Historical clues | Implications |
Pattern of initial onset | |
Abrupt | Suggests infectious/postinfectious or drug- or dietary-induced diarrhea. |
Gradual | Can be seen in many disorders, including IBD and functional diarrhea. |
Potential triggers | |
Dietary changes | |
Initial onset after a change from breast milk to formula or from formula to unmodified cow's milk | Possible food protein-induced allergic proctocolitis or enterocolitis (usually related to cow's milk). |
Initial onset after an increase in dietary fructose, sucrose, or lactose or poorly absorbed carbohydrates (eg, sorbitol, xylitol) | Multiple possible mechanisms:
|
Onset coincided with introduction of gluten (eg, in wheat, rye, or barley) | Possible celiac disease. In severe cases, onset of symptoms may occur within weeks to months after gluten is introduced (or increased) but may occur at any time thereafter. |
Infectious exposures | |
Onset after acute diarrheal illness (in index patient or close contacts) | Infectious or postinfectious diarrhea. Postinfectious diarrhea often varies with diet (eg, exacerbated by lactose). |
Recent travel, particularly to equatorial/tropical countries with endemic enteric pathogens | Potential prolonged enteric infection or postinfectious diarrhea. |
Recent visit to campgrounds; water supply from well | Consideration of parasitic exposure (eg, G. lamblia). |
Drugs | |
Onset associated with the use of certain drugs (eg, antibiotics, SSRIs) | Possible drug-related side-effect*. |
Physical symptoms | |
Bloating symptoms | Suggests abnormality of carbohydrate assimilation or small intestine bacterial overgrowth. |
Nausea/vomiting | Suggests intestinal inflammation (including FPIES) or impaired motility. |
Diarrhea pattern | |
Postprandial episodes | Suggests food intolerance or functional diarrhea (eg, IBS-D). |
Nocturnal episodes | Suggests an organic disorder with a component of abnormal electrolyte absorption/secretion. One exception is that young children with functional diarrhea sometimes have very low-volume nocturnal episodes of diarrhea. |
Stool appearance | |
Blood and/or mucus | Food protein-induced proctocolitis (eg, due to cow's milk), IBD, prolonged enteric infection (eg, C. difficile). |
Light tan or white | Absence of bile, suggesting biliary obstruction. Occasionally found in celiac disease. |
Family history | |
Family history of autoimmunity, IBD, or other significant systemic or gastrointestinal disorders | Increases the likelihood of heritable diseases, including celiac disease and IBD (both relatively common) or any other polygenic and monogenic disorders (rare). |
Signs/symptoms suggesting underlying medical illnesses | |
History of recurrent, persistent, or opportunistic infections or immunodeficiency diagnosis | Possible immunodeficiency, immune-mediated diarrhea, or graft-versus-host disease. |
Growth faltering or weight loss | Malabsorption, pancreatic exocrine insufficiency, anorexia nervosa. |
Intravenous drug use or other risk factors | HIV disease. |
History of chronic constipation and/or fecal incontinence | Possible retentive (constipation-associated) fecal incontinence (misinterpreted as diarrhea by the patient/family). |
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