What is the step-by-step evaluation for a 72-year-old female (F) with complaints (c/o) of severe diarrhea occurring every 5-10 minutes?

Evaluation and Management of Severe Diarrhea in a 72-Year-Old Female

This patient requires immediate emergency department evaluation due to the frequency and severity of diarrhea, which presents a high risk for severe dehydration and potential life-threatening complications.

Initial Assessment

Immediate Evaluation

1. Assess hydration status:

   • Check vital signs: heart rate, blood pressure (including orthostatic measurements)
   • Evaluate skin turgor, mucous membranes, capillary refill
   • Mental status assessment
   • Look for signs of severe dehydration: lethargy, altered consciousness, prolonged skin tenting (>2 seconds), cool extremities, decreased capillary refill 1

2. History taking:

   • Onset and duration of diarrhea
   • Stool characteristics (watery, bloody, mucus)
   • Associated symptoms (fever, abdominal pain, vomiting)
   • Recent medications (antibiotics, laxatives)
   • Recent travel or hospitalization
   • Dietary changes
   • Comorbidities (immunosuppression, inflammatory bowel disease)

3. Physical examination:

   • Abdominal examination for tenderness, distension, bowel sounds
   • Rectal examination to assess for impaction, blood, or mucus

Laboratory and Diagnostic Workup

1. Laboratory tests:

   • Complete blood count (CBC)
   • Comprehensive metabolic panel (electrolytes, BUN, creatinine)
   • Stool studies:
     • Stool culture (if bloody diarrhea or fever present)
     • C. difficile testing (especially if recent antibiotic use)
     • Ova and parasites (if travel history or persistent symptoms)
     • Fecal leukocytes or lactoferrin/calprotectin (for inflammatory diarrhea)

2. Imaging (if indicated by history/exam):

   • Abdominal X-ray (if obstruction suspected)
   • CT scan (if diverticulitis, inflammatory bowel disease, or other structural issues suspected)

Treatment Algorithm

Immediate Management

1. Rehydration therapy based on dehydration severity:

   • For severe dehydration (≥10% fluid deficit): IV rehydration with Ringer's lactate or normal saline boluses (20 mL/kg) until hemodynamically stable 1
   • For moderate dehydration (6-9% fluid deficit): Oral rehydration solution (ORS) 100 mL/kg over 2-4 hours if tolerated; IV fluids if not 1
   • For mild dehydration (3-5% fluid deficit): ORS 50 mL/kg over 2-4 hours 1

2. Replace ongoing losses:

   • Administer 10 mL/kg ORS for each watery stool 1

Pharmacologic Therapy

1. Antimotility agents:

   • Loperamide can be used if no fever or bloody diarrhea is present 2, 3
   • Contraindicated if infectious etiology suspected with fever or bloody stools 2

2. Antibiotics:

   • Only if indicated by clinical presentation (fever, bloody diarrhea) or positive stool cultures
   • Consider empiric treatment with fluoroquinolone if severe symptoms with suspected bacterial cause 1

3. Octreotide:

   • Consider for severe, refractory diarrhea (100-150 μg SC TID) 1

Likely Diagnoses to Consider

1. Infectious causes:

   • Viral gastroenteritis (most common)
   • Bacterial infection (C. difficile, especially with recent antibiotic use)
   • Food poisoning

2. Medication-induced diarrhea:

   • Review all medications (antibiotics, cardiac medications, laxatives)

3. Ischemic colitis:

   • Common in elderly patients with vascular disease

4. Inflammatory bowel disease flare

   • Less common new onset at this age but possible

5. Malignancy:

   • Consider colorectal cancer or other GI malignancies

Special Considerations for Elderly Patients

• Elderly patients dehydrate more quickly and have less physiologic reserve
• Higher risk for complications including acute kidney injury and electrolyte abnormalities
• More susceptible to C. difficile infection
• May have atypical presentations of serious conditions

Follow-up

• Reassess hydration status every 2-4 hours during initial treatment
• Monitor electrolytes and renal function
• Advance diet as tolerated once rehydrated, starting with clear liquids and progressing to BRAT diet (bananas, rice, applesauce, toast) 1
• Consider colonoscopy for persistent symptoms or if red flag symptoms present (weight loss, blood in stool)

Red Flags Requiring Immediate Intervention

• Hypotension or tachycardia unresponsive to initial fluid bolus
• Severe abdominal pain or peritoneal signs
• Bloody diarrhea with fever
• Altered mental status
• Significant electrolyte abnormalities

The frequency of diarrhea (every 5-10 minutes) in this elderly patient strongly suggests severe fluid loss with high risk for dehydration and complications, warranting urgent evaluation and management in an emergency setting rather than outpatient care.