More 4 Week

Diarrhoea - adult's assessment - NICE CKS https://cks.nice.org.uk/diarrhoea-adults-assessme...
Diarrhoea - adult's assessment

Last revised in December 2018 Next planned review by December 2023
Back to top
Changes
December 2018 — reviewed. A literature search was conducted in September

2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key
RCTs published since the last revision of the topic. New recommendations have
been added to the referral section, reflecting the National Institute for Health and
Care Excellence guideline on Suspected cancer: recognition and referral [NICE,
2015a (/diarrhoea-adults-assessment#!references)]. In the scenario on chronic
diarrhoea, there have been changes to the assessment section and new tests to
consider have been added to the recommendations on investigations.
Previous changes Back to top
March 2013 — reviewed. A literature search was conducted in February 2013 to

identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs
published since the last revision of the topic. There are no changes to the
recommendations.
September to December 2010 — this is a new CKS topic. The evidence-base has
been reviewed in detail, and recommendations are clearly justified and
transparently linked to the supporting evidence.
Back to top
Update
New evidence Back to top
Evidence-based guidelines
No new evidence-based guidelines since 1 September 2018.
1 dari 48 27/07/2019 10.34

HTAs (Health Technology Assessments)
No new HTAs since 1 September 2018.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2018.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 September 2018.
Primary evidence
No new randomized controlled trials published in the major journals since 1

September 2018.
New policies Back to top
No new national policies or guidelines since 1 September 2018.
New safety alerts Back to top
No new safety alerts since 1 September 2018.
Changes in product availability Back to top
No changes in product availability since 1 September 2018.
Back to top
Goals
2 dari 48 27/07/2019 10.34
To support primary healthcare professionals to:
Assess the symptoms of diarrhoea and diagnose an underlying cause where

possible in primary care.
Refer people with appropriate urgency for further investigation or treatment.
Back to top
Outcome measures
No outcome measures were found during the review of this topic.

Back to top
Audit criteria
No audit criteria were found during the review of this topic.

Back to top
QOF indicators
No QOF indicators were found during the review of this topic.

Back to top
QIPP - Options for local
implementation
No QIPP indicators were found during the review of this topic.

Back to top
NICE quality standards
NICE quality standard [QS134]. Coeliac disease (https://www.nice.org.uk/guidance

/qs134). Quality statement 1: Serological testing for coeliac disease.
People at increased risk or with symptoms of coeliac disease are offered a

serological test for coeliac disease.
NICE quality standard [QS114]. Irritable bowel syndrome in adults

(https://www.nice.org.uk/guidance/qs114). Quality statement 1: Excluding
inflammatory causes.
Adults with symptoms of irritable bowel syndrome are offered tests for
3 dari 48 27/07/2019 10.34

inflammatory markers as first‑line investigation to exclude inflammatory causes.
NICE quality standard [QS124]. Suspected cancer (https://www.nice.org.uk

/guidance/qs124). Quality statement 3: Testing for blood in faeces.
Adults presenting in primary care with symptoms that suggest colorectal cancer,
who do not meet the referral pathway criteria, have a test for blood in their
faeces.
[NICE, 2016a (/diarrhoea-adults-assessment#!references); NICE, 2016b

(/diarrhoea-adults-assessment#!references); NICE, 2016c (/diarrhoea-adults-
assessment#!references)]
Back to top
What is it?
Diarrhoea is a symptom, of which there are many causes (/diarrhoea-

adults-assessment#!backgroundSub:2).
Many different definitions of diarrhoea have been suggested, but the World
Health Organization defines diarrhoea as 'the passage of three or more loose or
liquid stools per day (or more frequent passage than is normal for the
individual)' [WHO, 2017 (/diarrhoea-adults-assessment#!references)].
Acute diarrhoea is defined as lasting for less than 14 days [Barr and Smith,
2014 (/diarrhoea-adults-assessment#!references); PHE, 2015 (/diarrhoea-
adults-assessment#!references)].
Persistent diarrhoea is defined as lasting more than 14 days [DuPont, 2016
(/diarrhoea-adults-assessment#!references); Riddle et al, 2016 (/diarrhoea-
Chronic diarrhoea is defined as lasting for more than 4
weeks [Arasaradnam et al, 2018 (/diarrhoea-adults-
assessment#!references)].
Back to top
What is the pathophysiology of
diarrhoea?
Mechanisms that can cause diarrhoea are [Kroser and Metz, 1996
4 dari 48 27/07/2019 10.34

(/diarrhoea-adults-assessment#!references); Crombie et al, 2013 (/diarrhoea-
adults-assessment#!references)]:
Increased osmotic load in the gut lumen.
Osmotic diarrhoea occurs when a soluble compound cannot be absorbed
by the small intestine, and thus draws fluid into the intestinal lumen.
Examples include: osmotic laxatives; magnesium-based antacids; and
foods containing mannitol, sorbitol, or xylitol. Osmotic diarrhoea can also
be due to generalised malabsorption (for example, coeliac disease and
pancreatic insufficiency).
Osmotic diarrhoea will stop if the person fasts.
Increase in secretion.
Secretory diarrhoea results from increased secretion of fluid and
electrolytes into the intestine with decreased absorption. Infections with
such organisms as Vibrio cholerae, E Coli, and C difficile can cause
secretory diarrhoea, as can bile salts in the colon (for example, after ileal
resection) some drugs (for example, laxatives, diuretics, theophylline,
cholinergic drugs, prostaglandins, caffeine, and ethanol) and gut allergies.
Even if a person fasts, secretory diarrhoea will persist.
Inflammation of the intestinal lining.
Damage to intestinal mucosal cells affects absorption of fluid and
electrolytes and results in fluid and blood loss. Infection (for example,
Shigella) and conditions such as ulcerative colitis and Crohn's disease are
causes of inflammatory diarrhoea.
Nocturnal symptoms are often present.
Increased intestinal motility.
This may present with an increased frequency of stool passage without an
increase in volume. It can occur with endocrine conditions such as
diabetes and hyperthyroidism.
More than one mechanism may cause diarrhoea in an affected person.
Back to top
What causes it?
What causes acute diarrhoea? Back to top
Worldwide, acute diarrhoea is most commonly caused by infection [BMJ

Best Practice, 2018a (/diarrhoea-adults-assessment#!references)].
5 dari 48 27/07/2019 10.34

Viruses are the most common infectious cause in the community [Tam
et al, 2012a (/diarrhoea-adults-assessment#!references)].
Among people who consult their GP, norovirus is one of the most common
organisms isolated, as well as sapovirus and rotavirus [Tam et al, 2012a
(/diarrhoea-adults-assessment#!references)]. Norovirus is the most
common cause of sporadic outbreaks of gastroenteritis affecting all age
groups [World Gastroenterology Organisation, 2012 (/diarrhoea-adults-
Bacterial causes include infection with Salmonella species, Campylobacter
jejuni, Shigella species, and Escherichia coli [Barr and Smith, 2014
(/diarrhoea-adults-assessment#!references)].
Campylobacter species is one of the most common organisms isolated
among people who consult their GP [Jones and Rubin, 2009 (/diarrhoea-
Clostridium difficile can cause infectious diarrhoea in people who have
taken antibiotics, especially those who are older, immunocompromised, or
have been in hospital [Barr and Smith, 2014 (/diarrhoea-adults-
assessment#!references); PHE, 2015 (/diarrhoea-adults-
assessment#!references); DuPont, 2016 (/diarrhoea-adults-
assessment#!references)]. For more information, see the CKS topic
on Diarrhoea - antibiotic associated (/diarrhoea-antibiotic-associated).
Parasitic causes are the most common infections causing persistent
diarrhoea. Protozoa are important and include Cryptosporidium, Giardia,
Entamoeba histolytica, and Cyclospora. Protozoan and bacterial infections
may cause persistent diarrhoea (duration of 14 days or more) [DuPont, 2016
Infections that can present with bloody diarrhoea include [Holtz et al,
2009 (/diarrhoea-adults-assessment#!references); Barr and Smith, 2014
(/diarrhoea-adults-assessment#!references)]:
Bacterial: Campylobacter jejuni, Salmonella, Escherichia
coli O157:H7, Vibrio parahaemolyticus, Shigella, Yersinia,
Aeromonas, Clostridium difficile.
Viruses: cytomegalovirus.
Parasites: Entamoeba histolytica, schistosomiasis.
For more information on infectious causes, see the CKS topic
on Gastroenteritis (/gastroenteritis).
Drugs associated with diarrhoea include laxatives, allopurinol, angiotensin-II
6 dari 48 27/07/2019 10.34

receptor blockers, antibiotics, chemotherapy, magnesium-containing antacids,
metformin, nonsteroidal anti-inflammatory drugs, proton pump inhibitors, and
selective serotonin reuptake inhibitors [Baldi et al, 2009 (/diarrhoea-adults-
assessment#!references); Barr and Smith, 2014 (/diarrhoea-adults-
assessment#!references); Chapman et al, 2015 (/diarrhoea-adults-
assessment#!references); Arasaradnam et al, 2018 (/diarrhoea-adults-
For more information on specific drugs and whether diarrhoea is a reported
adverse effect, see the manufacturer's Summary of Product Characteristics
at www.medicines.org.uk/emc (http://www.medicines.org.uk/emc/).
Other causes of acute diarrhoea include [Baldi et al, 2009 (/diarrhoea-adults-
assessment#!references); Jones and Rubin, 2009 (/diarrhoea-adults-
assessment#!references)]:
Anxiety.
Food allergy.
Acute appendicitis.
Pelvic radiation treatment.
Intestinal ischaemia.
Early presentation of a chronic cause (/diarrhoea-adults-
assessment#!backgroundSubSub:1) (for example, a first presentation of
inflammatory bowel disease).
What causes chronic diarrhoea? Back to top
Chronic diarrhoea has a broader differential diagnosis than acute

diarrhoea. More common causes of chronic diarrhoea include [Arasaradnam et
al, 2018 (/diarrhoea-adults-assessment#!references)]:
Irritable bowel syndrome
Irritable bowel syndrome is a functional disorder of the bowel. It is
characterized by frequent episodes of bowel disturbance, abdominal
discomfort or pain, and bloating which may affect daily activities. Diet or
stress may exacerbate symptoms. The cause is unclear, but there may be
an association with increased bowel sensitivity or abnormal muscle activity
in the bowel wall [NICE, 2013 (/diarrhoea-adults-
7 dari 48 27/07/2019 10.34

