Two Patients with Fulminant Clostridium difficile Enteritis Who Had Not Undergone Total Colectomy: A Case Series and Review of the Literature.

Eliza W Beal,Alan E Harzman,Rosara Bass

doi:10.1155/2015/957257

Eliza W Beal, Alan E Harzman + Show 1 more

Open Access

https://doi.org/10.1155/2015/957257

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Abstract

Introduction. Clostridium difficile is the most common cause of healthcare associated infectious diarrhea, and its most common clinical manifestation is pseudomembranous colitis. Small bowel enteritis is reported infrequently in the literature and typically occurs only in patients who have undergone ileal pouch anastomosis due to inflammatory bowel disease or total abdominal colectomy for other reasons. Presentation of Cases. We report here two cases in which patients developed small bowel C. difficile enteritis in the absence of these underlying conditions. Discussion. Neither patient had underlying inflammatory bowel disease and both had a significant amount of colon remaining. Conclusion. These two cases demonstrate that small bowel C. difficile enteritis should be included in the differential diagnosis of patients on antibiotic therapy who demonstrate signs and symptoms of worsening abdominal disease during their postoperative course, even if they lack the major predisposing factors of inflammatory bowel disease or history of total colectomy.

Highlights

Clostridium difficile is the most common cause of healthcare associated infectious diarrhea, and its most common clinical manifestation is pseudomembranous colitis
Red rubber catheters were placed in both sides of her ileostomy and her rectum taking care not to disrupt her coloanal anastomosis. 500 mg of vancomycin was placed in each of these tubes and down her nasogastric tube every 6 hours. Her hospital course was further complicated by ventricular tachycardia, heart failure intolerance of enteral feeds, cholestatic jaundice, need for reoperation for placement of absorbable mesh for closure of the abdominal cavity, leukocytosis, need for total parenteral nutrition (TPN), tracheostomy, development of enterocutaneous fistula, multiple intraabdominal abscesses, a repeat episode of C. difficile enteritis, atrial fibrillation with rapid ventricular rate, and a urinary tract infection
Of the 63 cases identified in the literature, thirty-one (49.2%) patients did not have a diagnosis of inflammatory bowel disease (IBD)

Summary

Introduction

Clostridium difficile is the most common cause of healthcare associated infectious diarrhea [1]. Symptoms and signs of severe C. difficile infection include watery, foul-smelling diarrhea, pseudomembranous colitis, marked peripheral leukocytosis, acute renal failure, and hypotension [2]. The incidence of C. difficile has increased significantly over the past 25 years with a concomitant increase in severity and mortality [2]. Intravenous metronidazole and oral vancomycin remain the treatments of choice for C. difficile colitis [2] and were long considered equivalent [3]. In a prospective, randomized, placebo-controlled trial it was demonstrated that the two agents had similar efficacy in mild infection, but that vancomycin had a significantly higher response rate in patients with severe infection (97% versus 76%, P = 0.02) [3]. Other agents currently being evaluated include difimicin and tolevamer [2]. The authors who have written on the topic seem to agree that early diagnosis is important in obtaining improved outcomes

Presentation of Cases

Discussion and Review of the Literature

Findings

Conclusion

Conflict of Interests