Clinical Approach to Diarrhoea and Constipation. Ian Arnott Consultant Gastroenterologist Western General Hospital Edinburgh

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1 Clinical Approach to Diarrhoea and Constipation Ian Arnott Consultant Gastroenterologist Western General Hospital Edinburgh

2 Objectives GI problems are common 1 in 10 GP consultation referrals in Lothian per annum For constipation and diarrhoea Overview assessment of constipation Address initial investigations Guidance on when to refer Some suggestions on treatment Focus on initial assessment with very little about secondary care

3 MH 45 years female 612 history of constipation and abdominal pain Constipation BOx1/week Right sided Increasing constipation associated with bloating, nausea, anorexia and fatigue No weight loss, appetite unchanged No past medical history Non-smoker

4 Examination Looks well Not cachexit Abdomen slightly distended Soft Mild tenderness No masses

5 Differential diagnosis Slow transit constipation Constipation predominant IBS Functional obstructive defecation Drugs Colon cancer Diverticular disease Non-GI causes Neurological and metabolic What Investigations should be done?

6 Investigation Full blood count Hb 127 WCC 7.9 Plt 293 TFT normal Calcium normal Coeliac screen normal Faecal calprotectin?

7 When to refer >50 years <50 years Alarm symptoms Refer now Refer now No alarm symptoms Treat Treat and refer if no resolution Constipation alone is a low risk symptom for colorectal cancer and colonoscopy is not needed for all

8 Approach to Treatment Spectrum between slow transit constipation and constipation predominant IBS. Latter defined by Abdominal pain Bloating Irregular bowel habit What should we treat this lady with?

9 Treatment Non-drug approach Lifestyle important Fibre - there is a dichotomous response to this Fluid intake some is good! Diet in general Exercise Stop implicated meds may be OTC IBS-C Wheat free diet for 4 weeks Esp. if bloating a problem Hot peppermint tea in the evening Careful explanation

10 Drug Treatment Lactulose Not in IBS-C Stimulants Short term to get them going! Macrogols Good think about movicol liquid as alternative if volume an issue

11 New Drugs Linaclotide SMC approved guanylate cyclase-c agonist Generally well tolerated Experience variable Prucalopride SMC not approved 5-HT 4 receptor agonist Well tolerated Others

12 Referral to Secondary Care What can the patient expect. Investigation CT often a better option Colonic transit

13 Diarrhoea

14 Miss CLM 33 year old female 2 year history of diarrhoea Much worse in the last 6 months BO 4-5x on a good day, 8-10 on a bad day Thick liquid stool No blood Urgency and cramping lower abdominal pain Dropped a dress size

15 History PMSH Gastroenteritis in Egypt 6 years previously Skin tag removed by surgeons 12/12 DH Nil FH Nil Socially Defence lawyer, lives alone, 4cpd, little alcohol What is the differential diagnosis?

16 Differential Diagnosis IBS-D Inflammatory bowel disease Colon cancer Others Microscopic colitis Bile salt malabsorption Small intestinal bacterial overgrowth Lactose intolerance Metabolic disorders Drugs Etc etc Symptoms are non-specific What are reasonable initial investigations?

17 Investigations FBC CRP Coeliac screen TFT 7α-OH Cholestenone Stool culture Faecal calprotectin Not currently available in primary care yet!

18 Faecal calprotectin

19 Faecal calprotectin in Lothian Functional v other GI conditions Sensitivity 89% Negative predictive value 93% Functional v IBD Sensitivity 99% NPV 100% NICE guidance Lothian pilot coming v soon!

20 FC algorithm

21 Delay in diagnosis of IBD is important

22 CML - Investigations FBC Hb 123 WCC 12.3 Plt 264 CRP <1 Faecal calprotectin <20µg/g Diarrhoea screen negative What is the most likely diagnosis? Should she be referred to secondary care?

23 When to refer >50 years <50 years Alarm symptoms Refer now Refer now No alarm symptoms Treat Think calprotecin Treat if obvious cause and refer if no resolution. Otherwise refer Diarrhoea is a higher risk symptom for colorectal cancer and other pathologies. A lower threshold for referral is needed.

24 Who to refer

25 Approach to treatment Lifestyle Psychological drivers 1 o care much better at addressing these issues CBT very effective for some Some evidence for hypnotherapy but no longer available in Lothian Stop implicated drugs diabetic drugs PPIs

26 Dietary treatment of IBS-D Diet In general Diet drinks, diluting drinks, processed foods, irregular meals, alcohol NICE IBS diet sheet Trial of lactose Wheat free diet Esp with bloating Less useful than in IBD-C Low FODMAP diet Referral to a dietician

27 Drug Treatment Antibiotics Loperamide Aim for stable daily dosage Use paediatric liquid if one capsule is too much Ask the patient not to chase symptoms Tricyclic antidepressants Especially when pain component Ondansetron Recent evidence that superior to loperamide for IBS-D

28 Conclusions Diarrhoea and constipation are common Systematic approach to investigation and referral can keep many patients in the community Diarrhoea is a stronger risk factor for pathology than constipation Low threshold for referral esp if >50 years Think about faecal calprotectin in younger patients Pilot in Lothian planned please take part!

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