Usefulness of the Severity Grading By Sigmoidscopy in the Prediction of Clinical Outcome in Patients with Pseudomembranous Colits

Abstract

Background: Clostridium difficile infection results in a broad spectrum of clinical course from mild disease to life-threatening pseudomembranous colitis (PMC). The purpose of this study was to evaluate whether the severity of PMC on sigmoidoscopy would be related to clinical outcomes. Methods: We reviewed sigmoidoscopic findings and medical records of 74 patients with PMC. Sigmoidoscopic grades of PMC were classified into mild (n = 45) when the pseudomembrane covered <1/3 of lumen, moderate (n = 18) when the pseudomembrane covered 1/3-2/3 of lumen, and severe (n = 11) when the extent of pseudomembrane was >2/3 of lumen. Enzyme immunoassay (EIA) for toxin A of Clostridium difficile in stool was performed. The relation between clinical course and sigmoidoscopic grades was analyzed. The relation between sigmoidoscopic grades and results of EIA for toxin A was also analyzed. Results: The mean age was 62 ± 16 years and 38 (51%) were male. The factors such as ileus(Odd ratio[OR] = 11.0, 95% Confidence interval[CI]: 1.4-84.6; p = 0.022), nasogastric tube feeding (OR = 16.0, 95%CI:1.3-194.6, p = 0.029) and lower serum albumin level (OR = 31.0, 95%CI: 2.0-470.6, p = 0.013) were independently associated with severe degree of sigmoidoscopic grade, whereas the endoscopic severity was not related to age, gender, positive culture, frequency of diarrhea, surgery and usage of steroid. Patients with severe grade showed markedly lower rate of 1-year survival rate (17 ± 14%) compared with mild group (85 ± 6%) and moderate group (84 ± 11%) (p < 0.001) although recurrence rate was not different (3/11, 27% versus 11/63, 18%; p = 0.443). On multivariate Cox analysis, age over 65 years (OR=2.6, 95%CI:1.0-6.4, p = 0.040) and severe sigmoidoscopic grade (OR = 10.8, 95% CI:3.8-29.8, p < 0.001) were independent predictors of death. EIAs for toxin A were negative in all 11 patients with severe grade while 38 of 58 (66%) with mild and moderate grade showed negative results on EIAs for toxin A (p < 0.001). Conclusion: Sigmoidoscopy may be a useful tool in the prediction of clinical outcome in patients with PMC. Sigmoidoscopy may be also useful in the diagnosis of PMC, especially in severe patients because noninvasive stool EIA for toxin A was negative in all the patients with severe sigmoidoscopic grade.