A 42-year-old woman visits her primary care physician, reporting 6 weeks of abdominal pain accompanied by bloody diarrhea. This occasionally wakes her from sleep.
- What additional questions would you ask to learn more about her diarrhea?
- How is diarrhea classified?
- Can you make a diagnosis through an open-ended history followed by focused questions?
- How can you use the patient history to distinguish between benign causes of diarrhea and serious ones?
Diarrhea accounts for up to 28 million office visits and 1.8 million hospital admissions in the United States each year, with up to 200 million total cases per year.1 The yearly incidence in adult patients has been reported to be 3% to 63% per year, depending on the referral source. In the United States, several billion dollars are spent annually on medical care and lost productivity due to diarrhea.1 Although a strict definition of diarrhea includes stool frequency and stool weight, many patients use the term when they experience increased stool liquidity. This chapter aims to clarify some key components of the history when interviewing a patient with diarrhea.
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|Acute diarrhea||Diarrhea lasting < 2 weeks.|
|Chronic diarrhea||Diarrhea lasting at least 4 weeks.|
|Diarrhea||Increased frequency of stools (> 3 per day) with increased stool weight (> 200 g/d). However, patients may use the term "diarrhea" to describe increased liquidity. In one series of patients referred to a gastrointestinal (GI) clinic for diarrhea, only 40% of patients actually had output > 200 g/d.2|
|Dysentery||The passage of bloody stools.|
|Irritable bowel syndrome (IBS)||A functional disorder characterized by the Rome III criteria, which include "Recurrent abdominal pain or discomfort at least three days per month in the last three months with symptom onset at least six months prior to the diagnosis, associated with two or more of the following: improvement with defecation, onset associated with a change in frequency of stool, and/or onset associated with a change in form (appearance) of stool."3|
|Organic versus functional diarrhea||Diarrhea with a known structural or biochemical explanation (ie, infection, inflammation, neoplasm) versus that without a known underlying cause.3|
|Persistent diarrhea||Diarrhea lasting 2–4 weeks. This time frame includes more prolonged and atypical presentations of acute diarrhea. Clinicians should not consider diarrhea to be chronic (and sufficient to evaluate for chronic diarrhea) unless it persists for at least 4 weeks.|
|Pseudodiarrhea, hyperdefecation||Increased frequency of defecation, but no increase in stool weight or change in stool consistency.|
|Tenesmus||Spasm of the anal sphincter associated with cramping and ineffective straining at stool.|
Because most episodes of diarrhea are self-limited, many patients never seek medical attention. For this reason, prevalence data must be viewed in the proper context: Patients referred to specialists are more likely to have chronic diarrhea, and conditions with alarm symptoms may be overrepresented. The prevalence of common etiologies of diarrhea in a primary care setting is unknown.