Diarrhea

Another fun topic, but pretty relevant on the Central Coast these past few weeks.

Three experiences over the years have taught me more on this than any textbook. The first was back in high school when giardia found the community, and I lost about 15 pounds in 2 weeks. It was a “slow burn” as I was able to keep playing soccer, and even take a painfully long school bus trip to Long Island. I still remember every pothole. From the experience I discovered the miracle of metronidazole (Flagyl), and I can recall my renewed sense of hope after just 24 hours.

Lesson two was aboard a cruise ship heading from Valparaiso to Rio with 300+ afflicted passengers. I’d really never witnessed such an outbreak before. Happily, I dodged the bullet myself, and everyone lived to tell the tale. Whatever it’s worth, I’m pretty sure it wasn’t even the ship’s fault, because a large number of passengers seemed to have brought it aboard from a tour the previous week in Peru.

Since then, my policy when traveling has included the following:

  1. Carbonated or recently boiled drinks only
  2. Steaming food only
  3. No ice, thank you
  4. No salads, thank you

Lesson three came last week when I finally got to experience a saline infusion. The Central Coast gastric typhoon first hit Vanessa, then me the following day. I was amazed by how fast dehydration set in, and how hard it was to pry my head off the floor. But what a difference that saline made. (Actually, now my mind is on IV self insertion techniques. Turns out it’s fairly easy all the way up to connecting the tubing to the IV one handed. Then it gets messy.)

Before leaving the safety and comfort of your own bowl to find an ER, know the buzzwords.

Red Flags:

• Abdominal pain (… above and beyond gurgling and cramping)
• Vomiting (… more concerning for dehydration)
• Bloody vomit or stools (… though bloody streaks after a day on the pot aren’t particularly shocking)
• Fevers
• Frail, elderly, pediatric
• Chronic medical problems (… diabetes, renal failure, liver failure, heart failure, etc.)
• Recent travel or concerning exposures (… cholera, C. difficile, etc.)
• Recent antibiotic use (… concerning for C. diff)
• Past history of C. diff (Notice a pattern? This is a big topic these days.)
• Recent hospitalizations or surgeries
• Already taking diuretics

Happy Words

• Still able to drink liquids
• “I’ve only had it for a couple hours.”
• “Loose stool only, and getting better already.”
• “I’m fine when I take Imodium.”
• “Everyone in the family had it, and they’re better now.”
• “Everyone in town has it and Flagyl seems to work. Can I have some?”

I think about four things when I meet patients with diarrhea:

  1. Is this life threatening?
    IV fluids are most useful. Sometimes we’ll do a CT if pain or fevers are a component looking for diverticulitis, appendicitis or other serious pathology. Studies looking for C. difficile, Salmonella, Shigella, E. Coli may be sent as well, though cultures generally take days. If we’re really concerned we may check electrolytes as well for some fine tuning.
  2. Is there a public health threat?
    Have multiple patients arrived from the same sushi bar, tour, ship, etc? Is a call to public health warranted?
  3. Is there time to watch and wait?
    Waiting is preferred, because use of antibiotics can turn a relatively benign, self limited problem into something more serious like C. diff superinfection, allergic reaction, hemolytic uremic syndrome… not to mention worse stomach pains.
  4. What’s the social dynamic?
    Can the patient spend a day or so near a toilet, or are they about to take a long bus ride through notoiletsville? Only then do I suggest use of OTC Imodium. Even more rarely do I consider prescribing Lomotil (basically never).

My typical parting advice for people with diarrhea is fairly zen:
“The problem is the solution.”
… unless it’s giardia, in which case I say:
“Take Flagyl. It’ll give you religion.”

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