Diagnosis Of Pseudomembranous Colitis Research Articles

Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications.PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females — 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%.The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy).RESULTS: the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics — 44.6%, glucocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy — 33.08%, laparoscopy — in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confirmation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients — 78.9%, mortality — 15.0%), colon resection (n = 6 (7.9%), mortality — 66.6%), ileo- or colostomy (n = 8 (10.5%), mortality — 37.5%), colectomy (n = 2 (2.6%), mortality — 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment — 8.8%.CONCLUSION: pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelming majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient’s condition and the development of severe intra-abdominal complications and sepsis.

Pseudomembranous colitis with negative Clostridium difficile PCR presenting with massive ascites: a case report and literature review

Pseudomembranous colitis (PMC) is characterized by the presence of an inflammatory pseudomembrane overlying the colonic mucosa, and is primarily caused by Clostridium difficile infection (CDI). PMC is often associated with the use of broad-spectrum antibiotics. Common symptoms include watery diarrhea, mucus in stool, abdominal cramps, and fever. We report a case of a 52-year-old female presenting with new abdominal distention, frequent bloody, mucoid, jelly-like diarrhea, and abdominal pain. Peritoneal fluid analysis showed neutrocytic ascites with low serum-ascites albumin gradient (SAAG). A diagnosis of pseudomembranous colitis was confirmed by flexible sigmoidoscopy. However, polymerase chain reaction (PCR) test for Clostridium difficile was negative. The patient was treated with metronidazole (500 mg IV q8h) and vancomycin (250 mg PO QID). Her symptoms resolved after several days of treatment with no ascites found by ultrasound. Neutrocytic ascites can be a complication of PMC. Physicians should also be aware that empirical treatment of Clostridium difficile may cause false negative diagnostic test result.

Incidental Detection of Colonic Inflammation on PET/CT Using 18F-FDG–Labeled Autologous Leukocytes

Labeled leukocyte scintigraphy and (18)F-FDG PET are well-documented techniques for the assessment of inflammatory bowel disease. In this study, a 28-year-old man with abdominal pain, vomiting, and raised serum amylase and lipase levels underwent PET/CT imaging using FDG-labeled autologous leukocytes to assess for pancreatic infection. While the pancreas showed no abnormal tracer uptake, colonic inflammation was incidentally detected, and a diagnosis of pseudomembranous colitis was subsequently confirmed on colonoscopy and biopsy.

A Case of Pseudomembranous Colitis after Voriconazole Therapy

This is a case report on a 35-year-old man with acute myelogenous leukemia who presented fever and intermittent mucoid loose stool to the emergency center. He had been taking voriconazole for invasive pulmonary aspergillosis. The flexible sigmoidoscopy was consistent with the diagnosis of pseudomembranous colitis.

Ultrasound diagnosis of pseudomembranous colitis

The diagnosis of pseudomembranous colitis (PMC) is based on the history of exposure to antibiotics, characteristic endoscopic findings and on demonstrating the presence of Clostridium difficile toxins in the faeces. This report presents typical sonographic features of PMC. The sonograms of 13 patients with PMC (7 males, 6 females, median age 70 years, range 55-84 years), were retrospectively analyzed. Patients' histories, clinical findings, the results of colonoscopy including histological findings and microbiological tests were related to the sonographic features of inflammation of the colon. At sonography the wall of the colon was thickened (6-17 mm) in each of the patients, different types of changed wall-architecture were seen. In 85% sonographic signs of colitis were restricted to the left colon, whereas in 15% a pancolitis was diagnosed. Ascites was detected in 38%, the colon contents were visible in 85%, in 77% the lumen was narrowed. Colonoscopy confirmed the diagnosis in six patients, in two patients endoscopy was performed only to control the effect of therapy and in five patients endoscopy was thought to be unnecessary. Sonography can supplement history and clinical findings if PMC is suspected. Potentially life-saving therapy can be initiated even if colonoscopy has not been performed and results of microbiological assessment are not yet available. However, the diagnosis of PMC remains to be based on the gold standard of colonoscopy and histological findings.

