CASE:

A 21 year old male developed watery diarrhea after eating in the town fiesta 8 hours prior to
consult.
1. What additional data will you elicit and why?

Accompanying signs and symptoms: To know if there are other symptoms other
than diarrhea like fever, abdominal pain, vomiting, any signs of dehydration, etc.
These data can help in identifying the probable cause, etiology or mechanism of
the diarrhea.

Number of episodes of loose bowel movement: To know if the patient is already

dehydrated.

Consistency and color of stool: To help in identifying what causes the diarrhea and
to check if there is the presence of blood in the stool.

Medications taken to relieve symptom: To know the next course of action for the
patients condition.

Food eaten before having the diarrhea: This can give a clue on the probable cause
of the diarrhea.

2. Discuss diagnosis and differentiate diagnoses with pathophysiologic bases.

The probable diagnosis for this case is acute diarrhea or acute gastroenteritis.
Though there are still other data that could be elicit from the patients history to
rule out other differential diagnosis. There are a lot of agents that can cause
acute gastroenteritis. Patients history and physical exam will be a great help in
identifying the agent. The most common cause of acute diarrhea is E. coli (ETEC),
which has non-bloody and non-mucoid stool. Pathophysiology includes
hypersecretion of water due to toxic peptides release by the bacteria, which
increases cAMP leading to diarrhea. In a town fiesta, the usual food being
prepared must be consider and its associated microorganisms. Examples are
chicken and undercooked burger for Salmonella, seafood for Vibrio sp, fried rice
for Bacillus cereus, and salads for Staphylococcus aureus.

3. Outline principles of management.

The reduced (low) osmolarity Oral Rehydration Solution (ORS) is the
recommended treatment for acute diarrhea.
When the patient is vomiting, IV hydration is recommended instead of ORS.
The amount of glucose is decreased in the new formulation because it might
cause diarrhea in higher amounts.
If there is MILD dehydration and activity is unrestricted, you should just observe
the patient and probably the diarrhea will resolve
If there is MODERATE dehydration and there is fever, bloody stools, leukocytes in
fecal exam, immunocompromised or elderly host, the patient is admissible. If not,
give antidiarrheal agents (Racecadotril or Loperamide).
In SEVERE dehydration (if the patient didnt respond to fluid and electrolyte
replacement), you will do stool microbiology studies.
In the microbiological studies, if no pathogen is found, give empiric treatment:
Metronidazole 500mg 3x a day for 7-10 days (for amoebiasis)
Quinolones: 200 or 500mg 2x a day
o Ofloxacin (200mg), Ciprofloxacin (500mg), Levofloxacin (500
750mg)
Chloramphenicol, Ceftriaxone (typhoid fever)

CASE:
A 50 year old female presents with a 6 weeks history of recurrent Loose Bowel Movement.
1. What additional date will you elicit and why?

Medications taken: This can help in identifying the cause of the 6 weeks LBM.

Are there general features to suggest malabsorption or inflammatory bowel

disease (IBD) such as anemia, dermatitis herpetiformis, edema or clubbing?

Is there an abdominal mass or tenderness?

Are there any abnormalities of rectal mucosa, rectal defects, or altered anal
sphincter functions?

Are there features to suggest underlying autonomic neuropathy or collagenvascular disease in the pupils, orthostasis, skin, hands, or joints?

Are there any mucocutaneous manifestations of systemic disease such as

dermatitis herpetiformis (celiac disease), erythema nodosum (ulcerative colitis),
flushing (carcinoid), or oral ulcers for IBD or celiac disease?
* All these data can help in identifying the cause of chronic diarrhea and the course
of action that will be done to the patients condition.
2. Discuss diagnosis and differentiate diagnoses with pathophysiologic bases.

The most probable diagnosis for this case is chronic diarrhea. This is because of
the 6 weeks history of recurrent loose bowel movement. Greater than 4 weeks of
diarrhea is considered as chronic. The usual cause of this is non-infectious.
Causes of chronic diarrhea include the following: secretory, osmotic, steatorrheal
causes, inflammatory, dysmotile causes or factitial causes. Due to incomplete
patients history in the case, it is hard to identify the real cause of the diarrhea.

Secretory is due to derangements in fluid and electrolyte transport across

enterocolic mucosa.

Osmotic occurs when ingested, poorly absorbable osmotically active solutes draw
enough fluid lumenward to exceed resorptive capacity of the colon.

Steatorrheal is due to fat malabsorption- greasy, foul smelling difficult to flush

diarrhea

Inflammatory is generally accompanied by pain, fever and bleeding.

Dysmotility is a rapid transit either secondary or contributory (usual)

Factitial accounts for >15% of unexplained diarrhea referred to tertiary care

centers.

3. Outline principles of management.

Curative:
o if cause can be eradicated
o if its colonic CA, then resect
Suppressive:
o Suppress underlying mechanism
o If patient has gluten enteropathy, remove Gluten from the diet
Empiric:
o Specific cause or mechanism evades diagnosis mild opiates
Diphenoxylate and Loperamide (mild or moderate)
Codeine/ tincture of Opium (severe diarrhea)
Clonidine (diabetic diarrhea)