How to manage a patient with chronic increased bowel frequency and recent exacerbation?

Management of Chronic Increased Bowel Frequency with Recent Exacerbation

This patient with chronic increased bowel frequency (6 stools/day for >1 year) and recent exacerbation requires focused investigation to exclude organic disease before attributing symptoms to a functional disorder, particularly given the history of small bowel inflammation and recent hernia surgery. 1

Immediate Diagnostic Approach

Key Clinical Features Suggesting Organic vs. Functional Disease

The absence of alarm features in this case is reassuring but does not exclude organic pathology:

• Favorable features: Normal stool consistency (no longer watery), no blood (except from known hemorrhoids/fissure), no nocturnal symptoms explicitly mentioned, no weight loss, soft non-tender abdomen, and normal bowel sounds 2
• Concerning features: Long duration (>1 year), recent change/exacerbation, history of inflamed jejunum and erosive gastritis, and recent abdominal surgery 1, 2

Weight loss, nocturnal diarrhea, and laboratory abnormalities (elevated ESR, anemia, hypokalemia, low albumin) are the most discriminating features for organic disease—62% of organic cases show laboratory alterations versus only 3% of functional cases 2

Essential First-Line Investigations

The planned investigations are appropriate but incomplete:

1. Erect abdominal X-ray: Reasonable to exclude obstruction or ileus given recent hernia repair, though unlikely with normal examination 1

2. Fecal occult blood test (FOBT): This is inadequate as a primary screening tool in this context 3, 4

   • Standard guaiac FOBT has poor sensitivity for significant colorectal disease
   • Quantitative fecal immunochemical test (FIT) for hemoglobin is superior and should replace FOBT 3
   • Single-specimen in-office testing is inappropriate for screening 4

3. Critical missing investigations that should be performed immediately 1:

   • Complete blood count (anemia)
   • ESR or CRP (inflammation)
   • Serum albumin (malabsorption/protein-losing enteropathy)
   • Electrolytes including potassium (secretory diarrhea)
   • Thyroid function tests (hyperthyroidism causes increased frequency) 1
   • Tissue transglutaminase antibodies or antiendomysial antibodies (celiac disease) 1
   • Stool microscopy and culture (if any suggestion of infection)

Risk Stratification for Colonoscopy

Given this patient's profile, colonoscopy is indicated and should not await FOBT results:

• History of inflamed jejunum and erosive gastritis (previous endoscopic findings suggest inflammatory potential) 1
• Age and symptom duration: If patient is >45 years or has family history of colorectal cancer, colonoscopy is mandatory 1
• Recent exacerbation of chronic symptoms warrants re-evaluation even if previously investigated 1
• Colonoscopy with biopsies is essential to exclude microscopic colitis, which presents with increased stool frequency and can have normal-appearing mucosa 1

Specific indications for colonoscopy in this case 1:

• Atypical features (history of small bowel inflammation, post-surgical timing)
• Need to exclude microscopic colitis (requires random biopsies even with normal-appearing mucosa)
• Previous inflammatory findings on endoscopy

Differential Diagnosis Framework

Most Likely Diagnoses to Exclude

1. Microscopic colitis 1

   • Presents with increased watery stools (though now improved to normal consistency)
   • Risk factors: Previous inflammatory findings
   • Requires colonoscopy with random biopsies

2. Bile acid diarrhea (BAD) 1

   • Consider if history of cholecystectomy (not mentioned but should be asked)
   • Post-meal exacerbation typical
   • SeHCAT scanning or serum 7α-hydroxy-4-cholesten-3-one (C4) if available

3. Small intestinal bacterial overgrowth (SIBO) 1

   • Risk increased with previous abdominal surgery
   • Associated with feeling of distension
   • Consider if malabsorption tests positive

4. Post-surgical complications 1

   • Recent hernia repair (4 weeks ago) could relate to adhesions or altered motility
   • Small bowel obstruction history increases adhesion risk

5. Inflammatory bowel disease progression 1

   • Previous finding of "inflamed jejunum" needs clarification
   • Could represent early Crohn's disease

6. Irritable bowel syndrome with diarrhea (IBS-D) 1

   • Diagnosis of exclusion only after organic causes ruled out
   • Rome IV criteria require abdominal pain (patient denies pain, only "pressure/distension")
   • This patient does NOT clearly meet IBS criteria as pain is not a prominent feature 1

Recommended Investigation Algorithm

Immediate (before follow-up appointment):

• Blood tests: CBC, ESR/CRP, electrolytes, albumin, thyroid function, celiac serology 1, 2
• Quantitative FIT (not standard FOBT) 3
• Stool microscopy if any infectious symptoms

Based on initial results:

• If ANY laboratory abnormalities: Proceed directly to colonoscopy with biopsies + consider small bowel imaging 2
• If all normal but symptoms persist: Still proceed to colonoscopy given history of inflammation and recent exacerbation 1
• During colonoscopy: Random biopsies throughout colon even if mucosa appears normal (to detect microscopic colitis) 1

If colonoscopy normal:

• Consider small bowel evaluation (MR enterography or capsule endoscopy) given history of inflamed jejunum 1
• Consider bile acid diarrhea testing if post-prandial pattern 1
• Consider breath testing for SIBO if bloating/distension prominent 1

Management Pending Investigation Results

Conservative measures while awaiting investigations 1:

1. Dietary assessment:

   • Reduce caffeine intake 1
   • Trial of lactose restriction if consuming >280ml milk daily 1
   • Avoid excessive poorly absorbed carbohydrates (fructose, sorbitol) 1
   • Keep symptom-food diary 1

2. Medication review:

   • Document all current medications including over-the-counter and supplements
   • Many drugs cause diarrhea 1

3. Avoid empiric antidiarrheal agents until organic causes excluded 1

Critical Pitfalls to Avoid

• Do not diagnose IBS without excluding organic disease in a patient with previous inflammatory findings and recent symptom change 1
• Do not rely on FOBT alone—it has poor sensitivity and quantitative FIT is superior 3, 4
• Do not skip colonoscopy with biopsies—microscopic colitis requires histological diagnosis 1
• Do not assume functional disease based on normal examination—62% of organic diarrhea cases have laboratory abnormalities that guide diagnosis 2
• Do not forget to evaluate the previous finding of "inflamed jejunum"—this may represent undiagnosed small bowel pathology 1

Follow-up Strategy

At scheduled follow-up appointment:

• Review all blood test results
• Review FIT result
• Arrange colonoscopy regardless of FOBT/FIT result given clinical context 1
• If colonoscopy normal, proceed to small bowel imaging given previous jejunal inflammation 1
• Only consider functional diagnosis after comprehensive organic workup is negative 1