Introduction
WIPER
Presenting Complaint
ICE: Ideas, Concerns, Expectations
Past Medical History
Medications
Family History
Social History
Change in bowel habits (CIBH) is an important symptom in primary care and could point to benign or sinister pathology. When taking a history for a change in bowel habits, start by asking about the nature of the change—diarrhoea, constipation, alternating patterns, or changes in stool consistency, colour, or frequency. Inquire about associated symptoms such as abdominal pain, blood or mucus in stool, weight loss, fever, or systemic symptoms. Ask about dietary habits, medications (including antibiotics and laxatives), travel history, recent infections, and family history of gastrointestinal diseases like colorectal cancer or inflammatory bowel disease. Also, assess for red flag symptoms, including unexplained weight loss, anaemia, or nocturnal symptoms, which may indicate serious pathology.
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
When did you first notice the change in your bowel habits?
Was it sudden or gradual?
Are your stools looser or harder than usual?
Are you going more or less frequently?
Do you feel an urgent need to pass stool?
Do you feel you are not fully emptying your bowels?
3. Stool Characteristics:
What does your stool look like (e.g., watery, pellet-like, greasy, bulky)?
Have you noticed any blood or mucus in your stool?
Have your stools become paler or darker than usual?
Have they become particularly foul-smelling?
Abdominal pain, bloating, nausea, vomiting, or weight lossTenesmus (feeling of incomplete emptying)
Abdominal pain, bloating, nausea, vomiting, or weight loss
Tenesmus (feeling of incomplete emptying)
Fever, night sweats, fatigue
Rectal bleeding, fresh blood, melaena (black tarry stools)
5. Triggers & Dietary Factors:
Have you changed your diet recently?
Have you started any new medications?
Have you recently travelled abroad?
Does anything make your symptoms worse (e.g., certain foods, stress)?
Has anything improved your symptoms (e.g., dietary changes, medications)?
Have your symptoms worsened over time?
10. Impact on Daily Life:
How has this affected your daily activities, work, or sleep?
Ideas: What do you think is causing this?
Concerns: Are you worried about anything specific (e.g., cancer, infection)?
Expectations: What are you hoping for in terms of treatment?
Current medications and recent changes including over the counter drugs.
Laxatives or antidiarrhoeals
NSAIDs, antibiotics, proton pump inhibitors (PPIs)
Recent changes in medication or over-the-counter drugs
Family history of bowel cancer, IBD, or coeliac disease
Dietary Habits: High fibre, lactose intake, recent changes
Hydration Levels: Fluid intake per day
Alcohol and Smoking History: Risk factors for bowel disease
Occupation: Stress levels, sedentary lifestyle
Travel History: Recent travel to regions with a risk of gastroenteritis
Risk Factors for Change in Bowel Habit (CIBH)
Age >50 with new-onset symptoms (higher malignancy risk)
Family history of bowel disease
Recent antibiotic use (risk of Clostridium difficile infection)
Immunosuppression (HIV, chemotherapy, long-term steroids)
Gastrointestinal Causes:Diarrhoea-Predominant:Infective gastroenteritisInflammatory bowel disease (Crohn’s, ulcerative colitis)Coeliac diseaseIrritable bowel syndrome (IBS)Malabsorption syndromes (e.g., pancreatic insufficiency)Constipation-Predominant:IBS (constipation type)Functional constipationDiverticular diseaseBowel obstruction (e.g., malignancy, volvulus)
Diarrhoea-Predominant:Infective gastroenteritisInflammatory bowel disease (Crohn’s, ulcerative colitis)Coeliac diseaseIrritable bowel syndrome (IBS)Malabsorption syndromes (e.g., pancreatic insufficiency)