assessment#!references)]. Associated symptoms include headache, back
pain, and psychosocial distress [Chapman et al, 2015 (/diarrhoea-adults-
For more information, see the CKS topic on Irritable bowel syndrome
(/irritable-bowel-syndrome).
Diet
For example fermentable oligo-, di-, mono-saccharides and polyols
(FODMAP) malabsorption, artificial sweeteners such as sorbitol, caffeine,
and excess alcohol [Arasaradnam et al, 2018 (/diarrhoea-adults-
Inflammatory bowel disease (Crohn's disease, ulcerative colitis).
For more information, see the CKS topics on Crohn's disease (/crohns-
disease) and Ulcerative colitis (/ulcerative-colitis).
Microscopic colitis
Microscopic colitis is a clinicopathological diagnosis that causes chronic
watery diarrhoea, especially in older women. Other symptoms may be
non-specific, but include abdominal pain, weight loss and arthralgia [Pardi,
2017 (/diarrhoea-adults-assessment#!references); Gentile and Yen, 2018
Coeliac disease
Coeliac disease is a common autoimmune disorder in which there is a
heightened immunological response to gluten. Coeliac disease can
present in adulthood (fourth or fifth decade) with symptoms including
abdominal pain, change in bowel habit, and anaemia, although people
with the condition do not always have abdominal symptoms or signs of
malabsorption [Mooney et al, 2014 (/diarrhoea-adults-
assessment#!references)]. For more information, see the CKS topic
on Coeliac disease (https://cks.nice.org.uk/coeliac-disease).
Other causes of malabsorption
These include lactose intolerance and pancreatic insufficiency [Chapman
et al, 2015 (/diarrhoea-adults-assessment#!references)].
Colorectal cancer
Colorectal cancer may present as diarrhoea. There may be rectal bleeding
or blood mixed in with the stools, and a palpable rectal or abdominal
mass. Weight loss and iron deficiency anaemia may also feature [Del
Giudice et al, 2014 (/diarrhoea-adults-assessment#!references)]. For more
information, see the CKS topic on Gastrointestinal tract (lower) cancers -
8 dari 48 27/07/2019 10.34

recognition and referral (https://cks.nice.org.uk/gastrointestinal-tract-lower-
cancers-recognition-and-referral).
Bile acid diarrhoea
Bile acid diarrhoea is due to imbalances in bile acid homeostasis in the
enterohepatic circulation and may occur as a result of ileal disease or
dysfunction (such as Crohn's disease or terminal ileum resection) or be
idiopathic. Excess bile acid in the colon causes diarrhoea through effects
on electrolyte balance and speeding up of large bowel transit
time [Mottacki et al, 2016 (/diarrhoea-adults-assessment#!references)].
Drugs
Examples include antibiotics (particularly macrolides such as
erythromycin), antihypertensives (for example ACE inhibitors) nonsteroidal
anti-inflammatory drugs, hypoglycaemic drugs (such as metformin and
gliptins), magnesium-containing products, proton pump inhibitors,
selective serotonin reuptake inhibitors, antineoplastic drugs, theophyllines,
antiarrhythmics, and furosemide [Crombie et al, 2013 (/diarrhoea-adults-
assessment#!references); Dosanjh and Pardi, 2016 (/diarrhoea-adults-
For more information on specific drugs and whether diarrhoea is a
reported adverse effect, see the manufacturer's Summary of Product
Characteristics at www.medicines.org.uk/emc
(http://www.medicines.org.uk/emc/).
Constipation and faecal impaction (leading to overflow) [Arasaradnam et
al, 2018 (/diarrhoea-adults-assessment#!references)].
This is common in frail older people [Crombie et al, 2013 (/diarrhoea-
Other less common diagnoses to consider include [Arasaradnam et al, 2018
(/diarrhoea-adults-assessment#!references)]:
Infection — it is unusual for chronic diarrhoea to be caused by infection in an
immunocompetent person, although chronic infections can result from
protozoan infections (for example giardiasis and amoebiasis).
Small bowel bacterial overgrowth.
Mesenteric ischaemia.
Lymphoma.
Surgical causes (for example, small bowel resection, internal fistulae).
9 dari 48 27/07/2019 10.34

Chronic pancreatitis, pancreatic carcinoma.
Radiation enteropathy.
Endocrine disorders — for example, hyperthyroidism, diabetes (may be
metformin-associated), hypoparathyroidism, Addison’s disease.
Cystic fibrosis.
Factitious diarrhoea — the person adds water to their stools or uses
laxatives.
Small bowel enteropathy (for example Whipple’s disease, tropical sprue,
amyloid).
Hormone secreting tumours (for example VIPoma, gastrinoma, carcinoid).
Autonomic neuropathy.
Brainerd diarrhoea (possibly due to an infectious cause, but not identified).
Back to top
How common is it?
Diarrhoea is one of the most common symptoms for which people seek
medical attention [Kroser and Metz, 1996 (/diarrhoea-adults-
For prevalence data for a specific condition, see the relevant CKS topic.
Acute diarrhoea
Infectious diarrhoea is common [PHE, 2015 (/diarrhoea-adults-
A prospective cohort study conducted in the UK has estimated that there are
up to 17 million cases and 1 million GP consultations attributed to acute
infectious diarrhoea every year [Tam et al, 2012a (/diarrhoea-adults-
A study of infectious intestinal disease in the community estimated that about
a quarter of people in the UK have an episode of infectious intestinal disease
in a year [Tam et al, 2012b (/diarrhoea-adults-assessment#!references)].
The most commonly isolated pathogens in the community presenting to
primary care were norovirus, sapovirus, Campylobacter spp. and rotavirus.
Clostridium difficile associated diarrhoea was rarely reported.
Chronic diarrhoea
Chronic diarrhoea is a common reason for referral to gastroenterology, but its
prevalence is difficult to estimate because definitions of chronic diarrhoea
vary [Dosanjh and Pardi, 2016 (/diarrhoea-adults-assessment#!references);
10 dari 48 27/07/2019 10.34

Arasaradnam et al, 2018 (/diarrhoea-adults-assessment#!references)]. In
population studies, reported prevalence was 14% in elderly people [Talley et
al, 1992a (/diarrhoea-adults-assessment#!references)], and 7% in a younger
US population [Talley et al, 1992b (/diarrhoea-adults-
Back to top
What are the complications?
In developed countries, diarrhoea is an important cause of morbidity, but

it is responsible for relatively few deaths [World Gastroenterology
Organisation, 2012 (/diarrhoea-adults-assessment#!references)].
Dehydration increases the risk of life-threatening illness and death,
particularly in young infants and children, and older people, and in less
developed countries [World Gastroenterology Organisation, 2012 (/diarrhoea-
adults-assessment#!references); Shane et al, 2017 (/diarrhoea-adults-
Chronic diarrhoea can negatively impact on quality of life, for example,
avoidance of travelling or going to new places where access to toilet facilities
may be difficult; and adaptation of food choices to avoid exacerbating
diarrhoea [Dosanjh and Pardi, 2016 (/diarrhoea-adults-
For information on the complications occurring as a result of specific infections
causing diarrhoea, see the CKS topic on Gastroenteritis (/gastroenteritis).
For complications of conditions causing diarrhoea, see the appropriate CKS
topic, for example, Coeliac disease (/coeliac-disease), Crohn's disease
(/crohns-disease), and Ulcerative colitis (/ulcerative-colitis).
Back to top
What is the prognosis?
Most infectious diarrhoea is of viral origin and is self-limiting, with nearly half of
episodes lasting less than a day [PHE, 2015 (/diarrhoea-adults-
It is thought that [CDC, 2017 (/diarrhoea-adults-assessment#!references)]:
Viral diarrhoea lasts around 2–3 days.
Untreated bacterial diarrhoea has a duration of around 3–7 days.
Protozoal diarrhoea can be present for weeks to months without treatment.
11 dari 48 27/07/2019 10.34

The prognosis of chronic diarrhoea will depend on the underlying cause
(/diarrhoea-adults-assessment#!backgroundSubSub:1).
Back to top
Scenario: Acute diarrhoea (less than
4 weeks)
From age 18 years onwards.
How should I assess a person with acute diarrhoea? Back to top
Determine the onset, duration, frequency, and severity of symptoms.

Enquire about the presence of red flag symptoms:
Blood in the stool.
Recent hospital treatment or antibiotic treatment. For more information, see
the CKS topic on Diarrhoea - antibiotic associated (/diarrhoea-antibiotic-
associated).
Weight loss.
Evidence of dehydration.
Nocturnal symptoms — organic cause more likely.
Attempt to ascertain the underlying cause (/diarrhoea-adults-
assessment#!backgroundSubSub). Assess for:
Quantity and character of stools (watery, fatty, containing blood or mucus).
Features suggesting infection, such as:
Fever.
Vomiting.
Recent contact with a person with diarrhoea.
Exposure to possible sources of enteric infection (for example, having
eaten meals out, or recent farm or petting zoo visits).
Travel abroad — increases the likelihood of infection. Ask about potential
exposures such as raw milk or untreated water.
Being in a higher risk group such as food handlers, nursing home
residents, and recently hospitalized people.
Any new drugs, especially antibiotics or laxatives. For examples, see
the Causes (/diarrhoea-adults-assessment#!backgroundSubSub) section
on Acute diarrhoea (/diarrhoea-adults-assessment#!backgroundSubSub).
12 dari 48 27/07/2019 10.34

