Management of Intractable Diarrhea in a 76-Year-Old Male Returning from Burkina Faso
The most effective approach for managing intractable diarrhea in this elderly patient returning from Africa is aggressive rehydration with oral rehydration solution (ORS), assessment for specific infectious causes, and appropriate antimicrobial therapy based on the suspected pathogen. 1
Initial Assessment and Rehydration
Assessment of Dehydration
- Evaluate for signs of dehydration:
- Sunken eyes
- Skin turgor
- Radial pulse quality
- Respiratory depth
- Mental status
- Number of vomiting episodes in past 24 hours 2
Immediate Rehydration Strategy
For mild to moderate dehydration:
- Administer ORS as much as the patient wants
- If patient fails to respond promptly to ORS, reassess to exclude cholera 1
For severe dehydration:
- Begin with IV rehydration if patient shows signs of shock
- Transition to oral rehydration once stabilized 1
- Monitor hydration status every 3-4 hours and adjust treatment accordingly
Diagnostic Workup
Immediate Testing
- Stool culture and sensitivity testing
- Test for Clostridium difficile toxins
- Stool examination for ova and parasites
- Rectal swabs for cholera if suspected (transport in Cary-Blair medium) 1
Additional Testing Based on Clinical Presentation
- Blood tests for electrolytes, renal function, and inflammatory markers
- Consider colonoscopy with biopsy if symptoms persist despite treatment for common infectious causes 3
- Test for cytomegalovirus (CMV) if patient remains symptomatic after treatment for bacterial causes 4
Specific Treatment Approach
Antimicrobial Therapy
- Initiate appropriate antimicrobial therapy based on suspected pathogen:
- For cholera: appropriate antibiotics based on sensitivity testing
- For Shigella dysentery: targeted antibiotics
- For amoebic dysentery: anti-amoebic agents
- For giardiasis: anti-giardia treatment 1
Nutritional Support
- Encourage energy-rich, easily digestible foods as soon as appetite returns
- Do not delay feeding until diarrhea stops - there is no justification for "resting" the bowel 1
- Offer food every 3-4 hours
Ongoing Management
Fluid Maintenance
- Continue ORS after each loose stool
- Encourage increased intake of locally available fluids (soups, rice water)
- Avoid soft drinks due to high osmolality 1
Monitoring Response
- Reassess hydration status regularly
- Monitor stool output
- Watch for signs of worsening: increased thirst, sunken eyes, fever, or failure to improve 1
Special Considerations for Elderly Patients
- Elderly patients are at higher risk for severe dehydration and complications
- Monitor renal function closely
- Be vigilant for atypical presentations of common infections
- Consider potential drug interactions with any medications prescribed
Common Pitfalls to Avoid
- Premature discontinuation of rehydration: Continue fluid replacement until diarrhea resolves
- Inappropriate use of anti-diarrheal agents: These are contraindicated in infectious diarrhea 1
- Failure to consider multiple pathogens: Coinfections (like C. difficile and CMV) can occur, especially in elderly or immunocompromised patients 4
- Missing non-infectious causes: Consider inflammatory bowel disease if infectious workup is negative and symptoms persist 3
- Overreliance on antibiotics: Antimicrobial drugs are contraindicated for routine treatment of uncomplicated, watery diarrhea 1
By following this structured approach with emphasis on aggressive rehydration, appropriate diagnostic testing, and targeted antimicrobial therapy when indicated, the intractable diarrhea in this elderly patient returning from Burkina Faso can be effectively managed to reduce morbidity and mortality.