Fulminant Postcesarean Clostridium difficile Pseudomembranous Colitis

Pseudomembranous colitis due to Clostridium difficile infection is rarely reported in the obstetric literature. This disease process is associated with prior antibiotic exposure. A term primigravida was delivered by primary cesarean for failed vacuum extraction. She received Intravenous cefazolin after cord clamping, which was continued for 36 hours for a presumptive diagnosis of endometritis. On day 3, oral amoxicillin and clavulanate was started for suspected cellulitis of the incision. She was readmitted 1 day after her discharge with severe diffuse abdominal pain and distention. Proctoscopy showed pseudomembranous colitis. Colectomy with temporary ileostomy was performed for worsening symptoms and imminent perforation. The diagnosis of pseudomembranous colitis should be considered in postpartum women who have low-grade fever, abdominal and gastrointestinal symptoms, and recent antibiotic exposure.

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

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.

Pseudomembranous colitis presenting as acute colonic obstruction without diarrhea in a patient with gastric Burkitt lymphoma

Pseudomembranous colitis (PMC) usually manifests as fever and diarrhea in hospitalized patients treated with systemic antibiotics. We described a case of PMC with intestinal obstruction but without diarrhea. A 60-year-old man was hospitalized for chemotherapy for the treatment of Burkitt lymphoma of the stomach. The patient became febrile and complained of crampy abdominal pain during the post-chemotherapy nadir. Plain abdominal radiography showed some intestinal gas and niveau. Because stool cytotoxin assay for clostridium difficile was positive and colon fiberscopic examination showed a pseudomembrane at the left side of the colon, and a diagnosis of PMC was made. Treatment with intracolonic vancomycin administration by colonoscopy and nasoileus tube was successful. Physicians should take into account the possibility of bowel obstruction due to PMC occurring in patients undergoing chemotherapy and perform emergency colonoscopy examination of suspected cases.

P0631 DIFFICULTY IN DIAGNOSING PSEUDOMEMBRANOUS COLITIS IN INFLAMMATORY BOWEL DISEASE (IBD)

Introduction: Clostridium difficile (C. diff) infections are commonly seen in patients with IBD, and may be seen both at initial presentation and during the course of the disease, often resulting in acute exacerbations. Diagnosis is routinely made by using rapid enzyme immunoassays (EIAs) which detect the presence of toxin A and B in stools. However in patients with severe diarrhea dilution of the toxin can occur, resulting in a negative test, delaying diagnosis and treatment which may lead to worsening of the clinical course Methods: We report two cases where the diagnosis of pseudomembranous colitis was made by colonoscopy. CASE 1: 16 yr old male with indeterminate colitis (IC) diagnosed at 8 yrs of age, previously well controlled on sulfasalazine alone. He presented with a one month history of increasing abdominal pain (AP), diarrhea (8–10 stools/day) and a 10 pound weight loss. Labs: ESR-4 (0–20), CRP-32 (<5), WBC count-14.5K (bands 10%). Only the last of three stool samples was positive for C. diff. Flagyl was given for one week. Due to worsening clinical course, colonoscopy was performed which revealed diffuse colitis with pseudomembranes in the transverse and distal colon. Although stool samples remained negative for C. diff., he was started on vancomycin and showed gradual improvement of hematochezia and AP. CASE 2: 20 yr old female with Crohn’s disease (CD), involving the colon and perineum, diagnosed at 3 yrs of age. She presented with a four day history of colicky AP, diarrhea (10–12 stools/day), and a 3 pound weight loss. She was on Flagyl (for a prior C. diff infection, 3 weeks earlier), Thalidomide, ciprofloxacil and prednisone. Labs: ESR-55 (0–20), CRP-66 (<5), WBC count-8.5K (bands 34%), 4 stool samples were collected and all were negative for C. diff. Colonoscopy revealed pancolitis with pseudomembranes throughout. Flagyl was discontinued and she was started on vancomycin with gradual improvement. Results: As seen from case 1, multiple stool assays may be necessary to diagnose C. diff infections in patients with IBD, and a negative test does not always rule out pseudomembranous colitis as seen in case 2. Conclusion: Routine diagnostic stool assays may not diagnose C. diff infections in patients with IBD, possibly due to a dilutional effect on toxin concentration from severe diarrhea. In patients in whom an infectious etiology is suspected, a limited colonoscopy may be helpful to diagnose and promptly treat pseudomembranous colitis in C. diff negative patients, leading to improvement in their clinical course

