Clostridium difficileEnteritis after Total Abdominal Colectomy for Ulcerative Colitis

Abstract

Introduction. Isolated Clostridium difficile small bowel enteritis is a rare condition with significant morbidity and mortality. Presentation of Case. An 83-year-old female with refractory ulcerative colitis underwent a total proctocolectomy and end ileostomy. Her postoperative course was complicated with return to the operating room for repair of an incarcerated port site hernia. Subsequently, she developed septic shock and multiorgan failure requiring intubation and mechanical ventilation, renal replacement therapy, and high dose vasopressors. Diagnostic workup revealed diffuse small bowel wall thickening on computed tomography scan as well as positive nucleic acid amplification test for C. difficile toxin B gene. Despite treatment with antibiotics and maximum attempts at resuscitation, the patient expired. Discussion. C. difficile infection most commonly affects the colon but rarely can involve the small bowel. The pathogenesis of C. difficile enteritis is unclear but is believed to mirror that of colitis. Surgical patients are susceptible for C. difficile infection, as they tend to be relatively immunosuppressed in the postoperative period. Radiologic findings of enteritis may mimic those of colitis and this includes small bowel dilation and thickening. Treatment for this condition has not been well established but it is approached similar to colitis. Conclusion. Despite an increase in the number of case reports of C. difficile enteritis, it continues to be a rare but potentially fatal infection. Clinicians should maintain a high index of suspicion especially in patients with inflammatory bowel disease who undergo colon resections.

The Current Knowledge on Clostridioides difficile Infection in Patients with Inflammatory Bowel Diseases

“…Imaging provides clues in severe colonic inflammation: bowel wall thickening, thumbprinting, accordion sign, pericolonic stranding and ascites [ 108 , 109 , 110 ]. Similar findings, consisting of small bowel dilatation, wall thickening, and ascites, have been described in CD enteritis [ 111 , 112 ]. Abdominal ultrasound allows the assessment of disease extent and severity, and specific features for both CDI and IBD can be detected: thickening of the bowel wall, colonic dehaustration, free fluid between bowel loops, colonic dilatation, or free air in complicated cases.…”

Clostridioides Difficile Enteritis: Case Report and Literature Review

“…Veterinary studies were excluded, as were basic science studies and articles focusing on pediatric patients (age <18 years). Per our selection strategy, 77 reported cases were identified in 49 publications and our results are presented in Table 1 [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ].…”

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection

“…18,19 Although C difficile most commonly causes colitis, a few reports describe its pathogenicity in the small bowel, as well. 20,21,68 In almost all of these cases, clinically significant disease was identified in patients with an ileostomy and was associated with patients with a history of IBD, a prolonged antibiotic course, or recent surgery or a prior episode of CDI. 69 Whether or not bowel preparation increases the risk for CDI remains controversial.…”