Recognising recurrence and what to do

The possibility of recurrence is no reason for fear, if you know what to watch for. In this chapter you will learn to recognise the early signs, to tell a passing upset from a genuine relapse, and you will know exactly what to do — from the diary to the doctor.

The early signs: when your diary speaks before your feeling does

Recurrence rarely bursts in from one day to the next — there is usually a quiet, few-day prelude that your diary often shows before you consciously feel it. The most telling early sign is the stool slipping back: the daily stool count begins to rise again, and the Bristol value^[G] creeps from the normal 3–4 band towards the looser, more watery 6–7. Bloating, cramping abdominal discomfort and a fall in appetite may join it — symptoms you already know from the earlier stage of the illness.

This is where it becomes invaluable that you have been keeping the diary for weeks: there is something to compare against. A lone worse day means nothing in itself — everyone has those. The real warning is when the numbers worsen consistently, over several days, stepping out of the stable band you grew used to during remission^[G]. It is this trend that is the signal, not the single fluctuation.

That is why it is worth not stopping the recording even during stabilisation, even when you feel well. The diary is most useful precisely when everything is fine: against the calm baseline you can judge whether a change is a genuine slipping-back, or just the natural fluctuation of everyday life.

Passing upset or genuine recurrence — and what to do

The most common question at this point: "is this a relapse now, or did I just get something wrong?" The difference lies largely in durability and in the accompanying symptoms. A fattier meal, a stressful day or an upset stomach can cause one or two looser stools that settle on their own within a day. A genuine recurrence is indicated when the symptoms persist or strengthen over several days — the stool count rises persistently, the Bristol value stays stubbornly in the 6–7 range, and the overall picture typical of the illness returns.

If you see this, what to do is simple and calm: do not start raising the dose or taking medication on your own, but get in touch with your treating physician, and take the most recent days of your diary with you. The logic of treating recurrence is familiar from before: your doctor typically responds by restoring the maximum dose and a repeat course, and if repeated relapse warrants it, switches to a different LOT, that is, a different batch of the product. These decisions always require medical judgement — your job is the early signal and accurate data.

And there is a boundary that must be highlighted separately: with certain symptoms you should not wait for the appointment with your treating physician, but seek help immediately. We have gathered these warning signs in the box at the end of the chapter — if you see any of them on yourself, it is a matter of urgent medical care, not of weighing it up at home.

🍽️ Eating during these days

The theme of these days is recognising recurrence in time — and eating works on the preventive side of this: the varied, fibre-rich plate keeps strong the diverse gut flora that makes it harder for the pathogen to gain a foothold again. The concrete eating task for the three days: keep up the familiar fluid replacement and the other built-in lifestyle steps even when you feel well, and every day work the day's plant into at least one meal. If you notice looser stool or bloating after any new source, mark that separately in the diary — this way you can tell a food's transient effect from a sign of genuine slipping-back.

For these days (70–72), the Plant Calendar (Appendix F) brings sourdough wholemeal bread (70), then two inulin-rich vegetables — Jerusalem artichoke (71) and globe artichoke (72). Inulin is a strongly fermentable prebiotic fibre: a favourite food of the beneficial gut bacteria, from which they make short-chain fatty acids — including butyrate; this supports the gut barrier and diversity. In the second half of the programme (about days 61–90) the goal is precisely to maintain full diversity and inulin-rich, fermentable sources, because a diverse, stable flora is the foundation of resilience — this is what makes the gut more resistant to recurrence. Inulin sources, however, can be more gas-forming, so introduce them according to your tolerance, in small portions; if they cause bloating, pull back and come back to them later.

References

[347] Guh AY, Mu Y, Winston LG, Johnston H, Olson D, Farley MM, Wilson LE, Holzbauer SM, Phipps EC, Dumyati GK, Beldavs ZG, Kainer MA, Karlsson M, Gerding DN, McDonald LC; Emerging Infections Program Clostridioides difficile Infection Working Group. Trends in U.S. Burden of Clostridioides difficile Infection and Outcomes. N Engl J Med. 2020. Link

Building on the Emerging Infections Program surveillance in ten US sites, the authors estimated the national burden of C. difficile infection from 2011 to 2017, adjusting for the higher sensitivity of NAAT-based diagnostics. The estimated total burden decreased over the period, driven largely by a reduction in health-care-associated CDI, while community-associated CDI remained stable. First-recurrence rates and in-hospital deaths also declined modestly. Trends were modeled with weighted random-intercept negative-binomial and logistic regression. The findings indicate that US-wide infection-prevention efforts have measurably reduced the health-care-associated CDI burden without comparable progress on community-associated disease.

[357] Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997. Link

The authors evaluated the responsiveness of the Bristol Stool Form Scale to changes in whole-gut transit time (WGTT). Sixty-six volunteers had WGTT measured with radiopaque markers and recorded stool form on a 7-point scale and defecation frequency; measurements were repeated under senna and loperamide. Baseline WGTT correlated with frequency (r=0.35, P=0.005) and stool output (r=-0.41, P=0.001), and best with stool form (r=-0.54, P<0.001). Senna (n=44) shortened WGTT and increased frequency, form score and output (all P<0.001); loperamide (n=43) lengthened WGTT and reduced frequency, form score and output (all P<0.001). The Bristol scale is a valid surrogate for intestinal transit time and is responsive to pharmacological alteration.