• Acute watery diarrhea with lower abdominal pain, lowgrade fever, and mild or absent leukocytosis

• Mild, with only three or four loose watery stools per day

• C. difficile toxins are present in stool, but sigmoidoscopic examination is normal.

• Profuse, watery diarrhea with 5 to 15 bowel movements per day, abdominal pain, abdominal distention, nausea, and anorexia

• Left or right lower quadrant abdominal pain and cramps that are relieved by passage of diarrhea.

• Dehydration and low-grade fever

• Sigmoidoscopic examination may reveal a nonspecific diffuse or patchy eryth-ematous colitis without pseudomembranes.

• Pseudomembranous colitis: Same symptoms as colitis, but sigmoidoscopic examination reveals a characteristic membrane with adherent yellow or off-white plaques, usually in distal colon.

• Toxic megacolon: Suggested by acute dilation of the colon to a diameter greater than 6 cm, associated systemic toxicity, and the absence of mechanical obstruction. It carries a high mortality rate.

• Fulminant colitis: Acute abdomen and systemic symptoms such as fever, tachycardia, dehydration, and hypotension. Some patients have marked leukocytosis (up to 40 x 103 white blood cells/mm3 [40 x 109/L]). Diarrhea is usually prominent but may not occur in patients with paralytic ileus and toxic megacolon.

• Relapsing colitis

• Risk factors include increased age, recent abdominal surgery, increased number of C. difficile diarrheal episodes, and leukocytosis.

• 12% to 24% of patients develop a second episode of CDAD within 2 months of the initial diagnosis.

• In most instances, C. difficile toxin testing of a single stool specimen effectively establishes the diagnosis. Various enzyme-linked immunosorbent assay (ELISA) kits are available to detect toxin A or toxin B or both. Those that detect both toxin A and B are preferred. Repeated testing can boost sensitivity.

• Leukocytosis, hypoalbuminemia, and fecal leukocytes are nonspecific but suggestive of C. difficile infection.

• In selected patients, sigmoidoscopy, colonoscopy, or abdominal CT scan can provide useful diagnostic information.

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