/1-recommendations#lowergastrointestinal-tract-cancers
Suspected Upper GI cancer
http://www.nice.org.uk/guidance/NG12/chapter/1-recommendations#uppergastrointestinal-tract-cancers
Appendix1
Drug induced diarrhoea-eg
metformin
nonsteroidal anti-inflammatory drugs
Allopurinol Colchicine
angiotensin-II receptor blockers,
Antibiotics
digoxin
thyroxine
cytotoxic drugs [such as methotrexate or chemotherapy],
H2-receptor antagonists, magnesium-containing antacids, proton pump inhibitors
selective serotonin reuptake inhibitors
statins
theophylline
high-dose vitamin C.
Thanks to Dr Les Ashton Nov 2015
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