Change in Bowel Habit History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you about your bowel movements. I will ask you some questions to try to work out what could be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for seeking medical attention, for example “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can offer valuable information about why the patient has sought medical attention as well as cues around their ideas, concerns, and expectations (ICE), which you can explore later in the consultation.

History of Presenting Complaint

Next, you should gather more specific information about the patient’s presenting complaint to establish the differential diagnosis. You can use a mixture of open and closed questions. 

An example of an open question here would be: “How would you describe your bowel movements recently?” or “Have you noticed any other symptoms alongside the constipation/diarrhoea you’ve told me about?”. Examples of closed questions include: “Have you had any diarrhoea?” or “Is there any blood when you wipe?”.

When taking a history of a change in bowel habit, it may be useful to think about the following structure for your questions:

• Onset – when did the symptoms start and what happened at the time of onset? E.g., “two nights ago, after reheating some old takeaway” may make you consider a diagnosis of gastroenteritis.
• Frequency – how often are the bowels opening? How does this compare to what is normal for the patient? E.g., “usually I go twice a day but now I haven’t been for 3 days” indicates a reduction in frequency compared to normal and would make you think that this patient may have constipation.
• Consistency – what is the consistency of the bowel movement? E.g., watery, mushy, solid, pellets. Using an aid like the Bristol Stool Chart may help patients to describe consistency, as some find this subject uncomfortable to talk about.
• Presence of blood – is there any blood present in the stool? If so, is it separate to the stool/only on wiping (more likely anal pathology e.g., haemorrhoid, fissure) or is it mixed in with the stool (more likely bowel pathology)? Causes of blood in a bowel movement include haemorrhoids, inflammatory bowel disease, gastroenteritis, malignancy, diverticular disease.
• Presence of mucus – is there any mucus present in the stool? Causes of mucus in a bowel movement include inflammatory bowel disease, coeliac disease, irritable bowel syndrome.
• Timing – what is the time-course of the symptoms? Is it constant or episodic? How long does an episode last? Is it worse at any particular time of day?
• Exacerbating & relieving factors – what makes the symptoms better? Does anything trigger the symptoms or make them worse? Examples may include gluten (coeliac disease), certain food, alcohol, caffeine, stress (irritable bowel syndrome), medications (e.g., opiate-induced constipation or metformin-induced diarrhoea).
• Associated symptoms – are there any other symptoms associated with the change in bowel habit e.g., abdominal pain, bloating, wind, vomiting.

System-specific History

After establishing further history of the change in bowel habit, you need to gather any relevant system-specific information; in this case, the relevant system is the gastrointestinal (GI) system. Try to think of GI symptoms that may present alongside bowel habit changes and ask about these. 

It is important not only to ask about these symptoms, but also to consider why their presence or absence is important in narrowing down the differential diagnosis. 

For example, the presence of vomiting and fever alongside diarrhoea may lead you to consider gastroenteritis in the differential, while bilious vomiting with constipation would raise greater concern for a bowel obstruction.

GI system symptoms to ask about include but are not limited to:

• Nausea and vomiting – how frequently? What is being vomited up? e.g., stomach contents, bile, faeces etc. Conditions such as gastroenteritis or bowel obstruction can present with diarrhoea or constipation associated with nausea and vomiting.
• Abdominal pain – where is the pain? What is the character of the pain? Does the pain improve or worsen with bowel movements? e.g., pain that improves with bowel movements is common with irritable bowel syndrome.
• Fever – while not a GI-specific symptom, fever can help identify infective or inflammatory causes of diarrhoea, e.g., gastroenteritis, inflammatory bowel disease.
• Diet and appetite – has the patient lost their appetite? Asking about the patient’s diet may provide useful insight into the possible cause of their symptoms. e.g., a lack of fibre or fluids is a risk factor for developing constipation. A patient who has recently tried cutting gluten-containing foods out of their diet and noticed relief from their symptoms may have coeliac disease.

Red Flags

It is important to ask about symptoms that may prompt you to consider more sinister causes of bowel habit change in the differential diagnosis, which may require more urgent investigation and management (e.g., malignancy or inflammatory bowel disease).

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information because they might find these symptoms concerning or may not have the same insight into their significance as you do. 

Red flags to screen for when taking a history of change in bowel habit include:

• Weight loss – could indicate malignancy, inflammatory bowel disease, malabsorption, coeliac disease.
• Bleeding per rectum – could indicate bowel cancer, inflammatory bowel disease (UC).
• Abdominal mass – could indicate malignancy.

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed; however, it is key to think about which systems are relevant to review so that your questions remain pertinent to the presenting complaint.

Relevant systems to review when taking a history of bowel habit change include:

• Endocrine – does the patient have any symptoms of thyroid disease? Thyrotoxicosis can cause diarrhoea, and other symptoms include goitre, sweating, tremor, weight loss, and eye changes (Grave’s disease). Hypothyroidism can cause constipation, and other symptoms include goitre, lethargy, weight gain, dry skin, and menorrhagia.
• Infectious Disease – could the patient have an infectious cause for their symptoms? The most likely cause with this history will be gastroenteritis. Are there any sick contacts (viral gastroenteritis)? Is there any history of foreign travel (Campylobacter)? Are there any suspect foods (unrefrigerated food – Bacillus Cereus, raw eggs – Salmonella)?

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you; some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing these symptoms?”
• Concerns – “Is there anything that is worrying you about this diarrhoea/constipation?” ‘Have you read or Googled anything about your symptoms that has worried you?”
• Expectations – “Was there anything specifically you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of bowel habit change,, e.g., if the patient has a known autoimmune disease and is presenting with diarrhoea and abdominal pain (coeliac disease).

Don’t forget to ask about any prior similar episodes of this presenting complaint.

Ask about previous surgery the patient may have undergone, especially if it will help to rule in/out a differential diagnosis, e.g., if the patient has recently had their gallbladder removed or undergone bariatric surgery and is now presenting with offensive diarrhoea (bile salt malabsorption). 

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer, e.g., over the counter medications, herbal or alternative medication, contraception, HRT, injections such as B12 and medication given in acute settings (e.g., hospital, ED, out-of-hours doctors). Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis, e.g., the patient presenting with diarrhoea who has just been started on an SSRI or metformin, or the patient who is more constipated than usual and has been given codeine to take by the hospital after an operation. 

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, beyond their presenting complaint.

• Who do they live with? Does anyone else at home have the same symptoms, e.g., infective gastroenteritis? Do they have a social support network, in case of a potential debilitating or terminal diagnosis?
• Do they work? Do they need time off work for infection control, e.g., gastroenteritis? Do they need to inform their employer, e.g., communicable diseases in certain professions?
• Do they drive? Does their condition affect their ability to drive or attend appointments?
• Have they had contact with someone with similar symptoms, e.g., infective gastroenteritis, viral hepatitis?
• Have they recently returned from travelling abroad, e.g., travellers’ diarrhoea or hepatitis?
• Do they smoke? Smoking is associated with some GI conditions, e.g., Crohn’s disease or malignancy and protective against others, e.g., ulcerative colitis.
• Do they drink alcohol? Alcohol can worsen symptoms of irritable bowel syndrome.
• Do they use recreational drugs?

Try to think about the relevance of the information you are given, e.g., the patient has presented with diarrhoea and vomiting and works as a nurse. You will need to discuss isolation prior to returning to work.

Family History

Does anyone in the family have any GI–specific conditions, e.g., gallstones or inflammatory bowel disease?

Do any health conditions run in the family, e.g., diabetes or other autoimmune conditions (increased risk of coeliac disease)?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation/imaging. 

Last updated Jan 2025

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