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  #1  
Old 06-24-2011
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GIT Management of non-bloody diarrhea in setting of recent antibiotics

A 48-year-old woman presents to her physician complaining of diarrhea for the last 2 days. The diarrhea came on suddenly, and she has not had any solid bowel movements since. She describes the diarrhea as watery and specifically denies seeing any blood or mucous. One month earlier, she had been hospitalized for administration of intravenous antibiotics after developing a productive cough, fever, and rigors. She does not take any regular medications and has no known allergies. She denies any recent ill contacts, visits to daycare, consumption of restaurant food, or travel. Her vital signs are as follows: blood pressure, 120/80 mm Hg; pulse, 84 beats/minute; temperature, 38.2C (100.7F); and respirations, 11 breaths/minute. Her abdomen is soft and diffusely tender to palpation. Bowel sounds are present, and the abdomen is tympanic to percussion throughout. A rectal examination is within normal limits. Laboratory investigations reveal the following:
Serum
Leukocyte count 14,000/mm3
Segmented neutrophils 65%
Bands 8%
Eosinophils 2%
Basophils 0%
Lymphocytes 25%
Monocytes 2%
Stool analysis
Clostridium difficile toxin [stool toxin assay] negative

What is the most appropriate next step in the management of this patient?

Answer Choices
A. C. difficile toxin assay
B. Colonoscopy
C. Stool electrolytes
D. Stool ova and parasite analysis
E. Trimethoprim-sulfamethoxazole (TMP-SMX)
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  #2  
Old 06-24-2011
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Answer D. Stool and parasite test
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  #3  
Old 06-24-2011
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colonoscopy
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  #4  
Old 06-25-2011
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Default E

I'll go for E
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  #5  
Old 06-25-2011
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I would go for repeating C diff toxin! A.


If the test is negative but the diarrhoea continues, another sample needs to be tested. The C. difficile toxin test does not detect 100% of cases and the toxin may have been missed the first time. Since the toxin breaks down at room temperature, a negative result may also indicate that the sample was not processed promptly or stored correctly prior to processing.

http://www.labtestsonline.org.uk/understanding/analytes/cdiff/test.html
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  #6  
Old 06-25-2011
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I agree. I would say A


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  #7  
Old 06-25-2011
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Guys...u can give empirically treatment with ATB since the problem is due to clostridium diff. So...in the real life we give atb's while repeating the dosage of the toxin. Of course we initiate tmp smx AFTER taking the sample...but the same day. But...don't forget that c. Difficile as a cause of atb treatments (pseudomembranose colitis) normally recovers by itself with only withdrawal of the causing antibiotic. I won't be surprised if they suggest colonoscopy.
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stool ova and parasites
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Old 06-25-2011
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Im gonna have to go against the C. Diff diagnosis as she was givent antibiotics a month ago , and the diarhrhea is actute 2 days the timing doesn't seem right to me hence why i'd go for the stool and ova test
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Old 06-25-2011
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Option A (C. difficile toxin assay) is correct. In a patient with watery diarrhea and recent (within 6 weeks) hospitalization or antibiotic use, pseudomembranous colitis caused by C. difficile overgrowth must be strongly suspected. In 80% of patients with pseudomembranous colitis, the toxin is identified after three stool samples. Thus, in this case, repeat stool sample analysis is warranted.

Option B (Colonoscopy) is incorrect. Pseudomembranous colitis, as the name suggests, has visible pseudomembranes, exudates, and plaques on colonoscopy. Although colonoscopy is a relatively safe procedure, it remains an invasive procedure with risk of bowel perforation. It is rarely used in the diagnosis of pseudomembranous colitis and should not be undertaken unless the condition is still strongly suspected after three negative stool toxin analyses.

Option C (Stool electrolytes) is incorrect. Stool electrolytes are used in the diagnosis of secretory versus osmotic diarrhea. In the present case, the recent antibiotic use strongly suggest pseudomembranous colitis.

Option D (Stool ova and parasite analysis) is incorrect. Stool ova and parasite analysis is not cost effective, and thus not warranted, in most cases of diarrhea unless specific predisposing events in the history suggest a cause. This includes patients with recent contacts to infants, travel to endemic regions, acquired immune deficiency syndrome (AIDS), and homosexual males.

Option E (Trimethoprim-sulfamethoxazole [TMP-SMX]) is incorrect. TMP-SMX is a commonly used antibiotic for severe infectious/invasive diarrhea. This patient is suspected of having C. difficile overgrowth, which is treated with metronidazole or vancomycin.

High-yield Hit 1
Pseudomembranous colitis
Pseudomembranous colitis is caused by colonization of the colon with Clostridium difficile, which produces toxins. It usually follows antibiotic therapy and should be suspected in patients in hospital who develop diarrhea after a period of antibiotics. It is usually of acute onset but may run a chronic course. The most frequently implicated antibiotic is clindamycin but few antibiotics are free of this side effect. Clinical features include diarrhea, fever and abdominal cramps.
Diagnosis
Diagnosis is by identification of the toxin in stool specimens. Sigmoidoscopy reveals an erythematous, ulcerated mucosa, which is covered by a membrane. Sigmoidoscopy, however, is not essential for the diagnosis.
Management
Suspected antibiotics should be stopped and patients should be isolated. Oral vancomycin or metronidazole is used as specific treatment.
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  #11  
Old 06-25-2011
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My understanding is that; if 2 courses of metronidazole does not resolve the diarrhea. Then start pt. on vancomycin.

Any other opinions?


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Quote:
Originally Posted by docspeed786 View Post
My understanding is that; if 2 courses of metronidazole does not resolve the diarrhea. Then start pt. on clyndamycin.

Any other opinions?


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clindmycin cause antibitic induced diarrhea
ithink u mean oral vancomycin used if metronidazole didnt stop diarrhea
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  #13  
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Sorry. Was a typo. I meant to say vancomycin. I corrected original post.


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