By Tedler D. Depaynos, MD
It was just after midnight when the male patient was brought to the Emergency Room. They came from a distant barangay and because they had a hard time waiting for a ride and preferably a taxi, they were delayed for nearly an hour. The patient had to go back to their house at least 2 or 3 times to relieve himself while waiting. It was good that his sphincters are still working fine and he was able to control them while on the way. I could imagine him probably pleading silently to the driver to hurry.
The family members were all together being a Sunday and they had lunch together after church. They practically ate the same kind of food in a nearby newly opened “carinderia” but it was only the patient who developed sudden diarrhea early evening. It was so sudden and it became uncontrollable that he could only guess that he had visited their comfort room more than 20 times. Although he tried drinking bottles of Gatorade bought from their small sari-sari store neighbor, he felt that he was getting weak and his vision was becoming blurred. He even thought he felt his lower legs getting stiff although he denies any pain. When he noticed that there was blood in his wet stools he then stopped contradicting his wife that he should be brought to the hospital immediately.
Obviously, the patient was starting to suffer severe dehydration which was buttressed by his highly colored and reduced usual urine. His left leg was about to experience “cramps” due to electrolyte imbalance which was perhaps partially reduced by his Gatorade intake. At the ER, his blood pressure appeared to be below normal so that he was immediately given intravenous fluids and electrolyte to correct the complications he was starting to experience.
Our old medical textbooks define Acute Diarrhea lasting not more than 2-3 weeks but in our limited experience we have not encountered patients manifesting diarrhea that long.
Episodes of 2 to 3 times diarrhea with small amounts of wet stools lasting for a day sometimes recurring after a few days or weeks or even months are common in our locality and most of the time it is due to Amoebiasis. Treatment with metronidazole may be adequate but recurrence is common because patients take in the same kind of water or food causing re-infection.
The patient denied any history of previous episodes of diarrhea nor any rectal bleeding. He was afebrile and despite the audible abdominal contractions he felt no significant pain. There was no nausea or vomiting so that he was able to take in fluids.
There are various causes of sudden acute diarrhea, but one of the most common culprits would be an infection so that it is termed “infectious diarrhea”. If other individuals who ate the same kind of food are affected, it would still be infectious in origin but the more dangerous “food poisoning” is entertained. In simple infectious diarrhea, relief usually follows when you passed out after several occurrences what you ate even with no medications. Sudden dehydration may only be the problem. In food poisoning, the “poison” may be absorbed into the systemic circulation so that the manifestations would be more serious. Abdominal pain would be significant and vomiting may accompany the continuous wet stools. Apparently a simple “infectious diarrhea” was the initial consideration in this patient.
Bleeding associated with diarrhea may imply inflammation of the colon or “colitis” especially if it is associated with fever. With high fever, typhoid fever is always considered and must be eliminated. Bloody diarrhea is termed, in general, “dysentery”. Various etiologic bacteria are entertained like Amoeba, Salmonella, Shigella, etc. Medications effective against the considered bacterial etiologies are routinely given by experienced MD.s. In severe cases however, the antibiotics are usually intravenously given because the intestinal absorption may not be adequate.
Even if “colitis” is entertained as the cause of bleeding, other possibilities are routinely considered. If bleeding is fresh and drips in the bowl, usually it comes from the rectal opening and may be caused by “hemorrhoids”. Bleeding coming from the upper gastro intestinal tract like the stomach or duodenum is usually “with digested blood” or in layman’s term “dinuguan-like” except when very massive. Bleeding admixed with stools and fresh usually comes from the colon. This was entertained in this patient but the possibility that it originated from a more serious condition like a “tumor” cannot be ruled out because of his significant “anemia” which necessitated a blood transfusion. It could be that even before his diarrhea he had been bleeding per rectum undetected which is termed “occult bleeding”. He was referred to a gastroenterologist for possible gastro-endo-colonoscopy.
Fortunately for the patient, the diarrhea ceased after 2 days in the hospital and the findings of the gastroenterologist was just “colitis” and nothing serious. He was discharged hydrated and with all smiles. He promised to take his home medications and would be more careful with his food intake and to avoid his favorite “kilawen”. In retrospect, although he thought that it was the “kilawen” that caused his intestinal problem because he consumed a lot, it was his first time to experience such. He was thinking of the new “carinderia”. **
