Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic, non-bloody, watery diarrhea. Symptoms include nocturnal diarrhea, urgency, and fecal incontinence. Associated symptoms include abdominal cramping, fatigue, and weight loss. No history of fever or hematochezia. Patient denies recent travel, antibiotic use, or NSAID consumption. Symptoms are persistent despite dietary modifications.
Clinical Examination Findings
General: Patient appears well-nourished, no acute distress. Abdomen: Soft, non-distended, non-tender to palpation. Bowel sounds are hyperactive. No organomegaly or palpable masses. Rectal exam: Normal sphincter tone, no fissures or hemorrhoids, no blood on digital rectal exam. Hydration status: Mucous membranes moist, skin turgor normal.
Treatment Protocol
Initiate Budesonide 9mg daily for 6-8 weeks with gradual tapering. Advise cessation of potential trigger medications (NSAIDs, PPIs, SSRIs). Recommend anti-diarrheal agents (Loperamide) as needed for symptom control. If refractory, consider second-line therapy with immunomodulators (Azathioprine or Methotrexate) or biologic agents. Monitor for clinical response and electrolyte balance.