著明な粘膜浮腫像を呈したvancomycin治療抵抗性偽膜性腸炎の1例

A 77-year-old female was referred because of abdominal pain and diarrhea, which occurred two days after antibiotic treatment (cefotiam, 2ｇ/day) . Because endoscopic examination showed multiple white plaques on the sigmoid colon and Clostridium difficile toxin was detected in colostrum, a diagnosis of pseudomembranous colitis was made. Although oral vancomycin (VCM) administration relieved the symptoms, fever and diarrhea recurred 11 days after the administration of VCM was terminated. Colonoscopy again revealed pseudomembranes as well as marked mucosal edema of the colon. Abdominal CT demonstrated double layers of the large bowels, being compatible with marked mucosal edema. Metronidazole (MTZ) was co-administered with VCM for 15 days and VCM was tapered in 22 days. The abdominal symptoms dissappeared and no abnomality was shown on endoscopic examination. Any relapse of pseudomembranous colitis was not observed after cessation of the treatment. Remarkable mucosal edema of the colon was rarely presented with pseudomembranous colitis and was supposed to be a finding related with VCM-resistancy of pseudomembranous colitis.

Computed Tomographic Findings in Pseudomembranous Colitis: An important Clue to the Diagnosis

Computed tomography (CT) is increasingly used to evaluate abdominal diseases, including those of the colon. Recent CT studies have documented colonic abnormalities in patients with pseudomembranous colitis; however, these findings are not widely appreciated by primary care physicians. Over a 25-month period, we prospectively identified 13 patients who had proven pseudomembranous colitis evaluated by abdominal CT. The primary indications for CT were abdominal pain with or without fever in 9 patients, fever of unknown origin in 1, evaluation of other abdominal processes in 1, and as part of this study after documentation of pseudomembranous colitis in 2. Importantly, the diagnosis of pseudomembranous colitis was first considered on the basis of the CT findings in 9 patients with abdominal pain or fever. Diffuse thickening of the colonic wall, ranging from 4 to 40 mm, was the most common radiologic finding, seen in 8 patients (62%). In 3 cases, wall thickening was seen in the descending colon and rectosigmoid, with one of these also having a thickened transverse colon. Colonic wall thickening, which may be dramatic, appears to be an almost uniform accompaniment of pseudomembranous colitis and may be present without clinically severe disease. These CT findings in the appropriate clinical setting should suggest colitis due to Clostridium difficile and prompt the appropriate evaluation for this disease.

HYPOVOLEMIC SHOCK DUE TO PSEUDOMEMBRANOUS COLITIS ON THE THIRD DAY FOLLOWING TOTAL GASTRECTOMY -A CASE REPORT-

A case of pseudomembranous colitis presenting with tachycardia, fever, and shock, but not accompanying by abdominal pain and diarrhea in an early stage after gastrectomy is described. Pseudomembranous colitis, if it occurs in an early stage after gastrointestinal operation, often lacks in abdominal symptoms. This case, being sucessfully diagnosed to start the treatment in a relatively early postoperative period, is rare.A 52-year-old man underwent total gastrectomy for primary malignant lymphoma. Cefotaxim (CTX) administration was started on the day of operation. From the 3rd postoperative day severe tachycardia, fever, and shock occurred, and nosotropic therapy failed to improve the general condition. Cause searching try also failed to disclose any complications such as anastomotic leakage and abdominal bleeding. On the 4th day a large amount of water diarrhea appeared. Endoscopic examination of the large intestine was performed. Based on macroscopic findings and biopsy cytodiagnosis, a diagnosis of pseudomembranous colitis was made. Administration of vancomycin hydrochloride and a large quantity of transfusion led to rapid symptomatic remission.

Pseudomembranous colitis: sonographic features.

The sonographic features of pseudomembranous colitis (PMC) are described in 13 patients and correlated with clinical, radiologic, and pathologic findings. At sonography, the wall of the entire colon was moderately to markedly thickened in all patients. The enlarged colon wall was most commonly shown as a wide band of heterogeneous medium echogenicity surrounded by a narrow hypoechoic layer. Pathologic correlations proved that the wide inner stratum represented severely edematous submucosa and mucosa, while the outer layer depicted the muscularis propria. Almost complete effacement of the lumen of the colon occurred secondary to the mural edema in 69% of the cases. The dearth of intraluminal gas combined with thickening of the colon wall and ascites facilitated excellent sonographic evaluation. The diagnosis of PMC is strongly suggested by the presence of these sonographic features in a patient with watery diarrhea and a history of antibiotic therapy.

