by Malia Kirby

Lately, I’ve been receiving a LOT of calls seeking advice on how to more effectively treat patients diagnosed with Clostridium difficile infections, to which my first thought usually runs along the lines of, “Hoo, boy. Do I feel sorry for you!” My next thought is, “Treat the presenting pattern.” So, considering that it appears to be antibiotic season right now, let’s talk shop about what’s going on in the Western side of things and then go full-on Phillipe Sionneau and break that puppy down into patterns, shall we?

So, what is Clostridium difficile, anyway? Well, to put it succinctly, C. diff is a pathogenic bacterium affecting the colon. Originally, it wasn’t considered infectious, mainly because healthy individuals contain a wide range of bacteria in the colon referred to as the normal flora, which acts symbiotically with the GI tract as a barrier mechanism against pathogenic influences as well as making it a highly competitive environment for the new bacterial kid on the block, not to mention synthesis of Vitamin K & some B vitamins, which we then get to absorb and benefit from (which, for the nerdy like me, is an association referred to as mutualism, ie, where both organisms benefit from living together). Today, we’d say that C. diff is a nosocomial infection, or an infection received through the course of medical treatment.

Let’s say, for sake of argument, that a normally “healthy individual” picks up a nasty case of strep throat, puts off going to the doctor until a bright red rash develops, winds up going to the emergency room and is admitted to the hospital for a few days, and promptly receives a prescription for a broad-spread antibiotic to be taken over a two-week period upon dismissal. The antibiotic clears up the skin rash and the throat infection, but it’s also managed to kill off some of the normal flora in the intestinal tract, suppressing normal reproduction and proliferation, so our patient now has frequent, profuse, foul-smelling watery diarrhea with abdominal cramping, a fever, loss of appetite, and maybe even some rebound tenderness. What are the two flags that would indicate that our previously “healthy individual” may have picked up a case of C. diff? The first is that our patient was hospitalized. The second is that our patient developed diarrhea after taking a course of antibiotics.

So, let’s go back to my original first thought of, “Hoo, boy.” Why would I think something like that? Here’s the thing about the Clostridium genus: they reproduce by spores, which are damn hard to kill. Go ahead, heat ‘em up. Dry them out. Freeze them. Boil them for hours. Douse them with toxic chemicals. Hey, even hit them up with radiation. Those endospores are just going to sit there laughing at you with, “What? That’s all you got?!?” Endospores also have the ability to sit dormant until the right opportunity comes around, making them not unlike the Terminator. Even if you kill off the original infection, if there are still spores hanging out in the colon…say it with me now in an Austrian accent, they’ll be back. But, guess what! They’re actually worse than Arnie’s old role, because those spores are going to grow up and create more spores, releasing toxin A and toxin B in the process, which kill off intestinal epithelial cells. C. diff is an intimidating bug because it’s a triple threat—bacteria, spores, & toxins. If a patient walks through your door, telling you that’s their diagnosis, you know you’re in for a long haul, a frank discussion of the importance of taking a probiotic with antibiotic therapy as a preventative, and maybe even a beer when you get home from the office.

Pattern Identification

Let’s take a look at those symptoms again:

Frequent and profuse, foul-smelling, watery diarrhea accompanied abdominal cramping, fever, loss of appetite, fatigue, lower abdominal tenderness and occasionally rebound tenderness, and potentially blood &/or pus in the stools.

That’s pretty clear cut as large intestine damp heat, even though the stools are watery, frequent, and profuse. How do we know that? There’s a fever, indicating heat. Loss of appetite accompanied by fatigue and watery diarrhea indicate dampness. Abdominal pain and particularly rebound tenderness indicate damp heat. Foul-smelling? Damp heat. Blood and/or pus? Damp heat. And just in case it’s not perfectly clear that this is damp-heat presentation from the signs and symptoms, here’s what a colon infected with C. diff that has progressed into pseudomembranous colitis actually looks like:

Endoscopic visualization of pseudomembranous colitis, a characteristic manifestation of full-blown Clostridium difficile colitis. Classic pseudomembranes are visible as raised yellow plaques, which range from 2-10 mm in diameter and are scattered over the colorectal mucosa. Courtesy of Gregory Ginsberg, MD, University of Pennsylvania.(1)

Seriously! Look at that! It’s raised and highlighter-yellow. By the way, they’re filled with cellular and bacterial debris, inflammatory cells, fibrin, and plasma, also hinting at damp heat. Other endoscopic images you’ll find on the internet will also show inflammation galore and weeping yellow-green pus. Any way you slice it, that’s damp heat.

Treatment Strategies

This is going to depend on each individual case on how you’re going to modify the formula, but your general strategy is to clear heat, resolve toxicity, transform dampness, and alleviate dysentery. You may need to tack on other strategies including but not limited to regulate and harmonize the qi and blood, harmonize the middle burner, cool the blood, stop pain, stop bleeding, nourish the blood, and enrich yin. Formula-wise, I’m probably reaching for Bai Tou Weng Tang for my base prescription. Maybe Shao Yao Tang. From there, I’m adding and subtracting. I might think about Chi Shao, Di Yu, and Mu Dan Pi if there’s more blood in the stools. If smoldering damp heat has been damaging yin and blood, I might think about adding some E Jiao, Mai Men Dong, and maybe even some Sha Shen to generate fluids. If the abdominal pain is severe, I’d start thinking about some Bai Shao and Mu Xiang. What I've listed here isn't even close to a full listing of what you might possibly be able to add or subtract.  It’s all dependent on how the pattern is presenting.

What SHOULDN’T You Do?

Don’t astringe. I’ll say it again. Don’t astringe, even if the patient appears to be deficient. For that matter, tell your patient to reach for fluids and to not even think about taking Imodium or Pepto. I get it, I can see where one might be concerned about loss of essence from profuse diarrhea. Don’t be. The diarrhea here is the body’s way of trying to expel the pathogen. And seriously, scroll back up and take a look at that endoscopy picture again. You don’t want to astringe that. You’ll make it worse, increasing the risk of toxic megacolon (Yes, that’s a real diagnosis, it’s surgical, and it will kill you without treatment. Go ahead and look it up for confirmation if you like, I’ll wait). Basically, what happens is that the colon dilates as a result of the infection and once it expands, there’s no returning back to normal. The affected area is removed. So, once again, with more feeling…DON’T ASTRINGE.

Anything Else I Should Do?

Yes!  First off, reassure your patient that they are definitely not alone in their gastrointestinal plight and that there really isn't any single quick fix.  Being realistic with treatment here will be key.  Under no circumstances should you tell your patient that acupuncture and herbs will fix them up in a jiffy, because is just isn't true.  This is a pattern and pathogen that takes time.  Patience really is a virtue in this particular case.

If your patient's physician hasn't already recommended a course of probiotics, now would be the time to have that discussion.

Dehydration will almost always be hiding around the corner.  Remind your patient that he or she will need to be aware of that and to drink plenty of fluids.  Water will be their best bet to remain hydrated, rather than coffee, tea, and caffeinated beverages, which can increase peristalsis.

Dietary recommendations might include avoiding acrid, hot and spicy foods, oily, fatty, or fried foods, and alcohol consumption.  Instead, incorporating more fresh (and cooked) fruits and vegetables, grains, and lean seafood and meats.  IF they can easily tolerate yogurt and/or fermented foods, then by all means, add those in as well, although bear in mind that dairy is not usually tolerated well.

Good luck!

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1. Medscape, Pseudomembranous Colitis Surgery. http://emedicine.medscape.com/article/193031-overview#a0103. 12/29/2011