Change in bowel habits
Gastroenterology
Introduction
Author: Sarosh Ibrahim
Change in bowel habits (CIBH) is an important symptom in primary care and could point to benign or sinister pathology. When taking a history for a change in bowel habits, start by asking about the nature of the change—diarrhoea, constipation, alternating patterns, or changes in stool consistency, colour, or frequency. Inquire about associated symptoms such as abdominal pain, blood or mucus in stool, weight loss, fever, or systemic symptoms. Ask about dietary habits, medications (including antibiotics and laxatives), travel history, recent infections, and family history of gastrointestinal diseases like colorectal cancer or inflammatory bowel disease. Also, assess for red flag symptoms, including unexplained weight loss, anaemia, or nocturnal symptoms, which may indicate serious pathology.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did you first notice the change in your bowel habits?
Was it sudden or gradual?
2. Nature of Change
Are your stools looser or harder than usual?
Are you going more or less frequently?
Do you feel an urgent need to pass stool?
Do you feel you are not fully emptying your bowels?
3. Stool Characteristics:
What does your stool look like (e.g., watery, pellet-like, greasy, bulky)?
Have you noticed any blood or mucus in your stool?
Have your stools become paler or darker than usual?
Have they become particularly foul-smelling?
4. Associated Symptoms:
Gastrointestinal:
Abdominal pain, bloating, nausea, vomiting, or weight loss
Tenesmus (feeling of incomplete emptying)
Systemic:
Fever, night sweats, fatigue
Bleeding Symptoms:
Rectal bleeding, fresh blood, melaena (black tarry stools)
5. Triggers & Dietary Factors:
Have you changed your diet recently?
Have you started any new medications?
Have you recently travelled abroad?
7. Exacerbating Factors:
Does anything make your symptoms worse (e.g., certain foods, stress)?
8. Relieving Factors:
Has anything improved your symptoms (e.g., dietary changes, medications)?
9. Progression:
Have your symptoms worsened over time?
10. Impact on Daily Life:
How has this affected your daily activities, work, or sleep?
ICE: Ideas, Concerns, Expectations
Ideas: What do you think is causing this?
Concerns: Are you worried about anything specific (e.g., cancer, infection)?
Expectations: What are you hoping for in terms of treatment?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
Laxatives or antidiarrhoeals
NSAIDs, antibiotics, proton pump inhibitors (PPIs)
Recent changes in medication or over-the-counter drugs
Family History
Family history of bowel cancer, IBD, or coeliac disease
Social History
Dietary Habits: High fibre, lactose intake, recent changes
Hydration Levels: Fluid intake per day
Alcohol and Smoking History: Risk factors for bowel disease
Occupation: Stress levels, sedentary lifestyle
Travel History: Recent travel to regions with a risk of gastroenteritis
Risk Factors for Change in Bowel Habit (CIBH)
Age >50 with new-onset symptoms (higher malignancy risk)
Family history of bowel disease
Recent antibiotic use (risk of Clostridium difficile infection)
Immunosuppression (HIV, chemotherapy, long-term steroids)
Differential Diagnosis
Gastrointestinal Causes:
Diarrhoea-Predominant:
Infective gastroenteritis
Inflammatory bowel disease (Crohn’s, ulcerative colitis)
Coeliac disease
Irritable bowel syndrome (IBS)
Malabsorption syndromes (e.g., pancreatic insufficiency)
Constipation-Predominant:
IBS (constipation type)
Functional constipation
Diverticular disease
Bowel obstruction (e.g., malignancy, volvulus)
Systemic Causes:
Hyperthyroidism (causing diarrhoea)
Hypothyroidism (causing constipation)
Diabetes mellitus (autonomic neuropathy affecting bowel motility)
Malignancies:
Colorectal cancer
Pancreatic cancer (pale, greasy stools)
Management
Bedside:
Physical examination to check for
Assess for signs of anaemia, dehydration, cachexia
Abdominal examination:
Palpate for masses, tenderness, distension
Percussion for hepatosplenomegaly
Bowel sounds (hyperactive in diarrhoea, reduced in obstruction)
Rectal Examination:
Assess for masses, rectal bleeding, haemorrhoids
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia (suggesting malignancy or IBD)
Inflammatory markers (CRP, ESR) – raised in IBD
Thyroid function tests – if endocrine cause suspected
Coeliac serology (anti-TTG antibodies)
Liver function tests (LFTs) and pancreatic enzymes (amylase, lipase)
Stool Tests
Stool microscopy, culture, and sensitivity (if infection suspected)
Faecal calprotectin (to differentiate IBD from IBS)
FIT test for malignancy screening
Imaging and Special Tests:
Colonoscopy – if malignancy, IBD, or chronic unexplained symptoms suspected
Abdominal X-ray – if obstruction suspected
CT/MRI Abdomen & Pelvis – if malignancy suspected
Management Plan
1.Immediate Symptom Relief:
Increase fluid intake, dietary modifications
Symptomatic management (antidiarrhoeals, laxatives if needed)
2. Treatment Based on Underlying Cause
Diarrhoea
Rehydration therapy if dehydration present
Antibiotics only if bacterial infection suspected (e.g., C. difficile)
Gluten-free diet if coeliac disease confirmed
Constipation
High-fibre diet, increased fluid intake
Laxatives (bulk-forming, osmotic, stimulant) if needed
Inflammatory Bowel Disease:
Steroids, immunosuppressants, or biologics under specialist guidance
Malignancy:
Urgent referral for colonoscopy and further oncological management
3. Monitoring and follow up:
Review symptoms in 2-4 weeks
Repeat stool or blood tests if symptoms persist
Referral to gastroenterology if red flag symptoms (unintentional weight loss, rectal bleeding, anaemia, persistent change in bowel habit)
5. Referral:
Urgent referral for suspected cancer (two-week wait pathway)
Gastroenterology referral for chronic unexplained symptoms
Dietitian referral if malabsorption suspected