A 26-year-old woman comes to the emergency department due to diarrhea. For the last 2 days she has had abrupt-onset diarrhea associated with crampy lower abdominal pain and fatigue. The patient is experiencing 4-6 watery bowel movements daily with visible blood throughout the stool. She reports no ill contacts and has not traveled outside the United States in the last 2 years. Medical history is notable only for a severe peanut allergy, and her only medication is an oral contraceptive. The patient does not use alcohol, but smokes up to 5 cigarettes daily and occasionally uses marijuana. Temperature is 37.5 C (99.5 F), blood pressure is 110/76 mm Hg, and pulse is 90/min. Abdominal examination reveals normal bowel sounds with mild diffuse tenderness and no peritoneal signs. Laboratory results are as follows: Which of the following is the most appropriate response to this patient?

Question

A 26-year-old woman comes to the emergency department due to diarrhea.  For the last 2 days she has had abrupt-onset diarrhea associated with crampy lower abdominal pain and fatigue.  The patient is experiencing 4-6 watery bowel movements daily with visible blood throughout the stool.  She reports no ill contacts and has not traveled outside the United States in the last 2 years.  Medical history is notable only for a severe peanut allergy, and her only medication is an oral contraceptive.  The patient does not use alcohol, but smokes up to 5 cigarettes daily and occasionally uses marijuana.  Temperature is 37.5 C (99.5 F), blood pressure is 110/76 mm Hg, and pulse is 90/min.  Abdominal examination reveals normal bowel sounds with mild diffuse tenderness and no peritoneal signs.  Laboratory results are as follows:  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf1c_aa27_8f63_01c6de476475_MD0005_00 Acute diarrhea is defined as diarrhea lasting <14 days. Most cases are due to viral pathogens and are characterized by bland, watery diarrhea and a self-limited course. In contrast, acute diarrhea with visible blood or mucus (dysentery) is more likely due to bacterial infection and is often associated with abdominal pain and systemic symptoms (eg, fever, malaise). Major causes include enterohemorrhagic Escherichia coli ([EHEC] eg, O157:H7), Shigella, Campylobacter, and Salmonella. Noninfectious causes include inflammatory bowel disease and ischemic colitis. The initial evaluation of dysentery should include a stool culture, immunoassay for Shiga toxin, and fecal leukocyte count. An unexpectedly low fecal leukocyte count can suggest invasive amebiasis, although this is uncommon in developed countries. Imaging (eg, CT scan of the abdomen) is not usually needed unless there is suspicion for ischemic colitis. Endoscopy is not needed immediately for most patients but could be considered for those with recurrent or persistent (>2 weeks) symptoms (Choice B). (Choice C) Clostridium difficile infection is usually seen in those with exposure to health care facilities, especially patients who have recently received antibiotics. Also, C difficile usually causes nonbloody diarrhea. (Choice D) Many experts advise empiric antibiotic therapy for patients with acute dysentery unless EHEC is suspected (antibiotic therapy in EHEC has been associated with increased risk for hemolytic uremic syndrome). However, oral antibiotics (eg, ciprofloxacin) are preferred. (Choice E) Simple hydration and expectant management would be appropriate for patients with uncomplicated, watery diarrhea. Dysentery warrants additional diagnostic evaluation. Educational objective: Acute diarrhea associated with visible blood or mucus (dysentery) is most commonly due to bacterial infection. Major causes include enterohemorrhagic Escherichia coli (eg, O157:H7), Shigella, Campylobacter, and Salmonella. Noninfectious causes include inflammatory bowel disease and ischemic colitis. The initial evaluation should include stool culture, immunoassay for Shiga toxin, and fecal leukocyte count. References: The patient presenting with acute dysentery--a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22266388)

A 26-Year-Old Woman Comes to the Emergency Department Due to Diarrhea