Stress or anxiety.
Abdominal pain, which is often present in inflammatory bowel disease,
irritable bowel syndrome, and ischaemic colitis.
History of recent radiation treatment to the pelvis.
Factors increasing the risk of immunosuppression (for example, human
immunodeficiency virus infection, long term steroid use, or chemotherapy).
Any surgery or medical conditions (for example, endocrine disease)
accounting for the diarrhoea.
Diet and use of alcohol or substances such as sorbitol.
Assess for complications of diarrhoea, such as dehydration.
Features indicating dehydration include increased pulse rate, reduced skin
turgor, dryness of mucous membranes, delayed capillary refill
time, decreased urine output, hypotension (check for postural changes), and
altered mental status. For more detail, see Clinical features of dehydration
(/diarrhoea-adults-assessment#!scenarioRecommendation:1).
Also consider underlying conditions that may increase the risk of
complications.
Perform an abdominal examination to assess for pain or tenderness,
distension, mass, increased or decreased bowel sounds, or liver enlargement.
Consider a rectal examination to assess for rectal tenderness, stool
consistency, and for blood, mucus, and possible malignancy.
If acute causes have been excluded and the person has features
suggestive of an early presentation of a chronic cause (/diarrhoea-adults-
assessment#!backgroundSubSub:1), see Scenario: Chronic diarrhoea (more
than 4 weeks) (/diarrhoea-adults-assessment#!scenario:1).
Clinical features of dehydration Back to top
Mild dehydration
Lassitude.
Anorexia, nausea.
Light-headedness.
Postural hypotension.
Usually no signs.
Moderate dehydration
Apathy/tiredness.
13 dari 48 27/07/2019 10.34

Dizziness.
Nausea/headache.
Muscle cramps.
Pinched face.
Dry tongue or sunken eyes.
Reduced skin elasticity.
Postural hypotension.
Tachycardia.
Oliguria.
Severe dehydration
Profound apathy.
Weakness.
Confusion, leading to coma.
Shock.
Tachycardia.
Marked peripheral vasoconstriction.
Systolic blood pressure less than 90 mmHg.
Oliguria or anuria.
[Farthing et al, 1996 (/diarrhoea-adults-assessment#!references); World

Gastroenterology Organisation, 2012 (/diarrhoea-adults-assessment#!references)]
Basis for recommendation Back to top
Determining onset, duration, frequency, and severity of symptoms
This recommendation is based on expert opinion in review articles on acute and

persistent diarrhoea [Barr and Smith, 2014 (/diarrhoea-adults-
assessment#!references); DuPont, 2016 (/diarrhoea-adults-
Identifying red flag symptoms
Expert opinion in a review article indicates that 'red flag' symptoms in people
with acute diarrhoea can indicate: an alarm symptom of a serious
gastrointestinal problem, serious systemic complications (such as sepsis,
14 dari 48 27/07/2019 10.34

dehydration or abdominal disease), or symptoms discriminating between key
diagnoses [Jones and Rubin, 2009 (/diarrhoea-adults-
assessment#!references)]. Red flag symptoms listed in this topic are also based
on expert opinion in a review article on the assessment and management of
diarrhoea [Crombie et al, 2013 (/diarrhoea-adults-assessment#!references)].
Determining the underlying cause
The recommendations on ascertaining the underlying cause of acute diarrhoea

are based on the 2017 Infectious Diseases Society of America Clinical Practice
Guidelines for the Diagnosis and Management of Infectious Diarrhea [Shane et
al, 2017 (/diarrhoea-adults-assessment#!references)] and review articles on
acute diarrhoea, persistent diarrhoea, and the assessment and management of
diarrhoea [Jones and Rubin, 2009 (/diarrhoea-adults-assessment#!references);
Crombie et al, 2013 (/diarrhoea-adults-assessment#!references); Barr and
Smith, 2014 (/diarrhoea-adults-assessment#!references); DuPont, 2016
Assessing for complications
The information on assessing for complications of diarrhoea is based on the

2017 Infectious Diseases Society of America Clinical Practice Guidelines for the
Diagnosis and Management of Infectious Diarrhea [Shane et al, 2017
(/diarrhoea-adults-assessment#!references)] and World Gastroenterology
Organisation Global Guidelines on acute diarrhoea in adults and children [World
Gastroenterology Organisation, 2012 (/diarrhoea-adults-
assessment#!references)]. Expert opinion in a review article and evidence
summary was also taken into account [Barr and Smith, 2014 (/diarrhoea-adults-
assessment#!references); BMJ Best Practice, 2018a (/diarrhoea-adults-
Abdominal and rectal examination
Features to check for on abdominal and rectal examination reflect expert

opinion in review articles and an evidence summary [Crombie et al, 2013
(/diarrhoea-adults-assessment#!references); Barr and Smith, 2014 (/diarrhoea-
adults-assessment#!references); BMJ Best Practice, 2018a (/diarrhoea-adults-
15 dari 48 27/07/2019 10.34

How should I investigate acute diarrhoea in primary care? Back to top
Send a faecal specimen for routine microbiology investigation if a person

with diarrhoea has:
Symptoms/signs or a clinical indication:
The person is systemically unwell; needs hospital admission, and/or
antibiotics.
There is blood or pus in the stool.
The person is immunocompromised.
The person has recently received antibiotics, a proton pump inhibitor
(PPI) or been in hospital — also request specific testing for Clostridium
difficile. For more information, see the CKS topic on Diarrhoea - antibiotic
associated (/diarrhoea-antibiotic-associated).
Diarrhoea occurs after foreign travel — also request tests for ova, cysts,
and parasites and state the countries visited on the form.
Amoebae, Giardia, or cryptosporidium are suspected, particularly if
diarrhoea is persistent (2 weeks or more) or the person has travelled to an
at-risk area.
There is a need to exclude infectious diarrhoea (for example severe
abdominal pain, exacerbation of inflammatory bowel disease, or irritable
bowel syndrome).
A public health indication:
Diarrhoea in high-risk people (for example food handlers, healthcare
workers, elderly residents in care homes).
Suspected food poisoning (for example after a barbeque, restaurant meal,
or eating eggs, chicken, or shellfish).
Outbreaks of diarrhoea in the family or community, when isolating the
organism may help pinpoint the source of the outbreak.
Contacts of people infected with certain organisms, for
example, Escherichia coli O157 or C. difficile, where there may be serious
clinical sequelae to an infection.
Close household contacts of a person with Giardia infection.
For more information on how to send a stool sample (such as what
information to include), see Sending a stool sample (/diarrhoea-adults-
assessment#!scenarioRecommendation:3).
Consider blood tests if infection and the other causes of acute diarrhoea have
16 dari 48 27/07/2019 10.34

been excluded and it is suspected that an episode of acute diarrhoea is due to
a chronic cause.
See the section on Investigations (/diarrhoea-adults-
assessment#!scenarioRecommendation:6) in the Scenario: Chronic
diarrhoea (more than 4 weeks) (/diarrhoea-adults-
assessment#!scenario:1) for advice on which blood tests to request.
Sending a stool sample Back to top
Send a single specimen (a quarter full specimen pot is the minimum needed for
routine microbiology investigation). Only send loose stools as the laboratory will
not examine formed stools.
If diarrhoea occurs after exotic travel abroad, is recurrent, or prolonged, request
ova, cysts, and parasites and give details of travel. Send three specimens a
minimum of 2 days apart (ova, cysts, and parasites are shed intermittently).
Ensure that the following details are included on the request form:
Clinical features (for example fever; bloody stool; severe abdominal pain).
History of immunosuppression.
Food intake (for example shellfish).
Recent foreign travel (specify countries).
Recent antibiotic therapy, proton pump inhibitor therapy, or hospitalization
(suggestive of Clostridium difficile infection).
Exposure to untreated water (suggestive of infection with protozoa).
Contact with other affected people, or an outbreak.
Repeat specimens are usually unnecessary, unless advised by a specialist
(microbiologist or consultant in public health), or ova, cysts and parasites are
suspected.
Sending a stool specimen
These recommendations are largely based on, and extrapolated from, Public
Health England (PHE) guidance on managing suspected infectious
17 dari 48 27/07/2019 10.34

diarrhoea [PHE, 2015 (/diarrhoea-adults-assessment#!references)].
Investigations are not always necessary for adults who present with acute
diarrhoea [World Gastroenterology Organisation, 2012 (/diarrhoea-adults-
assessment#!references)]. If the diarrhoea has stopped, stool culture is unlikely
to be necessary unless there is a public health indication [PHE, 2015
A bacterial pathogen is only found in a small proportion of stool specimens
sent to the laboratory (2–5%) [PHE, 2015 (/diarrhoea-adults-
Note that the organisms routinely looked for and reported are Salmonella,
shigella, clostridium, campylobacter, E. coli O157, and cryptosporidium,
therefore a negative report does not necessarily indicate there is no infection
as viruses, ova, cysts, and parasites and other less common pathogens are
not ordinarily sought [PHE, 2015 (/diarrhoea-adults-
Details to include on the request form are extrapolated from information from
PHE [PHE, 2015 (/diarrhoea-adults-assessment#!references)], the World
Gastroenterology Organisation [World Gastroenterology Organisation, 2012
(/diarrhoea-adults-assessment#!references)], and guidelines from the Infectious
Diseases Society of America on the diagnosis and management of infectious
diarrhoea [Shane et al, 2017 (/diarrhoea-adults-assessment#!references)].
Considering blood tests
This recommendation is pragmatic and is based on what CKS considers to be

good clinical practice.
When should I admit or refer a person with acute Back to top

diarrhoea?
Arrange emergency admission to hospital if:

The person is vomiting and unable to retain oral fluids, or
They have features of severe dehydration or shock (for more information, see
Clinical features of dehydration (/diarrhoea-adults-
18 dari 48 27/07/2019 10.34

assessment#!scenarioRecommendation:1)).
Other factors that influence the threshold for admission include (use clinical
judgment):
Older age (people 60 years of age or older are more at risk of complications).
Home circumstances and level of support.
Fever.
Bloody diarrhoea.
Abdominal pain and tenderness.
Increased risk of poor outcome, for example:
Coexisting medical conditions — immunodeficiency, lack of stomach acid,
inflammatory bowel disease, valvular heart disease, diabetes mellitus,
renal impairment, rheumatoid disease, systemic lupus erythematosus.
Drugs — immunosuppressants or systemic steroids, proton pump
inhibitors, angiotensin-converting enzyme inhibitors, diuretics.
Refer adults using a suspected cancer pathway referral (for an appointment
within 2 weeks) for colorectal cancer if:
They are aged 40 and over with unexplained weight loss and abdominal pain,
or
They are aged 50 and over with unexplained rectal bleeding, or
They are aged 60 and over with iron deficiency anaemia or changes in their
bowel habit, or tests show occult blood in their faeces.
Consider a suspected cancer pathway referral (for an appointment within 2
weeks) for colorectal cancer in:
Adults with a rectal or abdominal mass.
Adults aged under 50 with rectal bleeding and any of the following
unexplained symptoms or findings:
Abdominal pain.
Change in bowel habit.
Weight loss.
Iron-deficiency anaemia.
Refer if the diagnosis remains uncertain after a primary care
assessment — if infection and the other common causes of acute diarrhoea
have been excluded and it is suspected that an episode of acute diarrhoea is
due to a chronic cause (/diarrhoea-adults-assessment#!backgroundSubSub:1).
19 dari 48 27/07/2019 10.34

Admission criteria
The criteria for considering referral or admission are extrapolated from an expert
consensus guideline from the British Society for the Study of Infection on the
management of infective gastroenteritis in adults [Farthing et al, 1996
(/diarrhoea-adults-assessment#!references)] as acute diarrhoea is most
commonly caused by infection [BMJ Best Practice, 2018a (/diarrhoea-adults-
Suspected cancer pathway referral
The recommendations on referral for suspected colorectal cancer are based on

the National Institute for Health and Care Excellence guideline Suspected
cancer: recognition and referral [NICE, 2015a (/diarrhoea-adults-
Referral if the diagnosis remains uncertain
CKS has based this recommendation on what it considers to be good clinical

practice.
Back to top
Scenario: Chronic diarrhoea
(> 4 weeks)
How should I assess a person with chronic diarrhoea? Back to top
Determine the duration, frequency, pattern, and severity of symptoms.

