Objectives. This open-label trial assessed the efficacy and safety of rifaximin as first-line therapy in hospitalized patients with Clostridium difficile-associated diarrhea (CDAD). Methods. We enrolled thirteen patients who had a confirmed diagnosis of CDAD characterized by ≥3 unformed stools/day and positive C. difficile toxin assay. Those patients received rifaximin 400 mg three times daily for 10 days. Resolution of symptoms, repeat assay 10 days after treatment, and followup for recurrence were assessed. Results. Eight patients completed the study, and all reported symptom resolution during treatment. Mean time to last unformed stool was 132 h ± 42.5 h. Seven patients had no relapse by week 2 and in longer followup (median 162 days). One patient had recurrent CDAD during a repeat hospitalization. Conclusions. Rifaximin was effective and safe as first-line treatment for CDAD and did not result in recurrence in most patients.

No abstract

A physician's approach to patients with ulcerative colitis (UC) who are refractory to standard first-line therapies must be thoughtful and systematic and include the individual's physical and emotional state as the physician examines the various dietary, medical, and surgical options currently available. It is of foremost importance to confirm that the refractory patient's symptoms are not simply due to dietary indiscretion, concomitant bowel infection (especially with Clostridium difficile), an incorrect diagnosis (eg, colitis due to infection, NSAIDs, ischemia, diverticulitis, or Crohn's disease), or even a concomitant diagnosis (eg, celiac sprue, pancreatic insufficiency, functional bowel disorder, laxative or sorbitol intake). The ability to quickly assess the status of the colonic mucosa with flexible sigmoidoscopy aids in the ability to distinguish patients with refractory inflammation from those with other diagnoses. The initiation and optimization of the long-term purine analogues azathioprine (AZA) or 6-mercaptopurine (6-MP) remain the backbone of medical therapy for patients with refractory UC. For those unresponsive to corticosteroids, quicker induction of remission may necessitate infliximab, cyclosporine, or tacrolimus. Successful induction and maintenance with AZA, 6-MP, and/or infliximab should be followed by long-term therapy with these agents. Cessation of therapy often leads to relapse. Novel therapies under investigation hold the promise of offering more options for both the induction and maintenance of remission in refractory UC patients. Discussions of surgical intervention should not be put off as a last resort but rather included in the overall treatment plan offered to the patient.

A 43-year-old female with a history of polycystic liver disease presented for evaluation of chronic, intermittent nausea and vomiting, which began after orthotopic liver transplantation. The liver transplant was accompanied by the placement of an aortic jump graft due to thrombosis of the donor hepatic artery and a weak pulse in the recipient hepatic artery. On presentation, the physical examination was notable for abdominal distension and epigastric tenderness to palpation. Laboratory values were within normal limits, and esophagogastroduodenoscopy was normal. The patient subsequently underwent an upper gastrointestinal small bowel follow-through study. During the initial stages of the upper gastrointestinal study, the duodenum was found to remain within the right upper abdomen (Fig. 1). During the study, the patient vomited, and subsequent imaging demonstrated that the duodenum crossed the midline and assumed its expected position within the left upper abdomen, with the duodenal-jejunal junction at the level of the duodenal bulb (Fig. 2). Follow-up imaging then demonstrated the jejunal bowel loops to be within the left abdomen (Fig. 3).

No abstract