1. Bowel Habit Dr Beth Timmins, F2 18.10.2011

2. Introduction Why? Plan: History-taking Case studies Bowel habit by condition

3. Bowel Habit History Constipation Diarrhoea

4. Questions to Ask How do you open the discussion? HPC brainstorm Chronology Frequency Exactly what the stools are like [Bristol charts] Blood Mucus Pain Incontinence Tenesmus Background factors

5. Case Studies 62 year-old lady presents to GP with a change of bowel habit CRC: change in bowel habit, blood PR, weight loss Risk factors: age, polyps, diet low in fibre + high in red meat, familial syndromes, IBD Appearance: polypoid mass Histology: Duke’s staging Treatment: surgery +/- chemo Complications: fistulas, obstruction, perforation

6. Case 2 A 78 year-old woman on the general medical ward c/o a change in bowel habit. She has been in for 4 weeks, originally with a fall and UTI and now with pneumonia C. Difficile: Gram +ve bacillus associated with broad-spectrum abx Investigation: stool for C Diff toxin Management: vancomycin or metronidazole Complications: pseudomembranous colitis or toxic megacolon

7. Case 3 A 35 year-old lady on ETC c/o a change in bowel habit 2 days after cholecystectomy Iatrogenic constipation: secondary to opioids Mechanism: mu opioid receptors in the submucosal plexus in GI tract. Opioids decrease the propulsive peristalsis Treatment: laxatives. Prevent if possible by prophylactic prescribing and titrating opioid to effect

8. Short history of profuse watery diarrhoea and fever, starting on holiday Diarrhoea with blood and mucus 10-15 x daily with abdo pain, fever & weight loss Match the Bowel Habit with the Disease Irritable bowel syndrome Inflammatory bowel disease Alternating constipation & diarrhoea. Abdominal bloating and pain, relieved by defecation Chronic pancreatitis Infective gastroenteritis Bright red blood on the toilet paper and on the surface of normal stool Foul-smelling, pale, greasy stools that float in the toilet pan Haemorrhoids

9. History is crucial • Red flags: change in bowel habit weight loss blood PR • Don’t be embarrassed – asking about someone’s bowel habit could save a life Conclusion