Sometimes a pH study is needed, but that has to be planned, because patients may have to be taken off of a PPI in advance. That means those studies are not easy to set up in the hospital and might best be arranged by the gastroenterologist, Dr. Gyawali says.
4 In cases of acute diarrhea, order a stool sample right away.
That will help guide care from the gastroenterologist, if and when the gastroenterologist is called in, Dr. Pandolfino says.
“One of the things that is frustrating for the gastroenterologist is that we get called initially, but really the hospitalist should be getting stool studies, and they should have at least a very good idea of what they need from us,” he says. “Because, really, endoscopy is not usually needed very often in diagnosis of acute diarrhea.”
Broad-range stool studies, a good history and physical, and examining labs for a possible chronic inflammatory process or anemia are good ways to begin to assess patients with diarrhea, he says. Clostridium difficile colitis has to be considered as well, Dr. Pandolfino says.
Endoscopy is more helpful in evaluating acute diarrhea in those with bloody diarrhea suspected of having inflammatory bowel disease or an infectious diarrhea but on whom cultures have come back negative. For those with compromised immune systems, endoscopy could be done earlier, as well.
“So for us, I think we really need to get into the picture a little bit after the patient has been brought into the hospital and the stool study is negative, unless they’re an immune-compromised patient,” Dr. Pandolfino says.
5 When—and how—to test the stool.
If a patient develops diarrhea while already in the hospital, the only stool test needed is C. diff.
“They shouldn’t be developing a viral diarrhea, they shouldn’t be developing an infectious diarrhea—let’s say, from E. coli or Salmonella—unless they literally developed it a couple hours after getting in,” Dr. Jain says. “It should either be C. diff or a side effect of some medication. … We don’t need to spend the extra money, which is of low-value care to send for OVA and parasites, or bacterial pathogens and so forth.”
Dr. Jain says he thinks such testing is being done more appropriately of late.
“But I still will see multiple stool tests sent on somebody who’s been in the hospital for a week and then develops diarrhea,” he explains.
6 Gastroenterologists do not need to be consulted for every C. diff infection.
“I think that we really should get involved when patients are either not responding or when they’re very ill,” Dr. Pandolfino says.
Hospitalists should consider whether patients are on antibiotics or a PPI and whether or not they need to stay on those medications. Also, medications that slow motility (i.e., loperamide) should be avoided, if possible.
“We don’t want it to linger,” Dr. Pandolfino says. “One of the basic mechanisms of how we get rid of pathogens is to expel them with diarrhea.
“But you certainly don’t want the patient to be uncomfortable to the point where they’re having 20 to 30 bowel movements a day.”
In non-severe patients who have some diarrhea, abdominal pain, nausea, and vomiting—but are able to keep food down—the specialists might not have to be called in, and patients can just be treated with oral metronidazole or oral vancomycin fairly simply, he says.
For those who seem severely ill with a dilating colon, are in nearly a septic state, and have very severe diarrhea, the gastroenterologist should probably be called in, he says.