Makindo Medical Notes

💡 Patients presenting with abdominal pain, altered bowel habit, or rectal bleeding require a careful and structured assessment. Causes range from benign (IBS, lactose intolerance) to life-threatening (colorectal cancer, severe IBD). History, examination, and judicious use of investigations help guide diagnosis and management.

📖 History Taking

• Symptom Onset & Duration: Acute (infection, diverticulitis) vs chronic (IBS, IBD, colorectal cancer).
• Nature of Bowel Habit Change: Diarrhoea, constipation, alternating pattern, urgency, nocturnal symptoms.
• Associated Symptoms: Rectal bleeding, weight loss, fever, fatigue, bloating, tenesmus.
• Dietary History: Lactose/gluten intake, recent travel, food poisoning risk.
• Medication History: Antibiotics (C. difficile risk), opioids (constipation), laxative use.
• Family History: IBD, colorectal cancer, coeliac disease.
• Systemic Review: Joint pain, skin rashes (IBD), neurological symptoms, menstrual history (in women, to avoid misattribution).

🩺 Clinical Examination

• General: Look for pallor (anaemia), weight loss, fever.
• Abdominal exam: Tenderness (localised in diverticulitis, diffuse in gastroenteritis), masses (cancer, Crohn’s strictures), organomegaly.
• Rectal exam: PR for masses, tenderness, presence of blood/mucus.
• Extraintestinal signs: Aphthous ulcers, erythema nodosum, clubbing (IBD); dermatitis herpetiformis (coeliac disease).

🔬 Investigations

• 🧪 Bloods: FBC (anaemia, infection), CRP/ESR, LFTs, U&E, coeliac serology (anti-tTG).
• 💩 Stool tests: Calprotectin (inflammation vs IBS), cultures/PCR (infection), FIT test (blood in stool).
• 📸 Endoscopy: Colonoscopy ± biopsy (IBD, cancer, coeliac disease — small bowel biopsy).
• 🖥️ Imaging: CT or MRI enterography for Crohn’s; CT abdomen for diverticulitis.
• 🧬 Special tests: Hydrogen breath test (lactose intolerance).

📊 Causes of Abdominal Pain & Altered Bowel Habit

⚠️ Red Flags (Require Urgent Referral)

• Rectal bleeding in patients >50 years or with family history of colorectal cancer.
• Unintentional weight loss, anorexia, night sweats.
• Iron-deficiency anaemia.
• Nocturnal symptoms (suggests organic disease, not IBS).
• Persistent vomiting or obstructive symptoms.

🗣️ Clinical Discussion

- IBS is the most common diagnosis in young patients with chronic abdominal pain and bowel habit change, but it is a diagnosis of exclusion. - Always screen for red flags to avoid missing cancer or IBD. - Fecal calprotectin is useful to distinguish functional (IBS) from inflammatory (IBD) bowel disease. - In older adults with new bowel symptoms, assume malignancy until proven otherwise. - Clinical reasoning: • Intermittent diarrhoea, bloating, worse with certain foods → IBS or lactose intolerance. • Chronic diarrhoea, blood, weight loss, systemic features → IBD or cancer. • Acute severe abdominal pain with fever and raised WCC → diverticulitis or infection.

📚 References

• NICE CG61: Management of Irritable Bowel Syndrome (2021 update)
• NICE NG151: Colorectal Cancer Diagnosis & Management
• British Society of Gastroenterology Guidelines on IBD (2019)
• Kumar & Clark’s Clinical Medicine, 10th Ed.