Change in Bowel Movements

Take a careful history of bowel habits. A change in bowel movements necessitates further elaboration. Ask these questions of the patient with acute onset of diarrhea:

''How long have you had the diarrhea?'' ''How many bowel movements do you have a day?'' ''Did the diarrhea start suddenly?''

''Did the diarrhea begin after a meal?'' If yes, ' 'What did you eat?'' ''Are the stools watery? bloody? malodorous?''

''Is the diarrhea associated with abdominal pain? loss of appetite? nausea? vomiting?''

The acute onset of diarrhea after a meal suggests an acute infection or toxin. Watery stools are often associated with inflammatory processes of the small bowel and colon. Shigellosis is a disease of the colon that produces bloody diarrhea. Amebiasis is also associated with bloody diarrhea.

The patient with chronic diarrhea should be asked the following: ' 'How long have you had diarrhea?''

''Do you have periods of diarrhea alternating with constipation?'' Are the stools watery? loose? floating? malodorous?'' Have you noticed blood in the stools? mucus? undigested food?'' ''What is the color of the stools?'' How many bowel movements do you have a day?'' Does the diarrhea occur after eating?'' What happens when you fast? Do you still have diarrhea?''

Is the diarrhea associated with abdominal pain? abdominal distention? nausea? vomiting?'' ''Have you noticed that the diarrhea is worse at certain times of the day?'' How is your appetite?'' Has there been any change in your weight?''

Diarrhea and constipation frequently alternate in patients with colon cancer or diverticulitis. Loose bowel movements are common in diseases of the left colon, whereas watery movements are seen in severe inflammatory bowel disease and protein-losing enteropathies. Floating stools may result from malabsorption syndromes. Patients with ulcerative colitis commonly have stool mixed with blood and mucus. Any inflammatory process of the small bowel or colon can manifest with blood mixed with stool or undigested food. Irritable bowel syndrome classically produces more diarrhea in the morning.

Patients complaining of constipation should be asked these questions:

How long have you been constipated?'' How often do you have a bowel movement?''

''What is the size of your stools?'' ''What is the color of your stools?'' ''Is the stool ever mixed with blood? mucus?''

''Have you noticed periods of constipation alternating with periods of diarrhea?'' ''Have you noticed a change in the caliber of the stool?'' ''Do you have much gas?'' How's your appetite?'' Has there been any change in your weight?''

Change in the caliber of the stool is significant. ''Pencil''-diameter stools may result from an anal or a distal rectal carcinoma. A change in the color of stools is important. As is discussed later, pale brown to gray stools indicate an absence of bile. This can result from an obstruction to bile flow from the gallbladder or from decreased production of bile. Weight changes are important with the symptom of constipation. An increase in weight may indicate decreased metabolism seen in hypothyroidisms decrease in weight may be associated with cancer of the colon or other hypermetabolic conditions.

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