Diarrhea in a Post-Colectomy Patient: Should We Still Consider Clostridium difficile?

Abstract

Clostridium difficile is the most common cause of antibiotic- associated diarrhea resulting in significant morbidity and mortality and is typically limited to the colon. We report a case of refractory diarrhea from C. difficile enteritis in a patient with a colectomy and end-ileostomy to illustrate the pathophysiology of this common pathogen infecting an uncommon site. A 50-year-old female presented with fever, chills, nausea, abdominal pain, and increased maroon colored stool through her ileostomy. Past medical history included end transverse diverting colostomy complicated by feculent perforation requiring right hemicolectomy with end-ileostomy. Patient reported recent use of trimethoprim/sulfamethoxazole for genital folliculitis. Physical exam revealed hyperactive bowel sounds, tenderness to palpation around ileostomy site, and increased dark-colored ileostomy output. Pertinent laboratory results included white blood count 9.4 billion per liter (3.3-10.7 billion/ liter), creatinine 0.82 mg/dl (0.4-1.4 mg/dl), and lactic acid 1.9. Computerized tomography of the abdomen revealed right-sided ascites and a focal fluid collection in the anterior pelvis with a thick wall of bowel. Clostridium difficile toxin from the ileostomy output resulted positive and the patient was treated with oral vancomycin every 6 hours with no improvement of the diarrhea severity. Fidaxomicin and rifaximin were then initiated with resolution of symptoms. Clostridium difficile, an anaerobic endospore-forming bacterium, is typically a colonic pathogen and is an important cause of nosocomial infection. Small bowel enteritis, however, is relatively uncommon C. difficile enteritis has been increasingly reported in literature and is not as rare as previously thought. The pathogenesis of C. difficile small bowel enteritis is not clearly established, however, the majority of reported cases occurred after treatment with antibiotics, thus disruption of small bowel flora is needed to establish infection. After colectomy, it is hypothesized that the mucosa of the small bowel undergoes morphologic changes resembling characteristics of colon, especially after gastrointestinal surgery, which makes it a good site for colonization with organisms favoring colonic mucosa. Unlike C. difficile colitis, the majority of the of small bowel enteritis cases present with systemic manifestations and its clinical course is much more severe with higher case-fatality rate.Figure: CT of the abdomen and pelvis with oral and intravenous contrast revealing focal fluid collection in the anterior pelvis with a thickened bowel wall.Figure: CT of the abdomen and pelvis with oral and intravenous contrast revealing focal fluid collection in the anterior pelvis with a thickened bowel wall.