There have been less than one-hundred reported cases of Clostridium difficile enteritis, demonstrating the rarity of our case. To date, there is no consensus on the treatment of C.difficile enteritis. Understanding the cause for C.diff enteritis and initial treatment is important to quickly identify and prevent potential associated complications.Figure 1Figure 2A sixty-four year-old male with familial adenomatosis polyposis s/p colectomy and J-pouch presented with recurrent gastrointestinal bleeding, abdominal pain, and diarrhea. A recent EGD and RBC scan failed to identify a bleeding source. An abdominal/pelvis CT performed two days prior to admission was significant for small bowel distention. Repeat abdominal/pelvis CT found enteritis of the J-pouch and fluid-filled bowel loops. A C. difficile antigen test was positive. Initial treatment with oral metronidazole was unsuccessful. Antibiotics were changed to intravenous metronidazole and oral vancomycin and finally oral vancomycin for two weeks. The diarrhea improved and repeat C.difficile antigen testing was negative. Following treatment, the abdominal pain and nausea persisted and the patient was unable to tolerate a colonoscopy prep. An abdominal x-ray revealed multiple loops of small bowel with air-fluid levels of discordant heights. Due to concerns for a small bowel obstruction an NG tube was inserted. An exploratory laparotomy with lysis of adhesions and pouch endoscopy were performed revealing an internal closed loop obstruction and a distal pouch obstruction due to anal stenosis, which was dilated. The constipation continued following the operation and a rectal tube was placed. A repeat enteroscopy two weeks after the laparotomy found an ileoanal stricture above the J-pouch and was dilated. Afterwards, the bowel obstruction and patient's condition improved. This case illustrates the delay in diagnosis of the cause of a small bowel obstruction following C.difficile enteritis leading to an extended hospital stay. This case raises the question of whether the stricture may have have been prevented with either earlier or more aggressive antibiotic therapy. Further, with no consensus for treatment of C.difficile enteritis, is aggressive initial antibiotic therapy necessary as compared to standard treatment for C.difficile colitis?