A Rare Case of Fulminant Clostridium difficile Enteritis in Patient With Ileal Pouch-Anal Anastamosis Causing Small Bowel Perforation: A Case Report With Review of Literature

Abstract

Miss X is a 37 year old lady with a past medical history of familial polyposis with subsequent proctocolectomy with ileal pouch-anal anastomosis (IPAA). Patient presented to the hospital in labor and underwent a normal vaginal delivery. The patient then developed diarrohea with systemic signs including fevers, chills and lethargy. She was stabilized in the medical intensive care unit and was given intravenous fluid hydration with lactated ringers. Obstetrics team out infection of the genitourinary tract. Figure 1 shows the trend in stool output and white cell count. Clostridium difficile toxin in stool was found to be positive and the patient was started on oral vancomycin. Patient's abdominal distention worsened and she was taken to the operating room. She had small bowel perforation. About 20cm of bowel was resected and anastomosis completed. Patient tolerated the procedure well. She was continued on oral vancomycin and intravenous metronidazole. Clostridium Difficile Enteritis (CDE) in patients with IPAA has been reported in several case reports. However, CDE causing perforation in a patient with IPAA is very rare. Table 1 shows the reported case reports and studies of CDE in patients with IPAA between 2000 and 2016.Table: Table. Studies on CDE in patients with IPAA from 1990-2016. [Inflmmatory bowel disease (IBD), Ulcerative Colitis (UC), Per Oral (PO), Intravenous (IV)] *mean age, **median ageFigure: Trend of patient's clinical course during hospital course. [White Blood Cell Count (WBC)].