Pharmacotherapy Case Study 8. Diner's Diarrhea By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study 8. Diner's Diarrhea By: Dr. Nehad Ahmed

 

Chief Complaint:

A 36-year-old male presents with a 2-week history of intermittent diarrhea, primarily occurring after dining at restaurants. He reports loose, watery stools and occasional bloating, particularly after eating meals in the evening.

Subjective Data:

History of Present Illness (HPI):

·        The patient reports that for the past two weeks, he has been experiencing episodes of diarrhea, typically occurring 30 minutes to 2 hours after eating dinner at various restaurants.

·        The stools are described as loose and watery, with no blood or mucus. There is no associated fever or abdominal cramping, but he occasionally feels bloated.

·        The diarrhea episodes typically resolve within 24 hours after onset, with the patient having no further symptoms in the morning after eating. He does not experience diarrhea on days when he does not eat out.

·        He has tried adjusting his meal choices but has not found any clear pattern of foods that trigger the symptoms.

·        He is concerned that the symptoms might be related to foodborne illness, although he has not experienced any nausea, vomiting, or fever.

·        The patient has not sought medical attention for these episodes previously but has now become frustrated with the recurring nature of the symptoms.

Past Medical History (PMH):

·        No significant past medical history.

·        No prior gastrointestinal issues (e.g., inflammatory bowel disease, irritable bowel syndrome).

·        No history of food allergies or intolerances.

 

Medications:

·        Multivitamin daily.

·        Ibuprofen 200 mg as needed for occasional headaches (no recent use).

Allergies:

·        No known drug allergies (NKDA).

Social History:

·        Non-smoker.

·        Drinks alcohol socially, about 3-4 drinks per week.

·        Works as a software developer, desk job with limited physical activity.

·        Enjoys dining out with friends, often choosing different restaurants with diverse cuisines.

·        No history of recent travel or eating at exotic locations.

Family History:

·        Father with a history of hypertension.

·        Mother with type 2 diabetes.

·        No family history of gastrointestinal disorders, such as Crohn's disease, celiac disease, or IBS.

Review of Systems (ROS):

·        Gastrointestinal: Diarrhea occurring primarily after dining at restaurants, with occasional bloating but no nausea or vomiting. No blood or mucus in stools. No constipation or changes in bowel habits.

·        Cardiovascular: No chest pain, palpitations, or edema.

·        Respiratory: No shortness of breath, cough, or wheezing.

·        Neurological: No headaches, dizziness, or visual changes.

·        Musculoskeletal: No joint pain or discomfort.

Objective Data:

Vital Signs:

·        Blood Pressure: 118/76 mmHg

·        Heart Rate: 82 bpm

·        Respiratory Rate: 16 breaths/min

·        Temperature: 98.6°F (37.0°C)

·        Weight: 190 lbs (86.2 kg)

·        Height: 5'11" (180 cm)

Physical Exam:

·        General: Alert and oriented, in no acute distress.

·        Abdomen: Soft, non-distended. Mild bloating noted. No tenderness, guarding, or rebound tenderness. Bowel sounds are normal.

·        Cardiovascular: Regular rate and rhythm, no murmurs or gallops.

·        Respiratory: Clear to auscultation bilaterally.

·        Neurological: Normal cranial nerve examination and reflexes. No focal deficits.

·        Skin: No rashes or jaundice.

Labs and Imaging:

·        Complete Blood Count (CBC):

o   Hemoglobin: 14.5 g/dL (normal)

o   Hematocrit: 43% (normal)

o   White Blood Cell Count: 6,800/mm³ (normal)

o   Platelets: 220,000/mm³ (normal)

·        Basic Metabolic Panel (BMP):

o   Sodium: 140 mEq/L (normal)

o   Potassium: 4.2 mEq/L (normal)

o   Chloride: 102 mEq/L (normal)

o   Bicarbonate: 23 mEq/L (normal)

o   Blood Urea Nitrogen (BUN): 14 mg/dL (normal)

o   Creatinine: 0.9 mg/dL (normal)

o   Glucose: 92 mg/dL (normal)

·        Liver Function Tests (LFTs):

o   Normal.

·        Stool Culture: Negative for pathogenic bacteria (e.g., Salmonella, E. coli, Shigella, Campylobacter).

·        Stool Ova and Parasite Test: Negative.

·        Celiac Disease Panel: Negative for antibodies (e.g., anti-tTG, anti-endomysial antibodies).

Assessment:

The patient's symptoms, including intermittent diarrhea occurring predominantly after eating meals at restaurants, point toward Diner's Diarrhea, a form of food-induced diarrhea that typically occurs after eating at establishments where food safety measures may not be as stringent. This could also be a result of dietary indiscretions (e.g., consuming foods rich in fats, spices, or other irritants), foodborne pathogens, or stress-related factors (as dining out can sometimes trigger gastrointestinal symptoms in those with underlying sensitivity).

The absence of fever, blood in the stools, or other systemic signs of infection (e.g., vomiting, weight loss) and the negative stool cultures make an infectious etiology less likely. The patient's normal lab results and lack of prior gastrointestinal history suggest that there is no underlying chronic gastrointestinal disease.

Plan:

Pharmacologic Treatment:

1.     Antidiarrheal Therapy:

o   Loperamide 2 mg orally after each loose stool, up to a maximum of 8 mg per day, as needed for diarrhea control after dining out. Caution should be used, as overuse of loperamide can lead to constipation.

2.     Probiotic Supplementation:

o   Lactobacillus GG 1 capsule (250 mg) daily to help normalize gut flora, especially after meals outside of the home.

Non-Pharmacologic Treatment:

·        Dietary Modifications: Recommend the patient keep a food diary to identify specific triggers at restaurants. Advise avoiding heavy, greasy, or spicy foods, as well as large meals late in the evening.

·        Hydration: Ensure adequate fluid intake, particularly water and oral rehydration solutions if diarrhea episodes are frequent.

·        Stress Management: Suggest stress reduction strategies such as yoga, deep breathing exercises, or meditation, as the patient reports work-related stress.

Monitoring and Follow-Up:

·        Follow-up in 1-2 weeks to assess the effectiveness of the treatment plan and review any improvement in symptoms. If symptoms persist or worsen, further investigation may be warranted.

·        If symptoms continue beyond a few weeks, consider further diagnostic testing (e.g., colonoscopy, food allergy testing) to rule out other potential causes, such as irritable bowel syndrome (IBS) or food intolerances.

Patient Education:

·        Educate the patient on the potential triggers of diner’s diarrhea, including restaurant food preparation practices and common irritants in restaurant foods (e.g., oils, sauces, spices).

·        Emphasize the importance of keeping a food and symptom diary to track patterns of food-related triggers.

·        Discuss the proper use of loperamide and probiotics, highlighting the need to avoid overuse of medications and to follow the prescribed dose.

·        Encourage the patient to stay hydrated and monitor for signs of dehydration, such as dry mouth, dizziness, and reduced urine output.

Referral:

·        If symptoms do not improve or worsen despite the initial management, referral to a gastroenterologist may be necessary to explore the possibility of functional gastrointestinal disorders, such as IBS or lactose intolerance.

Long-Term Management:

·        If diner’s diarrhea continues to be a recurrent problem, dietary counseling may be recommended to help the patient identify foods that may contribute to symptoms.

·        For chronic or frequent symptoms, cognitive-behavioral therapy (CBT) or mindfulness techniques may be explored to help the patient cope with potential stress-related triggers.