Bowel Habits

DIARRHEA

ABCs

  • Check vital signs and random blood glucose
  • Assess hydration and mental status

Red Flags

  • SBP <90, HR >100, dry mucosa → Shock
  • Fever >38.5°C + bloody stool → Infectious colitis / C. difficile
  • Altered mental status + metabolic acidosis → Sepsis / Severe dehydration
  • Recent antibiotics + watery diarrhea → C. difficile colitis
  • Immunocompromised + persistent symptoms → Opportunistic infection

HPI & Examination

  • Onset, frequency, amount
  • Character: watery, fatty, or bloody
  • Associated symptoms: fever, vomiting, pain
  • PMH: IBD, IBS, cancer, recent surgery
  • Meds: antibiotics, laxatives, PPIs, NSAIDs

  • Dehydration signs (dry mucosa, hypotension)
  • Abdominal exam: distension, tenderness
  • Bowel sounds: hyperactive (gastroenteritis), absent (ileus/obstruction)

Management

  • Encourage oral rehydration; give IV fluids if needed
  • Monitor stool output & hydration
  • Stop all laxatives

Labs:

  • CBC, electrolytes
  • Stool: C. difficile PCR, fecal leukocytes/calprotectin, ova & parasites
  • Lactate, ABG (if septic/metabolic acidosis)

Management Based on Cause

  • C. difficile colitis → Oral Vancomycin 125 mg QID × 10 days
  • Bacterial colitis (if severe or febrile) → Ceftriaxone ± Metronidazole
  • Viral gastroenteritis → Supportive care only
  • Parasitic infection (if travel or immunocompromised) → Treat based on identified organism (e.g., metronidazole for Giardia)
  • IBD flare (known IBD + bloody diarrhea) → Supportive care ± steroids if already diagnosed (consult GI)

Escalatieon

Call Surgery STAT

  • Toxic megacolon
  • Complete obstruction
  • Ischemic colitis

Call ICU STAT

  • Septic shock (lactate >4, hypotension)
  • Severe acidosis or hyperkalemia

CONSTIPATION

ABCs

  • Check vitals and random blood glucose

Red Flags

  • Severe pain + vomiting + no gas/stool → Bowel obstruction
  • Distension + absent bowel sounds → Paralytic ileus
  • Acute neuro symptoms + constipation → Spinal cord pathology
  • Weight loss + new-onset constipation in elderly → Colorectal cancer

HPI & Examination

  • Duration, last bowel motion, flatus
  • Associated pain/distension
  • Post-op status
  • Meds: opioids, chemo, diuretics
  • Abdominal exam: distension, tenderness
  • Rectal exam: impaction, bleeding
  • Bowel sounds:
    • Normal: gurgles every 5–10 sec
    • Absent: paralytic ileus
    • Hyperactive: possible gastroenteritis

Management

  • Start stool chart
  • Hold laxatives temporarily if obstructed
  • Correct electrolytes (K⁺, Ca²⁺)

If suspect obstruction:

  • NPO + NGT
  • Call Surgery STAT
  • Labs: CBC, VBG, RFT, lactate
  • Consider AXR

If No Obstruction Suspected

Mild Constipation

  • Encourage oral hydration and increase fiber intake
  • Glycerin suppository and reassess
  • If abdominal pain is present:
    • Give phosphate enema STAT
    • Add Buscopan PO/IV or Perfalgan 1 g IV for pain relief
  • Start regular laxative if needed (e.g., Lactulose 15–30 mL PO at bedtime)

Moderate Constipation (>48 hours)

  • Continue above measures
  • Increase lactulose frequency to 15–30 mL PO BID or TID

Severe Constipation (>72 hours or symptomatic)

  • Rule out fecal impaction with digital rectal exam
  • If impacted:
    • Perform manual disimpaction STAT
    • Follow with glycerin suppository ± phosphate enema
MOC