Diagnosis

• Rectal examination to rule out impaction with overflow. Consider sigmoidoscopy if colitis or C. difficile suspected (pseudomembrane seen).

• Stool sent to laboratory for MC & S, C. difficile toxin.

• Fat estimation (malabsorption) is rarely necessary in the ICU patient

• If ischaemic or inflammatory bowel disease suspected, perform a supine abdominal X-ray and inspect for dilated loops of bowel (NB toxic megacolon), thickened walls (increased separation between loops) and 'thumbprinting' (suggestive of mucosal oedema). Fluid levels seen on erect or lateral abdominal X-ray may be seen in diarrhoea or paralytic ileus and do not necessarily indicate obstruction. Diarrhoea is often but not always bloody.

• If abscess suspected, perform ultrasonography or CT scan

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