Fatal Clostridium difficile Infection of the Small Bowel after Total Colectomy: A Case Report and Review

Abstract

Introduction:Clostridium difficile infection occurring in the small bowel is exceedingly rare, especially following total colectomy. We describe a case of C. difficile small-bowel enteritis occurring in a patient 27 years after total colectomy and review cases of C. difficile enteritis in patients following complete colectomy. Case: A 74-year-old male nursing home resident with a past medical history of ulcerative colitis with subsequent colectomy and Kock pouch ileostomy, DM and dementia was evaluated for stomal obstruction and infection following increased difficulty with stoma self-care and mild epigastric pain. He received a seven-day course of antibiotics and pouch care while the surgical team contemplated a revision of the ileostomy. On the 12th day of admission, he developed nausea, vomiting, cramping abdominal pain and increased ileostomy output. On abdominal examination, he had marked diffuse tenderness, hyperactive bowel sounds and voluminous output from the stoma. Laboratory investigation revealed a WBC count of 31,000 cells/mm3 and a sudden worsening of renal function with a serum creatinine of 3.8mg/dl. On the 14th day of admission, ileostomy stool cultures tested positive for C. difficile toxin A and B; he previously tested negative for this on the 3rd day of admission. He subsequently developed septic shock and despite aggressive resuscitation and treatment with oral vancomycin, flagyl and vancomycin solution via ileostomy, he died on the 20th day of admission. Discussion: Isolated small bowel C. difficile infection in the absence of colonic involvement, especially post-colectomy, is exceedingly rare. A review of cases of C. difficile enteritis post-colectomy revealed a high mortality rate that is likely due to missed diagnosis and delayed institution of treatment because of low clinical suspicion. Advanced age and prior or ongoing antibiotic therapy are associated with increased mortality. The high mortality rate of almost 60% seen in C. difficile enteritis is worse than is seen in colitis and has been attributed to the increased permeability of the small bowel predisposing to septicemia and multi-organ involvement. The pathogenesis of C. difficile in the small bowel following colectomy is thought to be due to phenotypic changes that occur in the small bowel mucosa leading to colonic-type metaplasia and partial villous atrophy. These changes facilitate fecal floral establishment in the small bowel and explain the development of C. diff enteritis in this group of patients. Small bowel C. difficile infection should be strongly considered in the differential diagnosis of high risk patients even in the absence of a colon as early diagnosis and treatment could be life saving.