What is the best course of management for a patient with diarrhea, mild leukocytosis (elevated white blood cell count), and an abdominal computed tomography (CT) scan showing air-fluid levels?

Management of Patient with Diarrhea, Mild Leukocytosis, and Air-Fluid Levels on CT

This patient requires immediate stool testing for Clostridioides difficile toxin, broad-spectrum antibiotics, IV hydration, and close monitoring for signs of complicated disease including neutropenic enterocolitis or perforation. 1, 2

Immediate Diagnostic Workup

The presence of diarrhea with leukocytosis and air-fluid levels on CT mandates urgent evaluation for infectious colitis, particularly C. difficile, which is the most common cause of nosocomial infectious diarrhea and can present with these exact findings 1, 2:

• Obtain stool studies immediately: Test for C. difficile toxin using enzyme immunoassays or the 2-step antigen assay 1, 2
• Do NOT obtain stool white blood cell count, bacterial pathogen cultures, or tests for ova and parasites in hospitalized patients—these are not necessary 1
• Laboratory evaluation: Complete blood count to assess degree of leukocytosis (marked elevation >15,000-20,000 suggests fulminant disease), electrolyte profile, and assess for metabolic derangements 1, 3

The CT scan showing air-fluid levels is critical diagnostic information that helps differentiate between simple colitis and more severe complications 1.

Risk Stratification: Complicated vs. Uncomplicated Disease

This patient should be classified as "complicated" based on the presence of leukocytosis and CT findings 1, 2:

Red Flags Present (Complicated Disease):

• Elevated white blood cell count (even if mild) 1, 3
• CT findings of air-fluid levels suggesting bowel involvement 1
• Any associated fever, abdominal pain/cramping, or signs of dehydration would further confirm complicated status 1, 2

Critical Warning: Neutropenic Enterocolitis Consideration

If this patient has any history of recent chemotherapy or immunosuppression, neutropenic enterocolitis (typhlitis) must be strongly considered 1:

• Neutropenic enterocolitis presents with: Diarrhea, fever, bowel wall thickening on CT, and abdominal pain in neutropenic patients 1
• Mortality is high if misdiagnosed—accurate differential diagnosis is mandatory 1
• This typically occurs 1-2 weeks after chemotherapy initiation 1

Immediate Management Protocol

For Suspected C. difficile Colitis:

Initiate empirical treatment immediately while awaiting diagnostic results 1, 2:

• Oral vancomycin (125 mg four times daily) OR oral metronidazole (500 mg three times daily) 1, 2
• Start treatment empirically if C. difficile infection is strongly suspected clinically, even before test results return 1
• IV fluids for hydration and electrolyte replacement 1, 2

For Complicated Disease (Which This Patient Has):

Aggressive management is required 1, 2:

• Hospital admission for IV fluids and close monitoring 1, 2
• Broad-spectrum antibiotics (e.g., fluoroquinolone) in addition to C. difficile treatment if sepsis is suspected 1
• Monitor for clinical response within 48-72 hours—lack of improvement requires treatment escalation 2

If Neutropenic Enterocolitis is Suspected:

Treatment should be nonoperative initially 1:

• Broad-spectrum antibiotics covering gram-negative and anaerobic organisms 1
• Bowel rest 1
• Reserve emergency surgery only for: Signs of perforation, ischemia, or clinical deterioration despite medical management 1

Critical Monitoring Parameters

Watch for signs of fulminant colitis or perforation 3, 4:

• Marked leukocytosis (>20,000-25,000) frequently precedes hypotension and is an indication for surgical consultation 3
• Absence of diarrhea occurs in 20% of patients with fulminant colitis—do not be falsely reassured 3
• Hypotension requiring vasopressors carries a poor prognosis; surgery should be considered before this develops 3
• Signs of perforation or toxic megacolon on imaging require immediate surgical consultation 2, 4

When to Escalate Care

Consider early surgical consultation if 2, 3:

• No clinical improvement within 48-72 hours of appropriate medical therapy 2
• Development of hypotension, severe abdominal pain, or peritoneal signs 2, 3
• Progressive leukocytosis or bandemia despite treatment 3
• CT findings suggesting perforation, toxic megacolon, or gangrenous bowel 4

Common Pitfalls to Avoid

• Do not delay antibiotic treatment while waiting for stool test results if clinical suspicion is high 1, 2
• Do not use anti-diarrheal medications (like loperamide) until infectious causes are ruled out 2
• Do not underestimate mild leukocytosis—even modest elevation can herald severe disease, especially in immunocompromised patients 1, 3
• Do not miss neutropenic enterocolitis in any patient with recent chemotherapy—this has high mortality if surgery is delayed inappropriately 1
• Do not wait for vasopressor requirement before considering surgery in fulminant colitis—early colectomy improves survival 3