Ask about and look for 'red flag' indicators (symptoms and/or features that
may be caused by another condition that need referral (/diarrhoea-adults-
assessment#!scenarioRecommendation:7) or further investigation). These
include:
Unexplained weight loss.
Unexplained rectal bleeding.
Persistent blood in the stool.
20 dari 48 27/07/2019 10.34

Abdominal mass.
Rectal mass.
Severe abdominal pain.
Iron deficiency anaemia.
Raised inflammatory markers (may indicate inflammatory bowel disease).
Nocturnal or continuous diarrhoea or both (suggestive of an organic rather
than functional disorder).
Fever, tachycardia, hypotension, dehydration.
Look for other features suggestive of an underlying cause (/diarrhoea-
adults-assessment#!backgroundSubSub:1), including:
Travel abroad — consider an infective cause, especially Giardia.
Laxative use (including for treatment of hepatic encephalopathy).
Other drugs. For examples, see the section on chronic causes of diarrhoea
(/diarrhoea-adults-assessment#!backgroundSubSub:1).
Recent use of an antibiotic or proton pump inhibitor is associated
with Clostridium difficile infection.
Chronic fatty diarrhoea — suggests fat maldigestion (for example pancreatic
insufficiency) or fat malabsorption (for example coeliac disease).
Previous abdominal surgery — suspect bile acid diarrhoea if the person has
a history of cholecystectomy or ileal resection.
Family history of coeliac disease or inflammatory bowel disease.
Diet and relationship of symptoms to eating — lactose intolerance is
suggested if symptoms are worsened by dairy products; diarrhoea may be
due to consumption of caffeine or food additives, such as sorbitol.
Excessive alcohol intake — can cause a toxic effect on intestinal epithelium
or rapid gut transit.
Abdominal pain — may indicate coeliac disease, Crohn's disease, or
malignancy.
Weight loss, anxiety, palpitations, tremor — consider hyperthyroidism.
Lifelong history of constipation — consider impaction with overflow diarrhoea.
Immunocompromised person — consider opportunistic infection with
parasites (for example Giardia, Cryptosporidium, Cyclospora).
Features of systemic disease (such as thyrotoxicosis, diabetes, adrenal
insufficiency).
Systemic illness affecting gastrointestinal motility (for example scleroderma,
diabetes mellitus); history of inflammatory bowel disease; previous
gastrointestinal surgery with risk of stricture — consider small intestinal
21 dari 48 27/07/2019 10.34

bacterial overgrowth (SIBO).
Rashes (for example pyoderma gangrenosum or erythema nodosum in
inflammatory bowel disease; hyperpigmentation in Addison's disease;
dermatitis herpetiformis in coeliac disease).
Assess for features that indicate a diagnosis of irritable bowel syndrome.
For more information see the CKS topic on Irritable bowel syndrome
(/irritable-bowel-syndrome).
Perform an abdominal examination, looking for distension, an abdominal
mass, organomegaly, or tenderness.
Do a digital rectal examination, provided this is acceptable to the person
being examined. Note any faecal leakage, haemorrhoids, type of stool, and
presence of blood.
Determining duration, frequency, pattern, and severity of symptoms
This recommendation is based on advice in a review article on assessment and

management of diarrhoea [Crombie et al, 2013 (/diarrhoea-adults-
Identifying red flag symptoms
The red flag symptoms are largely extrapolated from a recommendation in the
National Institute for Health and Care Excellence (NICE) guideline on Irritable
bowel syndrome [NICE, 2008 (/diarrhoea-adults-assessment#!references)] and
referral criteria in the NICE guideline Suspected cancer: recognition and
referral [NICE, 2015a (/diarrhoea-adults-assessment#!references)].
CKS has also included information from the British Society of Gastroenterology
(BSG) guideline for the investigation of chronic diarrhoea in
adults [Arasaradnam et al, 2018 (/diarrhoea-adults-assessment#!references)],
expert opinion in review articles [Crombie et al, 2013 (/diarrhoea-adults-
assessment#!references)], and an evidence review [BMJ Best Practice, 2018b
(/diarrhoea-adults-assessment#!references)]. Red flag features that may
suggest an underlying diagnosis include [Dosanjh and Pardi, 2016 (/diarrhoea-
22 dari 48 27/07/2019 10.34

adults-assessment#!references)]:
Weight loss and bleeding — less likely to be a feature of irritable bowel
syndrome or functional diarrhoea.
Fever, bleeding, abdominal pain — indicate possible underlying inflammation.
Systemic symptoms (for example, fatigue, night sweats, fever, weight loss) —
suggest lymphoma.
Assessment for an underlying cause
This recommendation is extrapolated from the causes of chronic diarrhoea

in the BSG guideline for the investigation of chronic diarrhoea in
adults [Arasaradnam et al, 2018 (/diarrhoea-adults-assessment#!references)],
expert opinion in review articles [Crombie et al, 2013 (/diarrhoea-adults-
assessment#!references)], and an evidence review [BMJ Best Practice, 2018b
The BSG guideline outlines the purpose of the initial assessment as helping
to determine the need for further investigation, and whether this should be
tailored towards colonic, small bowel, or pancreatic disease, and notes that
primary care is an appropriate setting for this [Arasaradnam et al, 2018
Assessment for features of irritable bowel syndrome
Irritable bowel syndrome is specifically mentioned as a differential diagnosis as

it is the most common cause of chronic diarrhoea [Chapman et al, 2015
(/diarrhoea-adults-assessment#!references)]. For further information, see the
CKS topic on Irritable bowel syndrome (/irritable-bowel-syndrome).
Performing a physical examination
The recommendation on abdominal and digital rectal examination is based on

review articles that state although physical examination is not usually able to
provide a specific diagnosis, digital rectal examination is useful in the
assessment of diarrhoea as it can allow evaluation of the stool and identify anal
pathology (such as fistulae and abscesses in inflammatory bowel
disease) [Crombie et al, 2013 (/diarrhoea-adults-assessment#!references);
23 dari 48 27/07/2019 10.34

Chapman et al, 2015 (/diarrhoea-adults-assessment#!references); Dosanjh and
Pardi, 2016 (/diarrhoea-adults-assessment#!references)].
How should I investigate chronic diarrhoea in primary Back to top

care?
Tailor investigations to the individual, and if necessary, refer (/diarrhoea-

adults-assessment#!scenarioRecommendation:7) for further investigation.
Request the following blood tests in all people with chronic diarrhoea:
Full blood count — to detect anaemia.
Urea and electrolytes.
Liver function tests, including albumin level.
Calcium.
Vitamin B12 and red blood cell folate.
Iron status (ferritin).
Thyroid function tests.
ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein).
Testing for coeliac disease — immunoglobulin A (IgA), and IgA tissue
transglutaminase (tTG), or IgA endomysial antibody (EMA).
Note that antibodies usually will become negative when a person is on a
gluten-free diet, so the test should be carried out when they are eating a
diet containing gluten.
For more information, see the CKS topic on Coeliac disease (/coeliac-
disease).
Consider CA125 testing if there are symptoms suggestive of ovarian
cancer. For more information, see the CKS topic on Ovarian cancer (/ovarian-
cancer).
Consider HIV serology if underlying immunodeficiency is suspected. For
more information see the CKS topic on HIV infection and AIDS (/hiv-infection-
and-aids).
Consider sending stool for:
Routine microbiology investigation and examination for ova, cysts and
parasites, if an infectious cause is suspected or there is a history of
exotic foreign travel.
24 dari 48 27/07/2019 10.34

Send three specimens at least 2 days apart, as ova, cysts, and parasites
are shed intermittently.
For more information on how to send a stool sample, see Sending a stool
sample (/diarrhoea-adults-assessment#!scenarioRecommendation:3) in
the Scenario: Acute diarrhoea (less than 4 weeks) (/diarrhoea-adults-
assessment#!scenario).
Clostridium difficile testing, particularly if the person has recently been
admitted to hospital or treated with antibiotics or a proton pump inhibitor, or if
a previous episode has resolved and the symptoms have recurred. For more
information, see the CKS topic on Diarrhoea - antibiotic associated
(/diarrhoea-antibiotic-associated).
Faecal calprotectin testing to help differentiate between irritable bowel
syndrome and inflammatory bowel disease in people under the age of 40
years if specialist assessment is being considered and cancer is not
suspected.
Note that faecal calprotectin should not be used for people:
With new onset rectal bleeding or bloody diarrhoea.
In whom there is a need to rule out cancer.
For more information, see the CKS topics on Crohn's disease (/crohns-
disease) and Ulcerative colitis (/ulcerative-colitis).
Testing for blood in the faeces in people with symptoms suggestive of
colorectal cancer who do not meet suspected cancer referral pathway
criteria.
Approach to investigating chronic diarrhoea
First-line investigations for a person with chronic diarrhoea (blood, stool, and
serological tests) are usually performed in primary care. Because there are
many conditions causing chronic diarrhoea with differing symptomatic impact
and duration it is not possible to advise one course of action regarding
investigations. Experts discourage indiscriminate use of a large number of tests,
and clinical judgement should be used when deciding on which particular
causes to focus investigation. Tests may be requested to rule out rather than
diagnose certain conditions [NICE, 2013 (/diarrhoea-adults-
25 dari 48 27/07/2019 10.34

