DR Medhat MRCP

Clostridium difficile:
- Is a Gram positive rod often encountered in hospital practice.
- It produces an exotoxin which causes intestinal damage leading to a syndrome called
pseudomembranous colitis.
- Clostridium difficile develops when the normal gut flora are suppressed by broadspectrum
antibiotics.
- Clindamycin is historically associated with causing Clostridium difficile but the
aetiology has evolved significantly over the past 10 years.
- Second and third generation cephalosporins are now the leading cause.
• Features:
1) Diarrhea.
2) Abdominal pain.
3) If severe, toxic dilatation (toxic megacolon).
4) Sometimes seen in nosocomial outbreaks
• Diagnosis
- Is made by detecting Clostridium difficile TOXIN (CDT) in the stool.
• Management:
1) ORAL metronidazole for 10-14 days.
2) ORAL vancomycin may be used If severe or not responding to metronidazole
3) Oral vancomycin + I.V metronidazole combination should be used For lifethreatening
infections .
Anal fissures
- Are longitudinal or elliptical tears of the squamous lining of the distal anal canal.
- If < 6 weeks = acute , if > 6 weeks = chronic.
- Around 90% of anal fissures occur on the posterior midline
• Management of an acute anal fissure (< 6 weeks):
1) Bulk-forming laxatives are first line : if not tolerated then lactulose should be tried.
2) Lubricants such as petroleum jelly may be tried before defecation.
3) Topical anaesthetics.
4) Dietary advice: high-fibre diet with high fluid intake
5) Sitz baths: hip baths in hot water for 2–5 minutes followed by cold water for 1 min.
N.B : Topical steroids do not provide significant relief.
• Management of a chronic anal fissure (> 6 weeks):
1) Topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure.
2) The above techniques should be continued.
3) Surgery or botulinum toxin: If topical GTN is not effective after 8 weeks.
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