A 32-year-old man is evaluated for a 3-month history of abdominal discomfort and diarrhea. He has had 3-4 loose stools per day and abdominal cramping that is relieved by bowel movements. The patient has also had blood in the stool during the past week. He has had no fevers or night sweats. Four months ago, the patient was diagnosed with Clostridium difficile colitis after taking antibiotics for a sore throat and was prescribed oral vancomycin. He has no other chronic medical conditions and takes no medications. He does not use tobacco, alcohol, or illicit drugs.
Temperature is 37.2 C (99 F), blood pressure is 112/76 mm Hg, and pulse is 88/min. The abdomen is soft with mild tenderness in the periumbilical and left lower-quadrant areas. There is no rebound tenderness or rigidity. Rectal examination shows guaiac-positive stool.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old man is evaluated for a 3-month history of abdominal discomfort and diarrhea.  He has had 3-4 loose stools per day and abdominal cramping that is relieved by bowel movements.  The patient has also had blood in the stool during the past week.  He has had no fevers or night sweats.  Four months ago, the patient was diagnosed with Clostridium difficile colitis after taking antibiotics for a sore throat and was prescribed oral vancomycin.  He has no other chronic medical conditions and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.
Temperature is 37.2 C (99 F), blood pressure is 112/76 mm Hg, and pulse is 88/min.  The abdomen is soft with mild tenderness in the periumbilical and left lower-quadrant areas.  There is no rebound tenderness or rigidity.  Rectal examination shows guaiac-positive stool.
Laboratory results are as follows:
 Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient with chronic abdominal pain, diarrhea, and guaiac-positive stool likely has inflammatory bowel disease (IBD). Most cases of IBD are diagnosed in individuals age 15-40. Patients with mild disease typically have <4 bowel movements/day that can be bloody and are associated with mild abdominal pain and tenesmus. Severe disease is characterized by frequent bloody stools, nausea/vomiting, systemic toxicity (eg, fatigue, fever), and rapid weight loss. Colonoscopy with biopsy is indicated for diagnosis, with examination of the terminal ileum (ileocolonoscopy) if ileocolonic Crohn disease is suspected (eg, right lower-quadrant pain ± fistulas/perianal disease). Caution should be taken in patients with fulminant colitis due to the risk of perforation. IBD and Clostridium difficile infection (CDI) may have similar presenting features, and patients with IBD have a high prevalence of C difficile colonization, likely due to colonic inflammation and alterations of the enteric microbiome. CDI may also be responsible for approximately 5% of IBD relapses; therefore, patients with known IBD who develop disease flares should undergo screening for CDI. However, this patient's negative stool PCR assay and near-normal leukocyte count make recurrent CDI unlikely. (Choice B) Duodenal or jejunal aspirate or biopsy may be indicated in patients with small intestine bacterial overgrowth (SIBO) if noninvasive tests are equivocal. SIBO typically presents with malabsorption (eg, diarrhea, bloating, flatulence) in patients with risk factors (eg, blind intestinal loops, pancreatic insufficiency). Bleeding is unexpected. (Choices C, D, and E) A prolonged taper of oral vancomycin can be used to treat recurrent CDI, and rifaxamin is sometimes used as an adjunct therapy in those with multiple recurrences. Selective anaerobic stool culture for C difficile has limited clinical utility as it is time-consuming and cannot differentiate toxin- versus non-toxin-forming strains. The negative stool PCR assay and near-normal leukocyte count make CDI recurrence unlikely in this patient. Educational objective: Inflammatory bowel disease often presents in early adulthood with abdominal pain, diarrhea (with occult or gross blood), and systemic symptoms (eg, weight loss, fever, fatigue). It is associated with a high prevalence of Clostridium difficile colonization/infection. Colonoscopy with biopsy is the diagnostic study of choice for ulcerative colitis, and ileocolonoscopy should be considered for patients with suspected ileocolonic Crohn disease. __________ References: Clostridium difficile infection in newly diagnosed pediatric patients with inflammatory bowel disease: prevalence and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/21936029)

A 32-Year-Old Man Is Evaluated for a 3-Month History of Abdominal