The British Society of Gastroenterology (BSG) guideline on investigating chronic
diarrhoea advises blood and serological tests, with stool testing if an infectious
or inflammatory cause is suspected as an initial assessment in primary
care [Arasaradnam et al, 2018 (/diarrhoea-adults-assessment#!references)].
Requesting blood tests
This recommendation is based on expert opinion in guidelines from the BSG on

the investigation of chronic diarrhoea in adults [Arasaradnam et al, 2018
(/diarrhoea-adults-assessment#!references)], guidelines from the National
Institute for Health and Care Excellence (NICE) on irritable bowel
syndrome [NICE, 2008 (/diarrhoea-adults-assessment#!references)] and coeliac
disease [NICE, 2015b (/diarrhoea-adults-assessment#!references)], and expert
opinion in a review article on investigating young adults with chronic diarrhoea
in primary care which suggests CA125 and HIV testing for selected
people [Chapman et al, 2015 (/diarrhoea-adults-
assessment#!references)]. Chronic diarrhoea is a common symptom in patients
newly diagnosed with human immunodeficiency virus (HIV) [Arasaradnam et al,
2018 (/diarrhoea-adults-assessment#!references)].
The results of blood tests can help guide diagnosis and management, for
example, [Chapman et al, 2015 (/diarrhoea-adults-assessment#!references);
Arasaradnam et al, 2018 (/diarrhoea-adults-assessment#!references)]:
High erythrocyte sedimentation rate, anaemia, or low albumin are highly
specific for organic disease (low albumin is suggestive of inflammation or
malabsorption).
Iron deficiency is sensitive for small bowel enteropathy, including coeliac
disease (but is not a specific test).
Liver pathology can be associated with inflammatory bowel disease.
Urea may be raised in organic diarrhoea, and diarrhoea may cause
electrolyte disturbances.
A suppressed thyroid-stimulating hormone is a good predictor for
hyperthyroidism.
Stool microbiological investigations and examination for ova, cysts, and

parasites
26 dari 48 27/07/2019 10.34

The recommendations on stool investigations are based on expert opinion in
guidelines from the BSG on the investigation of chronic diarrhoea in
adults [Arasaradnam et al, 2018 (/diarrhoea-adults-
assessment#!references)], and guidance from Public Health England (PHE) on
managing suspected infectious diarrhoea [PHE, 2015 (/diarrhoea-adults-
Chronic infections are unusual if the person is immunocompetent and are most
likely to result from protozoan infections, such as giardiasis and amoebiasis;
therefore, stool examination for ova, cysts, and parasites is important
(sensitivity 60–90%) [Chapman et al, 2015 (/diarrhoea-adults-
Clostridium difficile testing
This recommendation is based on guidance from PHE on managing suspected

infectious diarrhoea [PHE, 2015 (/diarrhoea-adults-
assessment#!references)] and expert opinion in a review article on investigating
young adults with chronic diarrhoea in primary care [Chapman et al, 2015
In Clostridium difficile infection, diarrhoea can persist through failure of initial
treatment or rapid relapse [Arasaradnam et al, 2018 (/diarrhoea-adults-
Faecal calprotectin testing
The recommendation on faecal calprotectin testing is based on a NICE

diagnostic guideline on Faecal calprotectin diagnostic tests for inflammatory
diseases of the bowel [NICE, 2013 (/diarrhoea-adults-
assessment#!references)] and BSG guidance on the use of faecal
calprotectin [British Society of Gastroenterology, 2016 (/diarrhoea-adults-
assessment#!references)] and the investigation of chronic diarrhoea in
adults [Arasaradnam et al, 2018 (/diarrhoea-adults-assessment#!references)]. It
is considered an appropriate initial investigation for primary care before referral
to a specialist [Arasaradnam et al, 2018 (/diarrhoea-adults-
assessment#!references)]. Detail on who to test also reflects expert opinion in a
review article on investigating young adults with chronic diarrhoea in primary
care [Chapman et al, 2015 (/diarrhoea-adults-assessment#!references)].
27 dari 48 27/07/2019 10.34

Faecal calprotectin is an inflammatory marker [Arasaradnam et al, 2018
(/diarrhoea-adults-assessment#!references)] that has been found to have a
high sensitivity and specificity for discriminating between inflammatory bowel
disease and functional gastrointestinal disorders [British Society of
Gastroenterology, 2016 (/diarrhoea-adults-
assessment#!references)]. People with low calprotectin levels are unlikely to
have any active inflammatory processes at the time the sample was taken,
making a diagnosis of inflammatory bowel disease less likely. Raised levels
of faecal calprotectin may indicate inflammatory bowel disease, but can also
be caused by colorectal cancer, infectious gastroenteritis and non-steroidal
anti-inflammatory drugs [Arasaradnam et al, 2018 (/diarrhoea-adults-
The BSG emphasizes that measurement of calprotectin is not necessary for all
patients with clear-cut irritable bowel syndrome in primary or secondary
care [British Society of Gastroenterology, 2016 (/diarrhoea-adults-
Faecal occult blood testing
This recommendation is based on the NICE quality standard for suspected

cancer that suggests adults presenting in primary care with symptoms that
suggest colorectal cancer, who do not meet the referral pathway criteria, have a
test for blood in their faeces [NICE, 2016c (/diarrhoea-adults-
assessment#!references)]. The BSG Guidelines for the investigation of chronic
diarrhoea in adults discuss two types of faecal occult blood test: the older faecal
occult blood test (gFOBT) and the newer faecal immunochemical testing (FIT),
which it recommends in primary care as a test of exclusion, or to prioritise
investigations in people with lower gastrointestinal symptoms without rectal
bleeding [Arasaradnam et al, 2018 (/diarrhoea-adults-
A NICE diagnostics guidance on quantitative faecal immunochemical tests to
guide referral for colorectal cancer in primary care recommends specific
faecal immunochemical tests for adoption in primary care to guide referral for
suspected colorectal cancer in people without rectal bleeding who have
unexplained symptoms but do not meet the criteria for a suspected cancer
pathway referral [NICE, 2017 (/diarrhoea-adults-assessment#!references)].
The NICE guideline Suspected cancer: recognition and referral advises referring
28 dari 48 27/07/2019 10.34

adults using a suspected cancer pathway referral for colorectal cancer if tests
show occult blood in their faeces [NICE, 2015a (/diarrhoea-adults-
When should I refer a person with chronic diarrhoea? Back to top
Refer adults using a suspected cancer pathway referral (for an appointment

within 2 weeks) for colorectal cancer if:
They are aged 40 and over with unexplained weight loss and abdominal pain,
or
They are aged 50 and over with unexplained rectal bleeding, or
They are aged 60 and over with iron deficiency anaemia or changes in their
bowel habit, or tests show occult blood in their faeces.
Consider a suspected cancer pathway referral (for an appointment within 2
weeks) for colorectal cancer in:
Adults with a rectal or abdominal mass.
Adults aged under 50 with rectal bleeding and any of the following
unexplained symptoms or findings:
Abdominal pain.
Change in bowel habit.
Weight loss.
Iron-deficiency anaemia.
Refer for further assessment and management if:
History, examination, and blood test results suggest any of the following:
Coeliac disease. For more information, see the CKS topic on Coeliac
disease (/coeliac-disease).
Crohn's disease. For more information, see the CKS topic on Crohn's
disease (/crohns-disease).
Ulcerative colitis. For more information, see the CKS topic on Ulcerative
colitis (/ulcerative-colitis).
Bile acid diarrhoea.
Microscopic colitis.
Malabsorption.
A person less than 40 years of age does not have typical symptoms of
functional bowel disorder and/or has severe symptoms and documented
29 dari 48 27/07/2019 10.34

diarrhoea.
The diagnosis is uncertain.
Referral of people with red flag symptoms for colorectal cancer
These recommendations are based on National Institute for Health and Care
Excellence (NICE) guidelines on referral for suspected cancer [NICE, 2015a
This is supported by expert opinion in a review article on investigating young
adults with chronic diarrhoea in primary care which advises clinicians to
consider an underlying cancer, particularly in patients over 45 years, and to
urgently refer to secondary care if there are any red flags suggestive of cancer
or inflammatory bowel disease [Chapman et al, 2015 (/diarrhoea-adults-
Referral if an underlying condition is suspected
This recommendation reflects the NICE guideline on coeliac disease which

recommends referral for adults with positive serological test results for
endoscopic intestinal biopsy to confirm the diagnosis. Referral is also
recommended for further assessment of people with negative serological test
results in whom coeliac disease is still clinically suspected [NICE, 2015b
Expert opinion in a review article on investigating young adults with chronic
diarrhoea in primary care recommends referral for suspected organic disease
such as inflammatory bowel disease [Chapman et al, 2015 (/diarrhoea-adults-
assessment#!references)], which will require small bowel imaging [Arasaradnam
et al, 2018 (/diarrhoea-adults-assessment#!references)]. British Society of
Gastroenterology (BSG) guidelines on the investigation of chronic diarrhoea in
adults discusses colonoscopy with biopsies to confirm the diagnosis of
microscopic colitis as well as making a positive diagnosis of bile acid diarrhoea
with specialist tests. For malabsorption, investigations may involve faecal testing
to detect the relevant compound or test for an absorbed substance in the blood,
urine or other tissues [Arasaradnam et al, 2018 (/diarrhoea-adults-
assessment#!references)]. CKS, therefore, recommends referral if these
30 dari 48 27/07/2019 10.34

diagnoses are suspected.
Referral of people for whom the diagnosis is not clear
Referral of people aged less than 40 years without typical symptoms of

functional bowel disorder is based on BSG guidelines on the investigation of
chronic diarrhoea in adults which consider this group as needing further
evaluation [Arasaradnam et al, 2018 (/diarrhoea-adults-
Although the BSG notes there are no formal primary care referral guidelines, it
considers that the presence of normal first-line investigations with symptoms
severe enough to impair quality of life or interfere with normal activities despite
treatment to be a reason for referral [Arasaradnam et al, 2018 (/diarrhoea-
Expert opinion in a review article on the approach to assessment of chronic
unexplained diarrhoea suggests additional testing may be required
(depending on an assessment of the individual clinical circumstances) for
people with chronic diarrhoea without a diagnosis despite initial blood tests,
particularly if they have severe symptoms [Dosanjh and Pardi, 2016
Back to top
Search strategy
Scope of search
A literature search was conducted for guidelines and systematic reviews on
primary care assessment of diarrhoea.
Search dates
February 2013 - September 2018
31 dari 48 27/07/2019 10.34

