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Zorluk: KolayGastroenterology and Hepatology

A 72-year-old woman is evaluated in the outpatient clinic for a 4-day history of frequent, watery, foul-smelling diarrhea and mild lower abdominal cramping. She has a medical history of chronic obstructive pulmonary disease (COPD) and diet-controlled type 2 diabetes mellitus. Three weeks ago, she completed a course of oral clindamycin for a dental abscess. She currently feels fatigued but denies shortness of breath, cough, or weight loss. Her temperature is 38.0°C (100.4°F), blood pressure is 118/76 mm Hg, and pulse is 92/min. Physical examination reveals mild, diffuse lower abdominal tenderness with hyperactive bowel sounds; there is no guarding or rebound tenderness. Which of the following is the most appropriate next step in management?

  1. Stool assay for Clostridioides difficile toxins and glutamate dehydrogenase antigenCevap
  2. B
    Empirical intravenous piperacillin-tazobactam
  3. C
    Nasogastric tube decompression and surgical evaluation
  4. D
    Administration of systemic corticosteroids and nebulized albuterol
  5. E
    Measurement of serum thyroid-stimulating hormone

Cevap

Stool assay for Clostridioides difficile toxins and glutamate dehydrogenase antigen
The patient's clinical presentation of acute watery diarrhea, fever, and mild abdominal cramping shortly after completing a course of clindamycin is highly suspicious for Clostridioides difficile infection (CDI). Clindamycin, along with fluoroquinolones and broad-spectrum penicillins or cephalosporins, is classically associated with altering the normal colonic flora, allowing for C. difficile overgrowth and toxin production. The most appropriate next step in a hemodynamically stable patient with suspected CDI is to confirm the diagnosis by testing a liquid stool sample for C. difficile toxins (usually via enzyme immunoassay) or genes (via nucleic acid amplification testing), often in combination with glutamate dehydrogenase (GDH) antigen testing. Empirical treatment is generally reserved for patients with fulminant disease or severe instability while awaiting test results.

Adım Adım Çözüm

1
Identify the patient's primary symptoms and vital signs.
The patient has acute watery diarrhea, mild abdominal cramping, and a fever of 38.0°C (100.4°F).
To establish the acute, infectious nature of the gastrointestinal presentation.
2
Analyze the patient's medical history for relevant risk factors.
The patient recently completed a course of oral clindamycin.
Recent antibiotic use is the most significant risk factor for altering colonic flora and allowing pathogenic bacterial overgrowth.
3
Determine the most appropriate initial diagnostic step based on the suspected etiology.
The clinical picture strongly suggests an infection that must be diagnosed via stool assay before targeted treatment.
Testing the stool for specific toxins and/or antigens is required to confirm the diagnosis of antibiotic-associated colitis.

Anahtar Kavram

Diagnosis of Clostridioides difficile infection typically involves testing a liquid stool sample for toxins (via enzyme immunoassay) and/or genes (via nucleic acid amplification) in patients with a history of recent antibiotic use who present with acute watery diarrhea.
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Gastroenterology and Hepatology

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