Clostridium difficile Small-Bowel Enteritis After Total Proctocolectomy: A Rare But Fatal, Easily Missed Diagnosis. Report of a Case

Abstract

Review of previously reported cases of Clostridium difficile enteritis showed a high mortality rate. We attribute this to delayed diagnosis secondary to rarity of this illness. Some patients were diagnosed only after pseudomembranes in small-bowel segments were found at autopsy. This rare disease entity is firmly established among the differential diagnosis to clinicians treating patients with total proctocolectomy.

Risk Factors and Outcome of PCR-detected Clostridium difficile Infection in Ileal Pouch Patients

“…10,38 Additionally, there were two patients with positive results for C. difficile toxins who had normal appearance by pouch endoscopy. This might suggest that either these two patients were C. difficile carriers, or the small bowel might be a site of CDI in patients with ileal pouch as reported in several case reports, 37,39,40 or some patients diagnosed with irritable pouch syndrome might in fact have CDI. We chose vancomycin as our initial therapy for CDI in ileal pouch patients, based on evidence that vancomycin appeared superior to metronidazole for severe or complicated CDI.…”

Practice of gastroenterologists in treating flaring inflammatory bowel disease patients with clostridium difficile

“…3,5,12,13 This organism has been implicated in flares of disease especially in IBD patients with colonic disease, although cases of C. difficile-associated enteritis and pouchitis have also been reported. 14,15 Nevertheless, the exact pathogenic role of C. difficile in these settings has yet to be defined. In principle, C. difficile may cause an isolated infectious colitis superimposed on IBD, or conversely, may precipitate an IBD flare leading to two separate but simultaneous inflammatory processes.…”

Clostridium difficile infection in the absence of a colon

“…Pseudomembranous colitis is generally confined to the colon with a demarcation at the ileocaecal valve 2. Although CD has been described in jejunal aspirates,3 small bowel involvement occurring in patients with an ileostomy remote from the time of the colectomy for inflammatory bowel disease is rare 4–7…”

“…A literature search revealed 15 case reports of CD enteritis with prior abdominal surgery in 11 of 15 cases 1 7. An additional series described 12 cases of CD enteritis; 6 with an ileostomy, of whom only 1 had underlying inflammatory bowel disease 8.…”