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost
MEDLINE (searched 28th November 2018). These were combined with filters to
identify guidelines, systematic reviews and primary care relevant literature in
EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library
databases.
S3 S1 OR S2
S2 AB ( diarrhea* or diarrhoea* ) OR TI ( diarrhea* or diarrhoea* )
S1 (MH "Diarrhea")
Sources of guidelines
National Institute for Health and Care Excellence (NICE)
(http://www.nice.org.uk/)
Scottish Intercollegiate Guidelines Network (SIGN) (http://www.sign.ac.uk/)
Royal College of Physicians (http://www.rcplondon.ac.uk/)
Royal College of General Practitioners (http://www.rcgp.org.uk/)
Royal College of Nursing (http://www.rcn.org.uk/development/practice
/clinicalguidelines)
NICE Evidence (https://www.evidence.nhs.uk/topics/)
Health Protection Agency (http://www.hpa.org.uk/)
World Health Organization (http://www.who.int/)
National Guidelines Clearinghouse (http://www.guideline.gov/)
Guidelines International Network (http://www.g-i-n.net/)
TRIP database (http://www.tripdatabase.com/)
GAIN (http://www.gain-ni.org/index.php/audits/guidelines)
NHS Scotland National Patient Pathways (http://www.pathways.scot.nhs.uk/)
New Zealand Guidelines Group (http://www.nzgg.org.nz/)
Agency for Healthcare Research and Quality (http://www.ahrq.gov/)
Institute for Clinical Systems Improvement (http://www.icsi.org/)
National Health and Medical Research Council (Australia)
(http://www.nhmrc.gov.au/publications/index.htm)
Royal Australian College of General Practitioners (http://www.racgp.org.au/your-
practice/guidelines/)
32 dari 48 27/07/2019 10.34

British Columbia Medical Association (http://www.health.gov.bc.ca
/gpac/index.html)
Canadian Medical Association (http://www.cma.ca/index.php/ci_id/54316/la_id
/1.htm)
Alberta Medical Association (http://www.topalbertadoctors.org/cpgs.php)
University of Michigan Medical School (http://ocpd.med.umich.edu/cme/self-
study/)
Michigan Quality Improvement Consortium (http://mqic.org/guidelines.htm)
Singapore Ministry of Health (http://www.moh.gov.sg/content/moh_web
/home/Publications/guidelines/cpg.html)
National Resource for Infection Control (http://www.nric.org.uk/)
Patient UK Guideline links (http://www.patient.co.uk/guidelines.asp)
UK Ambulance Service Clinical Practice Guidelines (http://www2.warwick.ac.uk
/fac/med/research/hsri/emergencycare/jrcalc_2006/guidelines/)
RefHELP NHS Lothian Referral Guidelines (http://www.refhelp.scot.nhs.uk
/index.php?option=com_content&task=view&id=490&Itemid=104)
Medline (with guideline filter)
Driver and Vehicle Licensing Agency (http://www.dft.gov.uk/dvla/medical
/ataglance.aspx)
NHS Health at Work (http://www.nhshealthatwork.co.uk/oh-guidelines.asp)
(occupational health practice)
Sources of systematic reviews and meta-

analyses
The Cochrane Library (http://www.thecochranelibrary.com/):
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and

economic appraisals
33 dari 48 27/07/2019 10.34

NIHR Health Technology Assessment programme (http://www.hta.ac.uk/)
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health (http://www.cadth.ca/)
International Network of Agencies for Health Technology Assessment
(http://www.inahta.org/)
Sources of randomized controlled trials

Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and

evidence summaries
Bandolier (http://www.medicine.ox.ac.uk/bandolier/)
Drug & amp; Therapeutics Bulletin (http://dtb.bmj.com/)
TRIP database (http://www.tripdatabase.com/)
Central Services Agency COMPASS Therapeutic Notes
(http://www.medicinesni.com/courses/type.asp?ID=CN)
Sources of national policy

Department of Health (http://www.dh.gov.uk/)
Health Management Information Consortium(HMIC)
Patient experiences
Healthtalkonline (http://www.healthtalkonline.org/)
BMJ - Patient Journeys (http://www.bmj.com/bmj-series/patient-journeys)
Patient.co.uk - Patient Support Groups (http://www.patient.co.uk/selfhelp.asp)
34 dari 48 27/07/2019 10.34

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily
searched by CKS information specialists for all topics. Some of these resources
are not freely available and require subscriptions to access content.
British National Formulary (http://www.evidence.nhs.uk/formulary

/bnf/current)(BNF)
electronic Medicines Compendium (http://www.medicines.org.uk/)(eMC)
European Medicines Agency (http://www.ema.europa.eu/ema/)(EMEA)
LactMed (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT)
Medicines and Healthcare products Regulatory Agency (http://www.mhra.gov.uk
/index.htm)(MHRA)
REPROTOX (http://www.reprotox.org/Default.aspx)
Scottish Medicines Consortium (http://www.scottishmedicines.org.uk/Home)
Stockley's Drug Interactions (https://www.medicinescomplete.com/mc/stockley
/current/login.htm?uri=http%3A%2F
%2Fwww.medicinescomplete.com%2Fmc%2Fstockley%2Fcurrent%2F)
TERIS (http://depts.washington.edu/terisweb/teris/)
TOXBASE (http://www.toxbase.org/)
Micromedex (http://www.micromedex.com/products/hcs/)
UK Medicines Information (http://www.ukmi.nhs.uk/)
Back to top
Stakeholder engagement
Our policy
The external review process is an essential part of CKS topic development.
Consultation with a wide range of stakeholders provides quality assurance of the
topic in terms of:
Clinical accuracy.
Consistency with other providers of clinical knowledge for primary care.
Accuracy of implementation of national guidance (in particular NICE guidelines).
Usability.
35 dari 48 27/07/2019 10.34

Principles of the consultation process

The process is inclusive and any individual may participate.
To participate, an individual must declare whether they have any competing
interests or not. If they do not declare whether or not they have competing
interests, their comments will not be considered.
Comments received after the deadline will be considered, but they may not be
acted upon before the clinical topic is issued onto the website.
Comments are accepted in any format that is convenient to the reviewer,
although an electronic format is encouraged.
External reviewers are not paid for commenting on the draft topics.
Discussion with an individual or an organization about the CKS response to
their comments is only undertaken in exceptional circumstances (at the
discretion of the Clinical Editor or Editorial Steering Group).
All reviewers are thanked and offered a letter acknowledging their contribution
for the purposes of appraisal/revalidation.
All reviewers are invited to be acknowledged on the website.All reviewers are
given the opportunity to feedback about the external review process, enabling
improvements to be made where appropriate.
Stakeholders
Key stakeholders identified by the CKS team are invited to comment on draft
CKS topics. Individuals and organizations can also register an interest to
feedback on a specific topic, or topics in a particular clinical area, through the
Getting involved (http://cks.clarity.co.uk/get-involved/) section of the Clarity
Informatics (https://clarity.co.uk/) website.
Stakeholders identified from the following groups are invited to review draft
topics:
Experts in the topic area.
Professional organizations and societies(for example, Royal Colleges).
Patient organizations, Clarity has established close links with groups such as
Age UK and the Alzheimer’s Society specifically for their input into new topic
development, review of current topic content and advice on relevant areas of
expert knowledge.
Guideline development groups where the topic is an implementation of a
36 dari 48 27/07/2019 10.34

guideline.
The British National Formulary team.
The editorial team that develop MeReC Publications.
Reviewers are provided with clear instructions about what to review, what
comments are particularly helpful, how to submit comments, and declaring
interests.
Patient engagement
Clarity Informatics has enlisted the support and involvement of patients and lay
persons at all stages in the process of creating the content which include:
Topic selection
Scoping of topic
Selection of clinical scenarios
First draft internal review
Second draft internal review
External review
Final draft and pre-publication
Our lay and patient involvement includes membership on the editorial steering
group, contacting expert patient groups, organizations and individuals.
Back to top
Evidence exclusion criteria
Our policy
Scoping a literature search, and reviewing the evidence for CKS is a methodical
and systematic process that is carried out by the lead clinical author for each topic.
Relevant evidence is gathered in order that the clinical author can make fully
informed decisions and recommendations. It is important to note that some
evidence may be excluded for a variety of reasons. These reasons may be applied
across all CKS topics or may be specific to a given topic.
Studies identified during literature searches are reviewed to identify the most
appropriate information to author a CKS topic, ensuring any recommendations are
37 dari 48 27/07/2019 10.34

based on the best evidence. We use the principles of the GRADE and PICOT
approaches to assess the quality of published research. We use the principles of
AGREE II to assess the quality of published guidelines.
Standard exclusions for scoping literature:

Animal studies
Original research is not written in English
Possible exclusions for reviewed literature:

