S2781 A Case of Clostridium difficile Enteritis

Abstract

INTRODUCTION: Clostridium difficile (C. difficile) is the cause of 20–25% of antibiotic-associated diarrhea. Extracolonic manifestations of C. difficile are rare but include osteomyelitis and reactive arthritis. More rarely, the bacteria can colonize the small bowel and cause active small bowel enteritis with mortality reported as high as 25%. We present a case of C. difficile enteritis. CASE DESCRIPTION/METHODS: A 39-year-old woman with history of alcoholic liver cirrhosis and splenic embolization for thrombocytopenia one week prior to presentation was admitted for abdominal pain after paracentesis. Her labs were notable for leukocytosis, thrombocytopenia, elevated lactate and elevated INR. Computed-tomography of the abdomen revealed thickening of the proximal small bowel and right colon consistent with enterocolitis, splenomegaly and ascites. Ultrasound showed portal vein thrombosis. Her course was complicated by hepatic encephalopathy and spontaneous bacterial peritonitis. She was transferred to the intensive care unit and an indwelling intraperitoneal catheter was inserted to drain the ascites. The WBC of the peritoneal fluid peaked at 55,000/ml and cultures grew C. difficile. The serum WBC peaked at 66,500/ml and blood cultures also grew C. difficile. Stool was positive for toxigenic C. difficile PCR. Oral vancomycin, intravenous vancomycin and intravenous metronidazole were started. On the 10th day of admission, a donor liver became available and she was taken to the operating room (OR) for transplant. Multiple splenic and intra-abdominal abscesses were noted during the exploration phase of surgery and the surgery was cancelled. Decision was made to take the patient back to the OR for abdominal wash out and possible splenectomy. Unfortunately, she had cardiac arrest intraoperatively and expired after failed resuscitative efforts. DISCUSSION: The exact pathophysiology of C. difficile enteritis is not well-understood, especially in patients with intact small bowel. Majority of patients had prior gastrointestinal surgery such as colectomy. Our patient, however, had no prior abdominal surgeries or intervention. We presume that as a complication of her splenic embolization and raging peritonitis, she developed a portal vein thrombosis causing small bowel wall edema, allowing for translocation of C. difficile from her bloodstream into her small bowel and peritoneal cavity. There must be a high index of suspicion for C. difficile enteritis, as it is not a common entity and has a high mortality rate.