Patient presenting with diarrhea

1. What information do you want to illicit in a patient with diarrhea?
Information that could help to distinguish between irritable bowel disease and inflammation/neoplasia should be sought whenever a patient shows up with diarrhea. Irritable bowel syndrome is usually the most common cause of diarrhea associated with cramping. The factors that distinguish it from pathologic diarrhea are the absence of blood. It is not associated with nocturnal bowel movements and inflammatory signs (fever, arthritis) which are usually absent. Risk factors, for example, recent use of antibiotics should also be considered to exclude any bacterial or viral infections that could lead to diarrhea.
2. What physical findings and risks factors are important in this patient?
Appearance of blood in the diarrheal stool is the main risk factor in a patient of inflammatory bowel disease as the mucosal membrane is ulcerated. According to the patent there are nocturnal bowel movements which are almost never seen in irritable bowel syndrome. Recent smoking cessation could also be an additional risk factor as cigarette is supposed to protect the mucosal membrane against ulcers. The patient has been using NSAIDs (ibuprofen) recently and the prolong use of these drugs usually causes ulcers. The patient also has a family history of ulcers which makes her genetically predisposed to the disease. On physical examination, the patient appeared slim; signs of weight loss were prominent. The oral mucosa was dry. The heart rate was increased. There was also mild tenderness in the abdomen. All the signs of inflammatory disease, including fever, were present.
3. What are the indications for endoscopy in a patient presenting with diarrhea?
Patients presenting with chronic diarrhea are usually suggested for flexible sigmoidoscopy or colonoscopy. Endoscopy is performed when these non-invasive procedures fail to give a positive result and the patient still presents with the signs of inflammation. Endoscopy has some advantage over these procedures in a way that it does not only give a complete internal view of the organ but also allows the physician to collect samples for biopsy. Colitis is graded from mild to moderate and severe on the extent of the damage to the mucosal membrane. If on endoscopic examination the loss of mucosal integrity is not so severe the colitis is termed as mild or moderate. In contrast, patients presenting with sudden onset of signs and symptoms with a greater loss of the mucosa, the disease is termed as severe colitis. Flexible sigmoidoscopy although an efficient procedure, still requires colonoscopy to be done to rule out any false positive results.
4. How do the following lab test help focus your diagnosis?
The lab reports of the patient showed;
Negative test for C. difficile toxin and negative test for stool ova
Positive test for fecal leukocytes.
Sodium 139 mEq/L Potassium 3. 4 mEq/L Chloride 101 mEq/L
Bicarbonate 21 mEq/L Creatinine 0. 7 mg/dL
Albumin 3. 2 g/dL
Total protein 6. 7 g/dL
Alkaline phosphatase 110 U/L
Total bilirubin 0. 7 mg/dL
Aspartate aminotransferase 45 U/L
Blood urea nitrogen 30 mg/dL
Hematologic values
Leukocyte count 10. 9 × 103/mm3
Hemoglobin 11. 3 g/dL
Hematocrit 33. 2%
Platelet count 368 × 103/mm3
Erythrocyte sedimentation rate 73 mm/hr
Physical examination showed dehydration which is confirmed by the electrolyte imbalance shown in the reports. Leucocytes in stool confirm inflammation whereas negative stool culture for C. difficile rules out any infectious diseases. Anemia and thrombocytosis are mainly due to loss of blood in the stool and iron deficiency due to decreased absorption.
5. What serologic tests can be performed in order to give more definitive diagnosis?
Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and antisaccharomyces cerevisiae antibody (ASCA) serum assay are the two main serological tests usually performed for the diagnosis of ulcerative colitis. Better results could be obtained by using both tests together than by using one of them alone. These tests help in predicting the clinical course of the disease, thus, enabling the physician to provide better management and avoid post surgical complications.
Works Cited
Linskens, R. K., et al. ” Evaluation of Serological Markers to Differentiate Between Ulcerative Colitis and Crohn’s Disease: Panca, Asca and Agglutinating Antibodies to Anaerobic Coccoid Rods.” European Journal of Gastroenterology & Hepatology, 14. 9 2002: 1013-8. Print.
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Bhutani, Manoop S., and Rakesh K. Tandon. Advances in Gastrointestinal Endoscopy. New Delhi: Jaypee Brothers Medical Publishers, 2001. Print.
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