Mistakes in... 2022 - 28

ueg education
Mistakes in... 2022
Mistakes in the management of unexplained diarrhoea and how to
avoid them
Hans Törnblom and Magnus Simrén
Diarrhoea, acute or chronic, is a common gastrointestinal symptom in healthcare. In
most cases, acute diarrhoea in healthy individuals requires limited diagnostic and
therapeutic efforts, except for the replacement of fluid electrolytes, and stool
culture in severe occurrences. Acute diarrhoea is often self-limiting due to short-lived
reactions to food intake and bacterial or viral infections. However, diarrhoea can
persist and fulfil definitions of chronicity when a month or more has passed since
the onset.1
Here we discuss some basic mistakes that should be avoided when managing
unexplained non-bloody diarrhoea that persists beyond the acute setting. In this
context, the term 'unexplained' refers to a patient without apparent alarm features
and where initial consultations have failed at making a diagnosis. We used an
evidence-based approach and included aspects predominantly based on clinical
experience when appropriate.
Mistake 1 Miscommunicating and
overlooking the clinical history
In clinical practice, obtaining a clear
understanding of the patient's complaints about
bowel habit abnormalities and its associated
symptoms can be difficult. The number of
differential diagnoses obtained using simple
tools can be reduced without losing accuracy.
Most doctors are familiar with the Bristol Stool
Form Scale 2
, which can be recommended
for assessing bowel habits in research and
clinical practice. In a patient that reports a loose
or watery stool (types 6 and 7), it is more likely
that the disturbed bowel habit is related to an
accelerated gut transit time if normal (types 3-5)
or hard (type 1 and 2) stool types are absent or
uncommon. Therefore, it is essential to consider
the type and number of investigations required
before making an accurate diagnosis (see
mistakes 2 and 3).
Furthermore, in case the patient does not
respond to symptomatic treatment, such as
loperamide, which can reduce diarrhoea and
improve the diarrhoeal symptoms, a suspicion of
a communication mismatch should be raised. In
hard-to-understand cases, filling out a stool diary
for 1-2 weeks is clinically helpful to complement
a good clinical history (the diary can contain
information on the frequency of bowel
© UEG 2022 Törnblom and Simrén
Cite this article as: Törnblom H and Simrén M. Mistakes in the
management of unexplained diarrhoea and how to avoid them.
UEG Education 2022; 22: 16-19.
Hans Törnblom is Associate Professor of Gastroenterology at the
Department of Molecular and Clinical Medicine, Institute of
Medicine, Sahlgrenska Academy, University of Gothenburg,
Gothenburg, Sweden.
16
movements, stool consistency and time of
the day). The presence of bowel movement
clusters after meals does not implicate the exact
pathophysiological mechanisms of diarrhoea
(suspicion of a sensitive rectum). However, an
evenly distributed watery bowel movement may
affect sleep (suspicion of secretory diarrhoea).
Additional important features for
understanding the more difficult to treat patients
with diarrhoea can be obtained through a
multidimensional clinical profile (MDCP).3
This
strategy involves adding layers of clinical
information regarding detailed symptom
descriptions and their emotional impact on
the patient's life, psychosocial modifiers, and
biomarkers (laboratory tests, transit time, and
histopathology). Good communication skills
form a fundamental basis for understanding why
a patient presenting symptoms for an extended
period has now decided to seek help from a
doctor.4
These efforts increase the possibility of
educating the patient about the diagnosis and
providing reassurance.5
Moreover, this approach
will lead to a diminished need for excessive health
care consumption due to the misunderstanding
of the intention of the treatment in irritable bowel
syndrome with diarrhoea (IBS-D), where the
abdominal pain component might not respond as
well as the bowel habit abnormality to a specific
type of treatment (e.g., loperamide).6
Mistake 2 Not recognising the
epidemiology of chronic diarrhoea
A simple rule of thumb is that the most
common causes underlying chronic diarrhoea
will also be the most frequent diagnoses in
clinical practice. (i.e., functional GI disorders).7
In a recent internet-based global epidemiology
study including twenty-six countries,8
the
prevalence of diarrhoea in adults with bowel
disorders have a predominance of 5.9% and 8.8%
in unspecified functional bowel disorder of whom
a substantial proportion also had symptoms
but did not rank them as the most bothersome
symptom.8
It is also essential to consider that bile
acid diarrhoea can be a contributing or fully
explaining factor in 25-30% of cases of chronic
diarrhoea.10
This finding should guide further
investigations, particularly in patients not
responding well to first-line treatments such as
loperamide.
Finally, basic clinical and epidemiological
knowledge of microscopic colitis can guide the
clinician in deciding when to consider this
diagnosis in patients with chronic diarrhoea
without overlooking biopsy retrieval from a
normal mucosa at colonoscopy. This should be
considered in patients with frequent watery,
non-bloody diarrhoea, where pain and other GI
Magnus Simrén is Professor of Gastroenterology at the
Department of Molecular and Clinical Medicine, Institute of
Medicine, Sahlgrenska Academy, University of Gothenburg,
Gothenburg, Sweden.
Illustrations: J. Shadwell.
Correspondence to: hans.tornblom@gu.se.
Conflicts of interest: HT has served as an advisory board
member/consultant and/or speaker for Takeda, Tillotts, Biocodex,
Dr Falk Pharma GmbH. MS has received unrestricted research
grants from Glycom, and served as an advisory board member/
consultant and/or speaker for Danone Nutricia Research,
Ironwood, Menarini, Biocodex, Genetic Analysis AS, DSM, Tillotts,
Takeda, Arena, Kyowa Kirin, Adnovate, Atnahs Pharma, Takeda,
AlfaSigma, Sanofi, Janssen Immunology, Pfizer, Ferrer, and Falk
Foundation.
Published online: July 7, 2022.
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