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In this case study, the 47-year-old patient came to the doctor’s office complaining about stomach pain and diarrhea that started three days ago. The man rated the pain as five out of ten on average, but he admits that initially, it was as intense as nine out of ten. The patient did not take any medications to relieve his current condition, but he takes some prescription medications, including Lisinopril and Amlodipine for hypertension, and Metformin and Lantus for diabetes. Although gastroenteritis is a likely diagnosis, other diseases such as diverticulitis, inflammatory bowel disease, lactose intolerance, bile acid malabsorption, and diabetic diarrhea should be considered.
The suggested diagnosis is gastroenteritis, an inflammatory syndrome of the intestines or stomach caused by viral, bacterial, toxic, or other agents and accompanied by abdominal pain, nausea, vomiting, and diarrhea. It is essential to establish if food poisoning was in a restaurant or during travel. The diagnostic test that can be done to determine the possible cause is a microscopic stool examination (Skyum et al., 2018). The microorganisms that can cause gastroenteritis are Shigella spp., Campylobacter jejuni, Vibrio cholera, Salmonella spp., Giardia lamblia, and norovirus (Skyum et al., 2018). Since the diagnostic results are currently unavailable, the patient should be started with fluids to restore his electrolyte balance.
The first differential diagnosis is diverticulitis, an inflammation of the diverticular, a pouch formed by herniation of colonic mucosa and submucosa through muscular layers. It is prevalent in countries where the Western diet is predominant (Kamal et al., 2019). Since the patient is an obese male with diabetes, he might have had unhealthy nutrition for a long time before he developed the disease. Obesity and a low-fiber diet are predisposing factors for diverticulosis and occasionally diverticulitis if the colonic pouch becomes inflamed (Kamal et al., 2019). Diverticulosis is a common cause of GI bleeding that may stop abruptly. JR had left lower quadrant (LLQ) pain and a history of GI bleeding four years ago, which points to this disease. Diverticulitis presents with LLQ pain, fever, and leukocytosis (Kamal et al., 2019). Abdominal computer tomography (CT) should be done in this case to confirm or exclude this diagnosis.
The second differential diagnosis is lactose intolerance, an enzyme deficiency that results in the intestines’ inability to hydrolyze and absorb lactose, leading to osmotic diarrhea. It is typical for this malabsorption syndrome to develop later in life, especially after a viral illness that may damage the intestinal brush border (Jansson-Knodell et al., 2020). The diagnosis is confirmed with a lactose tolerance test based on the principle of blood sugar rise after lactose load (Jansson-Knodell et al., 2020). The patient interview should reveal any associations between milk product intake and diarrhea.
The third differential diagnosis is bile acid malabsorption, which can be caused by such factors as small intestinal bacterial overgrowth (SIBO) and Celiac disease. Since the patient’s history does not include this information, Celiac disease can be excluded; however, SIBO should be considered. The prevalence of SIBO in diabetic patients ranges from 15% to 40% (Selby et al., 2019). The procedure to confirm this diagnosis is a lactulose breath test, and the curative treatment is antibiotic therapy (Selby et al., 2019). Since the preponderance of SIBO in patients with diabetes is high, JR should also be assessed.
Fourth, diabetic diarrhea (DD) is a diagnosis of exclusion, and it should be considered because the patient has T2DM. DD is usually painless and chronic, which does not fit JR’s clinical presentation (Selby et al., 2019). Still, the patient’s current state may be an adverse reaction to Metformin; thus, the duration of his illness and anti-diabetic medication intake should be asked. Notably, the information about JR’s compliance with his treatment regimen is essential because DD is more common in poorly controlled diabetes.
The fifth differential diagnosis is an inflammatory bowel disease presented in the two most common forms, Crohn’s disease and ulcerative colitis. The clinical presentation of these illnesses is similar at the beginning, abdominal pain and chronic bloody diarrhea; hence, they can only be differentiated with laboratory, endoscopic, and histologic findings (Gecse & Vermeire, 2018). This diagnosis is likely, but it is too early in the course of illness; therefore, if gastroenteritis does not improve with fluids, other causes should be considered.
I would accept the current diagnosis, which will require a microbiologic stool assessment. Still, three other possible causes of the patient’s abdominal pain and diarrhea are diverticulitis, lactose intolerance, and SIBO. The additional diagnostic tests that should be done are abdominal CT, lactulose breath test, and lactose tolerance test. The present assessment of JR contains several gaps; thus, it would be reasonable to ask JR about the onset of his current state, inciting event, previous similar episodes, frequency, stool consistency, aggravating, and any relieving factors. It is essential to know about JR’s recent use of antibiotics and travel history. Furthermore, it is crucial to ask about the patient’s response to illness and his thoughts about possible causes. The record should also include a detailed description of the circumstances that caused gastrointestinal (GI) bleeding four years ago. The review of systems should reveal any recent weight changes. Moreover, clinicians should do rectal and stool analyses to determine the presence of melena. Overall, the assessment is supported by subjective and objective information because the patient presented with mild fever, abdominal pain, and diarrhea, which points to gastroenteritis.
References
Gecse, K. B., & Vermeire, S. (2018). Differential diagnosis of inflammatory bowel disease: Imitations and complications.The Lancet Gastroenterology & Hepatology, 3(9), 644-653. Web.
Jansson-Knodell, C. L., Krajicek, E. J., Savaiano, D. A., & Shin, A. S. (2020). Lactose intolerance: A concise review to skim the surface.Mayo Clinic Proceedings, 95(7), 1499-1505. Web.
Kamal, M. U., Baiomi, A., & Balar, B. (2019). Acute diverticulitis: A rare cause of abdominal pain. Gastroenterology Research, 12(4), 203–207. Web.
Selby, A., Reichenbach, Z. W., Piech, G., & Friedenberg, F. K. (2019). Pathophysiology, differential diagnosis, and treatment of diabetic diarrhea. Digestive Diseases and Sciences, 64(12), 3385-3393. Web.
Skyum, F., Andersen, V., Chen, M., Pedersen, C., & Mogensen, C. B. (2018). Infectious gastroenteritis and the need for strict contact precaution procedures in adults presenting to the emergency department: A Danish register-based study. Journal of Hospital Infection, 98(4), 391-397. Web.
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