Abstract
Small intestinal Clostridium difficile seems to be increasing in incidence. The spectrum of Clostridium difficile infection (CDI) has definitely expanded with small bowel involvement. They are more frequently reported in patients with inflammatory bowel disease (IBD) who have undergone total colectomy or patients with Ileal anal pouch anastomosis. The most common presentation is increased ileostomy output with associated dehydration. High clinical suspicion, early recognition and appropriate treatment are the keys to successful resolution. The increase in the number of these patients may actually reflect an increase in the rising incidence of CDI in general or increasing virulence of the organism. Heightened public awareness and initiation of prompt preventive measures are the keystones to control of this infection. This disease is no longer limited to the colon and physicians should be educated to think beyond the colon in patients with CDI.
Highlights
A 38-year-old woman with history of Crohn's disease (CD) presented with nausea, vomiting, and abdominal pain
Patient was diagnosed with small bowel Clostridium difficile infection (CDI) and was started on oral vancomycin (125 mg q.i.d.), which resulted in resolution of the symptoms and decrease in the ileostomy output and her repeat stool studies for CDI became negative
inflammatory bowel disease (IBD) patients are at risk because of antibiotic use, hospitalizations, the dramatic risk of infection cannot be fully explained by the above risk factors and raises the question whether abnormalities in mucosal immune response in IBD might play a role in CDI
Summary
Increasing ileostomy output seems to be the most common clinical presentation of small bowel CDI. Increased ileostomy output was the presenting manifestation in 16/ 17 patients in two large case series [16,17]. Increased ileostomy output is severe enough in some patients to result in acute renal failure and in the largest series to date, 8/11 presented with acute renal failure [17]. It is interesting to note that more than 50% of patients (19/34) with small bowel CDI had IBD. The rising incidence of CDI should raise suspicion of Cl. difficile when IBD patients develop profuse diarrhea, in patients who underwent recent surgical intervention. The susceptibility of IBD patients to CDI both of the colon and small bowel is intriguing. IBD patients are at risk because of antibiotic use, hospitalizations, the dramatic risk of infection cannot be fully explained by the above risk factors and raises the question whether abnormalities in mucosal immune response in IBD might play a role in CDI
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