CASE 34
A 20-year-old white man was brought to the emergency department of a local hospital for evaluation of severe abdominal cramping and diarrhea. The patient had lower abdominal discomfort and reported having had eight loose bowel movements per day in the 3 days before his arrival at the hospital. He had recently noticed bloody bowel movements as well.
LABORATORY STUDIES
Diagnostic Work-Up
Table 34-1 lists the likely causes of illness (differential diagnosis). A clinical diagnosis of enteritis (or dysentery) was considered based on the febrile illness and bloody diarrhea. For enteritis, examination of feces, before ordering any stool test, may produce useful information. Feces should be examined for (1) too much fluid (watery or secretory diarrhea); (2) leukocytes (inflammatory enteritis); or (3) frank or occult blood and mucus (dysentery syndrome). In most cases of acute diarrhea, screening for fecal leukocytes is recommended. Diarrhea investigation may include
TABLE 34-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: There are many causes of enteritis, and it is difficult to arrive at a specific diagnosis on clinical grounds alone. The presence of bloody stools does narrow the etiologies to those that are more invasive, such as those listed above. E. coli O157:H7 does not usually manifest with fever because it is not invasive. C. difficile is almost always associated with prior antibiotic use. However, noninfectious etiologies such as Crohn disease or UC must also be considered because they may manifest in an identical manner.
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