A 28-year-old man returns to the emergency department due to abdominal cramps and diarrhea. The patient has a 3-year history of ulcerative colitis and initially presented 2 weeks ago with abdominal pain and bloody stools. He was hospitalized and underwent colonoscopy, which revealed active colitis in the rectum, sigmoid, and descending colon. His symptoms gradually improved with medical treatment, and he was discharged on prednisone and 5-aminosalicylic acid therapy. The patient's symptoms had resolved completely, but he has now had 2 days of mild abdominal cramps and voluminous watery diarrhea despite taking medications as prescribed. He has no other medical problems. Temperature is 37.9 C (100.2 F), blood pressure is 124/76 mm Hg, pulse is 78/min, and respirations are 12/min. No orthostatic changes are present. There is mild generalized abdominal tenderness without rebound tenderness or guarding. Bowel sounds are normoactive. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 28-year-old man returns to the emergency department due to abdominal cramps and diarrhea.  The patient has a 3-year history of ulcerative colitis and initially presented 2 weeks ago with abdominal pain and bloody stools.  He was hospitalized and underwent colonoscopy, which revealed active colitis in the rectum, sigmoid, and descending colon.  His symptoms gradually improved with medical treatment, and he was discharged on prednisone and 5-aminosalicylic acid therapy.  The patient's symptoms had resolved completely, but he has now had 2 days of mild abdominal cramps and voluminous watery diarrhea despite taking medications as prescribed.  He has no other medical problems.  Temperature is 37.9 C (100.2 F), blood pressure is 124/76 mm Hg, pulse is 78/min, and respirations are 12/min.  No orthostatic changes are present.  There is mild generalized abdominal tenderness without rebound tenderness or guarding.  Bowel sounds are normoactive.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient was recently hospitalized for an ulcerative colitis flare in the rectum and sigmoid/descending colon. His bloody stools resolved with medical management, but he subsequently developed large-volume watery stools and leukocytosis, raising suspicion for Clostridioides difficile infection (CDI). Although antibiotic use is the single greatest risk factor for CDI, other well-established risk factors include recent hospitalization and severe comorbid illness such as inflammatory bowel disease. CDI is typically marked by watery stools (≥3 episodes in 24 hours) with no frank blood or melena (unlike ulcerative colitis, which usually causes small-volume bloody stools). Patients with CDI also frequently have abdominal pain/cramping, low-grade fever, and nausea. The abdomen is usually tender, and laboratory evaluation often shows leukocytosis. Suspected cases require contact precautions and stool testing for C difficile toxins. Treatment with oral vancomycin is typically curative, but many cases recur. (Choice A) Abdominal CT scan is not usually necessary in individuals with suspected C difficile colitis but may be warranted for those with severe CDI (eg, abdominal distension, hypovolemia) or suspected perforation (eg, rebound tenderness). (Choice B) Patients with CDI should not generally undergo colonoscopy due to the risk of perforation during insufflation. Endoscopy may be warranted if stool testing for C difficile toxins is negative and the diagnosis remains unclear. (Choice C) Stool fat measurement can help diagnose malabsorptive diarrhea, which often occurs in the setting of small-intestine infection (eg, giardiasis), bacterial overgrowth, or chronic pancreatitis. Patients typically develop pale, foul-smelling, voluminous watery diarrhea, but do not generally have low-grade fever and leukocytosis. In addition, this patient's recent hospitalization and history of inflammatory bowel disease make CDI more likely. (Choice E) Tumor necrosis factor inhibitors are often used for refractory ulcerative colitis. However, ulcerative colitis usually causes small-volume bloody, not large-volume watery, stools. Therefore, testing for CDI is required prior to considering other therapies. Educational objective: Clostridioides difficile infection should be suspected in recently hospitalized patients who develop voluminous watery diarrhea, low-grade fever, and leukocytosis. Stool testing for C difficile toxin is generally diagnostic. Other established risk factors include antibiotic use, severe comorbid illness (eg, inflammatory bowel disease), and advanced age. References: Management of Clostridium difficile infection in inflammatory bowel disease: expert review from the Clinical Practice Updates Committee of the AGA Institute. (http://www.ncbi.nlm.nih.gov/pubmed/28093134)

A 28-Year-Old Man Returns to the Emergency Department Due to Abdominal