Diarrhoea (Inpatient) 💩
Inpatient guide to suspected infectious diarrhoea and vomiting: Bristol stool chart, SIGHT precautions, C. difficile severity, stool sampling, isolation, and when to refer. Follow local IPC and AMRIC protocols.
🧭 Clinical workflow
- Document baseline bowel habit (frequency and stool type when well) on admission. Without this you cannot tell if current stools are abnormal.
- Diarrhoea = increased frequency of loose stool: Bristol Stool Chart (BSC) types 5–7, or loose enough to take the shape of the specimen container.
- Rule out non-infectious causes first (drugs, overflow impaction, feeds, IBD flare). Send stool tests only if an infectious cause is being considered.
- Sudden-onset diarrhoea and/or vomiting not clearly due to known therapy or disease: start source isolation immediately. Do not wait for further episodes.
- If infective cause suspected, use SIGHT: Suspect infective if no clear alternative; Isolate while investigating; Gloves and apron for all patient/environment contact; Hand washing with soap and water before and after each contact (alcohol gel alone is insufficient for C. difficile/norovirus); Test stool promptly if infectious cause considered.
- Fluid balance chart, BSC documentation, and electrolyte replacement. Notify local infection prevention and control (IPC) per hospital policy.
📊 Bristol Stool Chart
- For this topic, diarrhoea = types 5–7 (soft blobs through watery). Types 3–4 are normal/ideal for baseline comparison.
- Chart stool type on the ward chart alongside frequency.
🚨 Red flags
- Haemodynamic instability, tachycardia, or hypotension.
- Severe abdominal pain, peritonism, distension, or toxic megacolon concern.
- Bloody diarrhoea with fever or significant toxicity.
- Acute abdomen or free air on imaging.
- Neutropenic patient with diarrhoea (febrile neutropenia pathway).
- Profuse diarrhoea with AKI or electrolytes not responding to initial fluids.
- Life-threatening C. difficile: hypotension, ileus, toxic megacolon, or CT evidence of severe colitis.
🧠 Common causes
- C. difficile: recent antibiotics, PPI, hospital exposure. Toxin-producing strains can cause severe colitis.
- Viral: norovirus most common in healthcare settings; also rotavirus (children), adenovirus. Often sudden onset; norovirus may need virology sample (not routine on MC&S alone).
- Bacterial foodborne: Salmonella, Campylobacter (history and stool culture if indicated).
- Non-infectious: laxatives, antibiotics side-effect, metformin, magnesium, enteral feeds, chemotherapy/immunotherapy colitis, IBD flare, ischaemic colitis, overflow from impaction.
💊 Medication review (suspected C. difficile)
- STOP where possible: precipitating antibiotics (discuss with microbiology if still needed), PPIs, laxatives, prokinetics (e.g. metoclopramide), anti-motility agents (loperamide), immunosuppressants/steroids, opioids.
- REVIEW in dehydration: NSAIDs, ACE inhibitors, ARBs, diuretics.
- Prebiotics and probiotics are not recommended for C. difficile (UK IPC guidance).
- Start C. difficile treatment per local AMRIC/microbiology protocol (NICE NG199: commonly oral vancomycin or fidaxomicin). Do not await stool result if high clinical suspicion and senior agrees.
🧪 Assessment & stool sampling
- History: onset, duration, BSC type and frequency, blood/mucus, vomiting, fever, travel, contacts, recent antibiotics/surgery/anaesthetic, baseline bowel habit.
- Exam: vitals, hydration, abdomen; PR if appropriate (blood, impaction).
- Bloods: FBC, U&E, CRP; lactate if unwell. Blood cultures if febrile and toxic.
- C. difficile suspected: send stool for MC&S and C. difficile toxin/PCR. Send same day including weekends if your lab accepts urgent samples.
- Prior positive C. diff within 28 days: treat as positive without re-sending sample (confirm with micro/records). Recurrence 28 days to 12 weeks after prior episode: consider repeat sample.
- Routine clearance samples after treatment are not required.
- Norovirus suspected: request virology on stool; do not send vomit to microbiology.
- Travel/endemic risk: add ova, cysts, and parasites (OCP).
- AXR/CT if severe pain, distension, or ischaemic/severe colitis concern.
🛡️ Isolation & ward management
- Source isolation until asymptomatic for at least 48 hours and passing a formed stool or normal stool for that patient (confirm with local IPC).
- C. difficile: single room where possible; dedicated toilet; gloves and apron; soap-and-water hand hygiene; no bedside commode in bays.
- Suspected norovirus in a bay: source-isolate affected patients in the bay; do not move one patient to a side room and leave others exposed; close bay to new admissions per outbreak policy.
- Fluids: oral or IV crystalloid; replace potassium/magnesium. Chart stool frequency and BSC type.
- Infective diarrhoea (non-C. diff): supportive care; antibiotics only with microbiology advice.
- IBD flare or immunotherapy colitis: urgent specialist input; no loperamide.
- Minimise transfers and procedures; inform receiving areas/ambulance of infection risk. Staff with D&V: exclude from work until 48 hours symptom-free (occupational health/local policy).
☎️ When to refer
- Severe or life-threatening C. difficile, toxic megacolon, or surgical abdomen.
- Bloody diarrhoea with systemic upset.
- IBD flare, immunotherapy colitis, or diagnostic uncertainty.
- Persistent symptoms despite initial management; negative C. diff with ongoing loose stools needs medical review for other causes.
- Possible ward outbreak: notify IPC immediately.
- Gastroenterology or microbiology consult topics for referral scripts.
🔗 Related topics
Based on
Note Template
Ready-to-use clinical note structure
🕒 12 / 07 / 2026 — 18:23 ATRP re: inpatient diarrhoea / vomiting Patient: [age] [sex] Location: [ward] Admission Dx: [reason for admission] 💩 Stool history: • Baseline bowel habit (when well): [frequency, normal BSC type] • Onset & frequency: [__ stools/24 h; BSC types 5–7] • Character: [watery / loose / bloody / mucus] • Vomiting: [yes/no — do not send vomit for MC&S] • Associated: [abdominal pain, fever, tenesmus] 📋 Risk factors & SIGHT: • Infective cause suspected: [yes/no — clear alternative cause?] • Source isolation commenced: [yes — time] • Recent antibiotics / PPI / laxatives: [__] • IPC team notified: [yes/no] 🩺 Assessment: • Vitals: [HR, BP, temp — stable/unwell] • C. diff severity documented: [mild / moderate / severe / life-threatening / N/A] • Hydration & abdomen: [soft/tender/distended/peritonism] 🧪 Investigations: • Bloods: [FBC, U&E, CRP, creatinine trend] • Stool: [C. diff toxin/PCR + MC&S / virology / OCP — sent/pending/results] • Imaging: [AXR/CT — indication and result / not done] 💊 Management: • Fluids: [oral / IV — volume given] • Medications stopped/reviewed: [antibiotics, PPI, laxatives, loperamide, NSAIDs/ACEi/diuretics] • Treatment: [oral vancomycin/fidaxomicin per AMRIC — severity __ / supportive only] • Isolation: [single room / bay isolation — 48 h rule discussed with IPC] 📌 Plan: • [BSC chart, fluid balance, chase results, discharge/transfer precautions] 👤 [Your Name], [Role] IMC: _______