Clinical

Diagnosis

Chonic Abdominal discomfort, Diarrhoea and Constipation

Background

  • Diarrhoea, constipation, abdominal pain and bloating are non specific symptoms that may be caused by diet, stress, medication, inadequate fluid intake, a neuromuscular disorder, an endocrine disorder (e.g.,diabetes, thyroid or parathyroid disease) or rarely cancer
  • About 8-9% of people suffer from chronic constipation and about 4-5% Chronic Diarrhoea .
  • Constipation is more common in the elderly where it is often due to faecal impaction.
  • In the very young it is often regarded as a behavioural problem but may rarely be caused by a neuromuscular impairment of gastrointestinal motility, such as Hirschsprung’s Disease.
  • In younger adults, chronic constipation is much more common in women than men.
  • A persistent unexplained change in bowel habit that is associated with abdominal pain and/or bloating is often diagnosed as Irritable Bowel Syndrome (IBS).
  • IBS is found in about 15% of people in the UK, the male to female ratio is about 3:2.
  • Most patients present in the late teens and early twenties though bouts of IBS can occur throughout life according to what happens to the individual.
  • Between 5 and 20% of people with gastroenteritis develop post infectious IBS.
  • A small proportion of patients may be found to have IBD, coeliac disease and very rarely cancer.

Patient View

  • Lower abdominal pain, bloating, and persistent diarrhoea or constipation disrupt social life, impair sexual intimacy, cause absenteeism and severely impair quality of life.
  • Symptoms may be too difficult to talk about.
  • People fear they may have cancer or that the doctor is missing something more serious. ‘Surely something as simple IBS would not make me feel so dreadful.’
  • Constipation is often associated with chronic depression and malaise.
  • Diarrhoea may be associated with urgency and incontinence, which severely restrict socialisation.
  • People often assume their diet is to blame. ‘It must be something I’m eating. I must have an allergy.’
  • The minority of patients who turn out to have Inflammatory Bowel Disease or Coeliac Disease may resent the extended diagnosis and lack of appropriate screening.

Current Practice

  • About 50% of patients with a chronic alteration in bowel habit with or without symptoms of abdominal pain or bloating are referred to secondary care where, depending on the severity of their condition, they are often investigated with colonoscopy, scans, and blood tests to rule out treatable conditions. Most often, tests are negative and patients are discharged to primary care with a diagnosis of IBS.
  • Those with incontinence may be referred to supraregional tertiary centres for anorectal function tests.

Opportunities For Integrated Working

  • Commissioners should require that all patients with diarrhoea lasting a maximum of a month should be screened with inflammatory markers, preferably sum CRP plus faecal calprotectin, and immunological tests for coeliac disease and only refer those patients who have indicators of pathological disease.
  • All patients with persistent pelvic pain should be screened in primary care for ovarian cancer using CA125, and patients above the age of 50 with recent onset symptoms should have pelvic ultrasound. A one stop gynaecological referral for patients with unexplained persistent pelvic pain resistant to treatment.
  • Patients with red flag symptoms (persistent fever or rectal bleeding, weight loss and unexplained change in bowel habit occurring for the first time in somebody over 50), those with a family history of bowel or ovarian cancer those with persistent anaemia and those with positive results on screening tests would be seen in hospital within 4 weeks for prompt investigation with endoscopy, scans and blood tests.
  • Patients with unexplained symptoms fail to respond to best management, should have rapid access (by telephone/email/referral) to regional/supraregional specialist centres, providing specialised tests of intestinal motility, anorectal function, imaging studies and psychotherapeutic assessment.

Opportunities For Savings

  • The use of screening in primary care would mean early diagnosis of pathological disease while IBS could be diagnosed with confidence and managed in primary care, saving expense and offering continuity of care. This would reduce unnecessary referrals to less than 5% patients and result in considerable savings.

Quality Indicators (Outcome Metrics)

  • Application of screening tests in primary care.
  • Rapid response to the development of red flag symptoms.
  • Misdiagnosis rate.
  • Patient satisfaction (that their illness is taken seriously and treated promptly).
  • Delay before diagnosis.
  • Days off work.
  • Time from presentation to diagnosis of inflammatory bowel disease or colorectal cancer
  • Time from development of “red flag” symptoms to diagnosis of organic disease

Social Policy And Public Understanding.

  • Provision and improved access to public toilets.
  • Public health education by approved sources (government/charities) to advise patients about;
    • the nature of their illness,
    • the risks,
    • when to see their doctor
    • how to manage their condition,
    • what to look out for, be aware of.

References