Investigations | Potential results | Clinical management plan: abnormal results |
---|---|---|
Dietary/ lifestyle/ medications assessment | High dietary fat intake Low/high fibre intake High fizzy drink intake High use of sorbitol-containing chewing gum or sweets High caffeine intake High alcohol intake Anxiety Drug induced, eg,
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Routine AND additional blood screen (pages 2–3) | Abnormal results Mg2+ low Coeliac disease | Follow treatment of abnormal blood results (pages 2–3).
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Stool sample: for microscopy, culture and Clostridium difficile toxin | Stool contains pathogen | Treat as recommended by the microbiologist and local protocols. |
Stool sample: for faecal elastase | EPI | See EPI (page 16) |
OGD with duodenal aspirate and biopsies and/or glucose hydrogen (methane) breath test | SIBO | Treatment for SIBO (page 17). |
Carbohydrate challenge | Specific disaccharide intolerance | Appropriate treatment (pages 16–17). |
SeHCAT scan | BAM | Treatment for BAM (page 16). |
Abdominal X-ray | Faecal loading with overflow | Bulking agent. |
1st Line | ||
Flexible sigmoidoscopy with biopsies from non-irradiated bowel (avoid biopsies from areas obviously irradiated in sigmoid and rectum) | Radiation proctopathy and frequency of defecation |
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Radiation proctopathy/colopathy and pelvic floor dysfunction (page 17) |
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Macroscopic colitis |
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Microscopic colitis | Discuss with supervising clinician and refer to a gastroenterologist. | |
2nd Line | ||
Colonoscopy with biopsies | Macroscopic or microscopic colitis | As above. |
Organic cause (eg, infection, inflammation, neoplastic) | Discuss with the appropriate clinical team within 24 h. | |
If diarrhoea is present in combination with other symptoms: flushing, abdominal pain, borborygmi, wheezing, tachycardia or fluctuation in BP | ||
3rd Line | ||
Gut hormones (Chromogranin A&B, gastrin, substance P, VIP, calcitonin, somatostatin, pancreatic polypeptide) and Urinary 5-HIAA and CT chest, abdomen and pelvis | Functioning NET, eg, carcinoid syndrome or pancreatic NET | Discuss and refer to the appropriate neuroendocrine tumour team requesting an appointment within 2 weeks. |
If all tests are negative, but symptoms persist | Reassure and suggest symptomatic treatment with antidiarrhoeal drugs. Trial of low-dose tricyclic antidepressants. Biofeedback. |
Note: faecal calprotectin as a marker for bowel inflammation is too non-specific and hence not recommended in this population.
BAM, bile acid malabsorption; EPI, excocrine pancreatic insufficiency; GP, general practitioner; IgA, immunoglobulin A; IgG, immunoglobulin G; OGD, oesophago-gastroduodenoscopy; PPI, proton pump inhibitor; NET, neuroendocrine tumour; SIBO, small intestinal bacterial overgrowth.