Sample size too small or study underpowered
Bias evident or promotional literature
Population not relevant
Intervention/treatment not relevant
Outcomes not relevant
Outcomes have no clear evidence of clinical effectiveness
Setting not relevant
Not relevant to UK
Incorrect study type
Review article
Duplicate reference
Back to top
Organizational, behavioural and
financial barriers
Our policy
The CKS literature searches take into consideration the following concepts, which
are discussed at the initial scoping of the topic.
Feasibility
Studies are selected depending on whether the intervention under
investigation is available in the NHS and can be practically and safely
38 dari 48 27/07/2019 10.34

undertaken in primary care.
Organizational and Financial Impact Analysis
Studies are selected and evaluated on whether the intervention under
investigations may have an impact on local clinical service provision or national
impact on cost for the NHS. The principles of clinical budget impact analysis are
adhered to, evaluated and recorded by the author. The following factors are
considered when making this assessment and analysis.
Eligible population
Current interventions
Likely uptake of new intervention or recommendation
Cost of the current or new intervention mix
Impact on other costs
Condition-related costs
In-direct costs and service impacts
Time dependencies
Cost-effectiveness or cost-benefit analysis studies are identified where
available.
We also evaluate and include evidence from NICE accredited sources which
provide economic evaluations of recommendations, such as NICE
guidelines. When a recommended action may not be possible because of resource
constraints, this is explicitly indicated to healthcare professionals by the wording of
the CKS recommendation.
Back to top
Declarations of interest
Our policy
Clarity Informatics requests that all those involved in the writing and reviewing of
topics, and those involved in the external review process to declare any competing
interests. Signed copies are securely held by Clarity Informatics and are available
on request with the permission of the individual. A copy of the declaration of
interest form which participants are asked to complete annually is also available on
request. A brief outline of the declarations of interest policy is described here and
full details of the policy is available on the Clarity Informatics website
(https://cks.clarity.co.uk/). Declarations of interests of the authors are not routinely
39 dari 48 27/07/2019 10.34

published, however competing interests of all those involved in the topic update or
development are listed below. Competing interests include:
Personal financial interests

Personal family interest
Personal non-financial interest
Non-personal financial gain or benefit
Although particular attention is given to interests that could result in financial gains
or losses for the individual, competing interests may also arise from academic
competition or for political, personal, religious, and reputational reasons.An
individual is not obliged to seek out knowledge of work done for, or on behalf of,
the healthcare industry within the departments for which they are responsible if
they would not normally expect to be informed.
Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting
on clinical content, particularly the recommendations should declare competing
interests. This includes the authoring team members, expert advisers, external
reviewers of draft topics, individuals providing feedback on published topics, and
Editorial Steering Group members. Declarations of interest are completed annually
for authoring team and editorial steering group members, and are completed at the
start of the topic update and development process for external stakeholders.
Competing interests declared for this topic:

None.
Back to top
Diarrhoea - adult's assessment:
Summary
Diarrhoea is the passage of three or more loose or liquid stools per day (or
more frequently than is normal for the individual).
40 dari 48 27/07/2019 10.34

Acute diarrhoea is defined as lasting less than 14 days.
Persistent diarrhoea is defined as lasting more than 14 days.
Chronic diarrhoea is defined as lasting for more than 4 weeks.
Acute diarrhoea is usually caused by a bacterial or viral infection. Other causes
include drugs, anxiety, food allergy, and acute appendicitis.
Causes of chronic diarrhoea include irritable bowel syndrome, diet,
inflammatory bowel disease, coeliac disease, and bowel cancer.
Diarrhoea is one of the most common symptoms for which people seek medical
advice.
Assessment for acute and chronic diarrhoea should include:
Determining onset, duration, frequency, and severity of symptoms.
Identifying red flag symptoms.
Ascertaining the underlying cause.
Looking for complications, such as dehydration.
Acute diarrhoea should be investigated with a stool specimen for routine
microbiology investigation under certain circumstances, including if:
The person is systemically unwell; needs hospital admission and/or
antibiotics.
There is blood or pus in the stool.
The person is immunocompromised.
The person has recently received antibiotics, a proton pump inhibitor (PPI) or
been in hospital (specific testing for Clostridium difficile should also be
requested).
Diarrhoea occurs after foreign travel (tests for ova, cysts, and parasites
should also be requested).
Amoebae, Giardia, or cryptosporidium are suspected, particularly if diarrhoea
is persistent (14 days or more) or the person has travelled to an at-risk area.
There is a need to exclude infectious diarrhoea.
Investigations for chronic diarrhoea should be tailored to the individual, but
blood tests should be requested in all people presenting with this problem.
These include full blood count, urea and electrolytes, liver function tests,
calcium, vitamin B12 and red blood cell folate, ferritin, thyroid function tests, ESR
and CRP, and testing for coeliac disease.
People with diarrhoea may require admission to hospital, referral using a
suspected cancer pathway, or routine referral for further assessment and
management depending on their presentation and the certainty of the diagnosis.
41 dari 48 27/07/2019 10.34

Have I got the right topic?

This CKS topic covers the assessment of acute and chronic diarrhoea in adults.
This CKS topic does not cover the assessment of diarrhoea in children, or the
management of diarrhoea. This CKS topic also does not cover the assessment of
post-operative diarrhoea, or diarrhoea associated with a stoma.
There are separate CKS topics on Bowel screening (/bowel-screening), Coeliac

disease (/coeliac-disease), Constipation (/constipation), Crohn's disease (/crohns-
disease), Diarrhoea - antibiotic associated (/diarrhoea-antibiotic-associated),
Diverticular disease (/diverticular-disease), Gastroenteritis
(/gastroenteritis), Gastrointestinal tract (lower) cancers - recognition and referral
(/gastrointestinal-tract-lower-cancers-recognition-and-referral), Irritable bowel
syndrome (/irritable-bowel-syndrome), and Ulcerative colitis (/ulcerative-colitis).
The target audience for this CKS topic is healthcare professionals working within
the NHS in the UK, and providing first contact or primary health care.
Back to top
How up-to-date is this topic?
Changes
Update
Back to top
Goals and outcome measures
Goals
Outcome measures
Audit criteria
QOF indicators
QIPP - Options for local implementation
NICE quality standards
42 dari 48 27/07/2019 10.34

Background information
Definition
Pathophysiology
Causes
Prevalence
Complications
Prognosis
Back to top
Management
Scenario: Acute diarrhoea (less than 4 weeks) (/diarrhoea-adults-

assessment#!scenario): covers the primary care assessment, investigation,
and referral of acute or persistent (less than 4 weeks' duration) diarrhoea in
adults.
Scenario: Chronic diarrhoea (more than 4 weeks) (/diarrhoea-adults-
assessment#!scenario:1): covers the primary care assessment, investigation,
and referral of chronic (more than 4 weeks' duration) diarrhoea in adults.
Back to top
Supporting evidence
This CKS topic is based on British Society of Gastroenterology Guidelines for the
investigation of chronic diarrhoea in adults [Arasaradnam et al, 2018 (/diarrhoea-
adults-assessment#!references)], the National Institute for Health and Care
Excellence guideline Suspected cancer: recognition and referral [NICE, 2015a
(/diarrhoea-adults-assessment#!references)], the Public Health England
publication Managing suspected infectious diarrhoea. Quick reference guide for
primary care [PHE, 2015 (/diarrhoea-adults-assessment#!references)], and
international guidelines and expert opinion in review articles.
The rationale for the diagnosis, primary care assessment, and referral of adults
with diarrhoea is outlined in the relevant basis for recommendation sections of the
topic.
Back to top
43 dari 48 27/07/2019 10.34

How this topic was developed

This section briefly describes the processes used in developing and updating this
topic. Further details on the full process can be found in the About Us
(http://cks.nice.org.uk/development) section and on the Clarity Informatics
(https://clarity.co.uk/) website.
Back to top
References
Arasaradnam, R.P., Brown, S. and Forbes, A. (2018) Guidelines for the

investigation of chronic diarrhoea in adults: British Society of Gastroenterology,
3rd edition. Gut 67(8), 1380-1399. [Abstract (https://www.ncbi.nlm.nih.gov
/pubmed/29653941)] [Free Full-text (https://gut.bmj.com/content
/67/8/1380.long)]
Baldi,F., Bianco,M.A., Nardone,G., et al. (2009) Focus on acute diarrhoeal
disease. World Journal of Gastroenterology. 15(27), 3341-3348. [Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/19610134)]
Barr, W. and Smith, A. (2014) Acute diarrhea in adults. American family
physician 89(3), 180-189. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed
/24506120)] [Free Full-text (https://www.aafp.org/afp/2014/0201/p180.html)]
BMJ Best Practice (2018a) Assessment of acute diarrhoea. BMJ Publishing
Group Ltd. bestpractice.bmj.com (http://bestpractice.bmj.com)
BMJ Best Practice (2018b) Assessment of chronic diarrhoea. BMJ Publishing
Group Ltd. bestpractice.bmj.com (http://bestpractice.bmj.com)
British Society of Gastroenterology (2016) BSG guidance document on use of
faecal calprotectin. British Society of Gastroenterology. www.bsg.org.uk
(http://www.bsg.org.uk) [Free Full-text (https://www.bsg.org.uk/resource/bsg-
guidance-on-the-use-of-faecal-calprotectin-testing-in-ibd.html)]
Connor, B.A. (2017) Travelers' diarrhea. Travelers' health. Chapter 2. The
pretravel consultation. Centers for Disease Control and Prevention.
wwwnc.cdc.gov (http://wwwnc.cdc.gov) [Free Full-text (https://wwwnc.cdc.gov
/travel/yellowbook/2018/the-pre-travel-consultation/travelers-diarrhea)]
Chapman, T.P., Chen, L.Y. and Leaver, L. (2015) Investigating young adults with
chronic diarrhoea in primary care. BMJ 350, h573. [Abstract
(https://www.ncbi.nlm.nih.gov/pubmed/25716699)]
44 dari 48 27/07/2019 10.34

