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Education in practice
How to manage chronic diarrhoea in the elderly?
  1. Benjamin Crooks1,2,
  2. Jimmy K Limdi3,4,
  3. John McLaughlin1,2,4
  1. 1 Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
  2. 2 Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
  3. 3 Section of IBD, Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK
  4. 4 Manchester Academic Health Science Centre, Manchester, UK
  1. Correspondence to Professor John McLaughlin, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester M13 9PL, UK; john.mclaughlin{at}manchester.ac.uk

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Introduction

Chronic diarrhoea is a common problem seen in both primary and secondary care, affecting up to 5% of the general population at any given time.1 Evaluation of chronic diarrhoea poses myriad challenges to the clinician, not in the least because ‘diarrhoea’ means different things to different people (patients and clinicians) but also because it has a diverse aetiology and can be multifactorial in any given individual. Patients relate to loose stool consistency, increased frequency of defaecation, urgency or incontinence (or in combination with one or some of these symptoms) as ‘diarrhoea’ while physicians have traditionally used an increased frequency of defaecation or increased stool weight to define diarrhoea.1

The recent publication of updated British Society of Gastroenterology (BSG) guidelines by Arasaradnam and colleagues addresses this inconsistency, providing a pragmatic definition and approach to the diagnosis and investigation of patients with chronic diarrhoea (figure 1).2 The guidelines define chronic diarrhoea as ‘the persistent alteration from the norm with stool consistency between types 5 and 7 on the Bristol stool chart and increased frequency greater than 4 weeks’ duration’.

Figure 1

Algorithm for the investigation of chronic diarrhoea based on clinical differential diagnosis. (from Arasaradnam et al, 2018, p. 1381). DG, diagnostics guidance; NG, NICE guideline; NICE, National Institute for Health and Care Excellence.

The challenges presented by the diagnostic workup of chronic diarrhoea are arguably more pronounced in the elderly, wherein diverse aetiologies in the face of multiple potential clinical comorbidities and polypharmacy for these conditions, and additional limitations posed by frailty and resultant inability to undergo recommended investigations need careful consideration. This article aims to offer a pragmatic approach to the assessment of chronic diarrhoea in the elderly (figure 2).

Figure 2

A proposed adapted algorithm for an approach to the assessment of chronic diarrhoea in the elderly. …

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