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FOCUSED SHIFT VIEW

Diarrhea

Volume first; then blood, fever, antibiotics, and the host.

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Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Volume first.
  2. Inflammatory (blood, fever, tenesmus) vs non-inflammatory.
  3. No antibiotics and no loperamide if STEC is possible. Fidaxomicin (or vancomycin) for C. difficile — not metronidazole first-line.

2 · Escalate now if

  • Pain out of proportion, AF, or vasculopathy
  • Bloody diarrhea with little fever after ground beef (STEC)
  • Recent antibiotics or hospitalization (C. difficile)
  • Shock, severe abdominal distension, or immunosuppression
  • Fever in a returned traveller
  • Anuria, petechiae, or rising creatinine after a diarrheal prodrome (HUS)

3 · Immediate workup

  • Glucose, orthostatics, pregnancy test when appropriate
  • POCUS for AAA/free fluid if ischemic or surgical features

4 · Don’t miss

  • Mesenteric ischemia
    Pain out of proportion ± bloody diarrhea in AF or vasculopathy — CTA, not stool studies first.
  • Toxic megacolon / fulminant C. difficile / IBD
    Fever, shock, distension, immunosuppression or recent antibiotics — AXR/CT, surgical consult, oral/NG vancomycin plus IV metronidazole for fulminant CDI; consider rectal vancomycin with ileus (IDSA/SHEA).
  • STEC / HUS
    Bloody diarrhea after undercooked beef or outbreaks, little or no fever — do not give antibiotics or antimotility agents; watch creatinine, hemolysis, platelets.
  • Cholera / severe secretory dehydration
    Rice-water stool, travel; WHO-ORS or IV; antibiotics as an adjunct once volume is restored.

5 · Disposition lane

Admit

Inability to maintain volume, severe electrolyte derangement, CDI, inflammatory diarrhea needing IV therapy, HUS under observation, high-risk host.

ICU / surgery / IR

Shock, toxic megacolon, mesenteric ischemia, fulminant CDI, severe HUS.