Crombie, H., Gallagher, R. and Hall, V. (2013) Assessment and management of
diarrhoea. Nursing times 109(30), 22-24. [Abstract (https://www.ncbi.nlm.nih.gov
/pubmed/23991535)]
Del Giudice, M.E., Vella, E.T. and Hey, A. et al (2014) Systematic review of
clinical features of suspected colorectal cancer in primary care. Canadian family
physician 60(8), e405-e415. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed
/25122831)] [Free Full-text (https://www.ncbi.nlm.nih.gov/pmc/articles
/PMC4131977/)]
Dosanjh, G. and Pardi, D.S. (2016) Chronic unexplained diarrhea: a logical and
cost-effective approach to assessment. Current opinion in gastroenterology
32(1), 55-60. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed/26628100)]
DuPont, H.L. (2016) Persistent diarrhea: a clinical review. JAMA 315(24),
2712-2723. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed/27357241)]
Farthing,M., Feldman,R., Finch,R., et al. (1996) The management of infective
gastroenteritis in adults. A consensus statement by an expert panel convened
by the British Society for the Study of Infection. 33(3), 143-152.
Gentile, N. and Yen, E.F. (2018) Prevalence, pathogenesis, diagnosis, and
management of microscopic colitis. Gut and liver 12(3), 227-235. [Abstract
(https://www.ncbi.nlm.nih.gov/pubmed/28669150)] [Free Full-text
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5945253/)]
Holtz,L.R., Neill,M.A. and Tarr,P.I. (2009) Acute bloody diarrhea: a medical
emergency for patients of all ages. Gastroenterology. 136(6), 1887-1898.
[Abstract (http://www.ncbi.nlm.nih.gov/pubmed/19457417)]
Jones,R. and Rubin,G. (2009) Acute diarrhoea in adults. BMJ. 338, b1877.
Kroser,J.A. and Metz,D.C. (1996) Evaluation of the adult patient with diarrhea.
Primary Care. 23(3), 629-647. [Abstract (http://www.ncbi.nlm.nih.gov/pubmed
/8888349)]
Mooney, P.D., Hadjivassiliou, M. and Sanders, D.S. (2014) Coeliac disease.
BMJ 348, g1561. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed/24589518)]
Mottacki, N., Simren, M. and Bajor, A. (2016) Review article: bile acid diarrhoea
- pathogenesis, diagnosis and management. Alimentary pharmacology and
therapeutics 43(8), 884-898. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed
/26913381)] [Free Full-text (https://onlinelibrary.wiley.com/doi/full/10.1111
/apt.13570)]
NICE (2008) Irritable bowel syndrome in adults: diagnosis and management of
irritable bowel syndrome in primary care (NICE guideline). National Institute for
Health and Clinical Excellence.. www.nice.org.uk (http://www.nice.org.uk) [Free
45 dari 48 27/07/2019 10.34

Full-text (http://www.nice.org.uk)]
NICE (2013) Faecal calprotectin diagnostic tests for inflammatory diseases of
the bowel (NICE diagnostics guidance). Diagnostics guidance 11. National
Institute for Health and Care Excellence.. www.nice.org.uk
(http://www.nice.org.uk) [Free Full-text (http://guidance.nice.org.uk
/DG11/Guidance/pdf/English)]
NICE (2015a) Suspected cancer: recognition and referral (NG12). National
Institute for Health and Care Excellence.. www.nice.org.uk
(http://www.nice.org.uk) [Free Full-text (http://www.nice.org.uk/guidance/ng12)]
NICE (2015b) Coeliac disease: recognition, assessment and management.
NICE guideline [NG20]. National Institute for Health and Care Excellence.
www.nice.org.uk (http://www.nice.org.uk) [Free Full-text (https://www.nice.org.uk
/guidance/ng20)]
NICE (2016a) Coeliac disease. Quality standard [QS134]. National Institute for
Health and Care Excellence. www.nice.org.uk (http://www.nice.org.uk) [Free
Full-text (https://www.nice.org.uk/guidance/qs134)]
NICE (2016b) Irritable bowel syndrome in adults. Quality standard. National
Institute for Health and Care Excellence.. www.nice.org.uk/
(http://www.nice.org.uk/) [Free Full-text (https://www.nice.org.uk/guidance
/qs114)]
NICE (2016c) Suspected cancer (QS124). National Institute for Health and Care
Excellence. www.nice.org.uk (https://www.nice.org.uk) [Free Full-text
(https://www.nice.org.uk/guidance/qs124)]
NICE (2017) Quantitative faecal immunochemical tests to guide referral for
colorectal cancer in primary care. Diagnostics guidance [DG30]. National
Institute for Health and Care Excellence. www.nice.org.uk
(http://www.nice.org.uk) [Free Full-text (https://www.nice.org.uk/guidance/dg30)]
Pardi, D.S. (2017) Diagnosis and management of microscopic colitis. American
journal of gastroenterology 112(1), 78-85. [Abstract
(https://www.ncbi.nlm.nih.gov/pubmed/27897155)]
PHE (2015) Managing suspected infectious diarrhoea. Quick reference
guidance for primary care. Public Health England. www.gov.uk
(http://www.gov.uk) [Free Full-text (https://assets.publishing.service.gov.uk
/government/uploads/system/uploads/attachment_data/file/409768
/Managing_Suspected_Infectious_Diarrhoea_7_CMCN29_01_15_KB_FINAL.pdf)]
Riddle, M.S., DuPont, H.L. and Connor, B.A. (2016) ACG Clinical Guideline:
Diagnosis, treatment, and prevention of acute diarrheal infections in adults.
46 dari 48 27/07/2019 10.34

American journal of gastroenterology 111(5), 602-622. [Abstract
(https://www.ncbi.nlm.nih.gov/pubmed/27068718)] [Free Full-text
(https://www.nature.com/articles/ajg2016126)]
Shane, A.L., Mody, R.K. and Crump, J.A. et al (2017) 2017 Infectious Diseases
Society of America Clinical Practice Guidelines for the Diagnosis and
Management of Infectious Diarrhea. Clinical infectious diseases 65(12), e45-
e80. [Abstract (https://www.ncbi.nlm.nih.gov/pubmed/29053792)] [Free Full-text
(https://academic.oup.com/cid/article/65/12/e45/4557073)]
Talley,N.J., O'Keefe,E.A., Zinsmeister,A.R. and Melton,L.J. (1992a) Prevalence
of gastrointestinal symptoms in the elderly: a population-based study.
Gastroenterology. 102(3), 895-901. [Abstract (http://www.ncbi.nlm.nih.gov
/pubmed/1537525)]
Talley,N.J., Weaver,A.L., Zinsmeister,A.R. and Melton,L.J.,III (1992b) Onset and
disappearance of gastrointestinal symptoms and functional gastrointestinal
disorders. American Journal of Epidemiology. 136(2), 165-177. [Abstract
Tam,C.C., Rodrigues,L.C., Viviani,L., et al. (2012a) Longitudinal study of
infectious intestinal disease in the UK (IID2 study): incidence in the community
and presenting to general practice. Gut. 61(1), 69-77. [Abstract
Tam, C., Viviani, L. and Adak, B. et al (2012b) The second study of infectious
intestinal disease in the community (IID2 study). Food Standards Agency.
www.food.gov.uk (http://www.food.gov.uk) [Free Full-text
(https://www.food.gov.uk/sites/default/files/media/document
/711-1-1393_IID2_FINAL_REPORT.pdf)]
WHO (2017) Diarrhoeal disease. Fact sheet. World Health Organization.
www.who.int (http://www.who.int) [Free Full-text (https://www.who.int/news-
room/fact-sheets/detail/diarrhoeal-disease)]
World Gastroenterology Organisation (2012) Acute diarrhea in adults and
children: a global perspective. World Gastroenterology Organisation..
www.worldgastroenterology.org (http://www.worldgastroenterology.org) [Free
Full-text (http://www.worldgastroenterology.org/acute-diarrhea-in-adults.html)]
© NICE 2019. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-

conditions#notice-of-rights).
47 dari 48 27/07/2019 10.34

48 dari 48 27/07/2019 10.34

More 4 Week

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

More 4 Week

Hochgeladen von

Copyright:

Verfügbare Formate

Diarrhoea - adult's assessment - NICE CKS https://cks.nice.org.uk/diarrhoea-adults-assessme...

Diarrhoea - adult's assessment

December 2018 — reviewed. A literature search was conducted in September

Previous changes Back to top

March 2013 — reviewed. A literature search was conducted in February 2013 to

New evidence Back to top

No new evidence-based guidelines since 1 September 2018.

1 dari 48 27/07/2019 10.34

No new HTAs since 1 September 2018.

No new economic appraisals relevant to England since 1 September 2018.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 September 2018.

No new randomized controlled trials published in the major journals since 1

New policies Back to top

No new national policies or guidelines since 1 September 2018.

New safety alerts Back to top

No new safety alerts since 1 September 2018.

Changes in product availability Back to top

No changes in product availability since 1 September 2018.

Assess the symptoms of diarrhoea and diagnose an underlying cause where

No outcome measures were found during the review of this topic.

No audit criteria were found during the review of this topic.

No QOF indicators were found during the review of this topic.

No QIPP indicators were found during the review of this topic.

NICE quality standard [QS134]. Coeliac disease (https://www.nice.org.uk/guidance

People at increased risk or with symptoms of coeliac disease are offered a

NICE quality standard [QS114]. Irritable bowel syndrome in adults

3 dari 48 27/07/2019 10.34

NICE quality standard [QS124]. Suspected cancer (https://www.nice.org.uk

[NICE, 2016a (/diarrhoea-adults-assessment#!references); NICE, 2016b

Diarrhoea is a symptom, of which there are many causes (/diarrhoea-

4 dari 48 27/07/2019 10.34

What causes acute diarrhoea? Back to top

Worldwide, acute diarrhoea is most commonly caused by infection [BMJ

5 dari 48 27/07/2019 10.34

6 dari 48 27/07/2019 10.34

What causes chronic diarrhoea? Back to top

Chronic diarrhoea has a broader differential diagnosis than acute

7 dari 48 27/07/2019 10.34

8 dari 48 27/07/2019 10.34

9 dari 48 27/07/2019 10.34

10 dari 48 27/07/2019 10.34

In developed countries, diarrhoea is an important cause of morbidity, but

11 dari 48 27/07/2019 10.34

From age 18 years onwards.

How should I assess a person with acute diarrhoea? Back to top

Determine the onset, duration, frequency, and severity of symptoms.

12 dari 48 27/07/2019 10.34

Clinical features of dehydration Back to top

13 dari 48 27/07/2019 10.34

[Farthing et al, 1996 (/diarrhoea-adults-assessment#!references); World

Basis for recommendation Back to top

Determining onset, duration, frequency, and severity of symptoms

This recommendation is based on expert opinion in review articles on acute and

Identifying red flag symptoms

14 dari 48 27/07/2019 10.34

Determining the underlying cause

The recommendations on ascertaining the underlying cause of acute diarrhoea

Assessing for complications

The information on assessing for complications of diarrhoea is based on the

Abdominal and rectal examination

Features to check for on abdominal and rectal examination reflect expert

15 dari 48 27/07/2019 10.34