Pseudomembranous colitis with rectosigmoid sparing on barium studies.

The classic description of pseudomembranous colitis on barium enema studies is that of pancolitis with thickened haustral folds, a shaggy luminal contour, and/or mucosal plaques. However, the authors describe six patients with proved pseudomembranous colitis in whom barium studies (four double-contrast barium enema studies, one single-contrast barium enema study, and one peroral pneumocolon study) demonstrated rectosigmoid sparing with proximal colitis extending from the cecum to the sigmoid colon (three cases) or to the descending colon (three cases). In all six cases, endoscopy revealed a normal rectum or mild, nonspecific proctosigmoiditis without evidence of pseudomembranes in the rectosigmoid colon. Four patients had an atypical clinical presentation with bloody diarrhea (three cases) or minimal mucous diarrhea (one case). Thus, the diagnosis of pseudomembranous colitis may initially be suggested on barium studies in patients who have relative sparing of the rectosigmoid colon with characteristic findings more proximally in the colon.

Pseudomembranous colitis following prophylactic antibiotic use in primary cesarean section

A report of a hospital outbreak of pseudomembranous colitis in three patients given prophylactic antibiotic therapy before and after primary cesarean section is presented. All patients shared the same ward and labor and delivery room, and the colitis occurred within an 8-day period. The diagnosis of pseudomembranous colitis was suspected clinically and confirmed by limited colonoscopy and biopsy followed by stool culture and toxin assay for Clostridium difficile. The high carrier rate of Clostridium difficile in the female urogenital tract and altered colonic motility during pregnancy, in addition to antibiotic use, may have contributed to the establishment of this disease. When diarrhea develops postoperatively in patients who have undergone cesarean section, pseudomembranous colitis as a potential serious complication must be kept in mind and necessary precautions taken to impede cross-contamination and development of secondary cases.

Clostridium difficile and cytotoxin in feces of patients with antimicrobial agent-associated pseudomembranous colitis.

Thirty patients with antimicrobial agent-associated pseudomembranous colitis (PMC) were studied for the presence of Clostridium difficile and its cytotoxin in feces. Either colonoscopy or barium enema radiography was required in three patients for the diagnosis of PMC because of nondiagnostic findings at sigmoidoscopy. Both the organism and cytotoxin were detected in 27 of the 30 patients; Staphylococcus aureus was excluded as the cause of PMC in two of the remaining patients. Eighteen of 19 patients with C. difficile-induced PMC who were treated with oral vancomycin had a salutary response; seven patients, however, had a relapse of colitis following the discontinuation of vancomycin. In general, relapses of colitis responded to retreatment with vancomycin. The implication of C. difficile as a cause of diarrhea is best achieved by the demonstration of colonic mucosal plaques or of a pseudomembrane. The value of fecal culture for C. difficile and cytotoxin assay is limited by the existence of asymptomatic carriers.

Cephalosporin-Associated Pseudomembranous Colitis due to Clostridium difficile

Recent studies have shown considerable progress in the diagnosis, etiology, and therapy of antibiotic-associated pseudomembranous colitis. Previous work has implicated a number of antimicrobial agents, but there are relatively few reports concerning the role of cephalosporins. The subject of the present report is 17 patients with pseudomembranous colitis associated with cephalosporin use. Tissue cultures of stools from all patients showed a cytotoxin that is neutralized by C sordellii antitoxin. Bacterial cultures of these specimens yielded strains of C difficile that produced a similar cytotoxin in vitro. Nine of the patients were treated orally with vancomycin hydrochloride and all responded. This experience illustrates the importance of considering the diagnosis of pseudomembranous colitis in patients in whom diarrhea develops in association with cephalosporin use. ( JAMA 242:2683-2685, 1979)

The Diagnosis of Pseudomembranous Colitis by Rectal Biopsy

The Diagnosis of Pseudomembranous Colitis by Rectal Biopsy