Indications and Relative Utility of Lower Endoscopy in the Management ofClostridium difficileInfection

Abstract

Background. Diagnosis and management of Clostridium difficile infection (CDI) rely upon clinical assessments and diagnostic studies. Among diagnostic tests, lower gastrointestinal (GI) endoscopy in the setting of CDI remains controversial. Objective. To describe the role of lower endoscopy in CDI management. Methods. Retrospective study of lower endoscopies in CDI at four metropolitan hospitals, July 2005 through December 2007. Results. Of 1760 CDI inpatients, 45 lower endoscopies were performed on 43 patients. Most common indications were ruling out other etiologies (42%), inconclusive stool studies (36%), and worsening course (11%). Most endoscopies (73%) had positive findings, including pseudomembranous colitis (49%) and nonspecific colitis (24%). Biopsies were performed in 31 cases, more with nonspecific colitis (10/11, 92%) compared to pseudomembranous colitis (14/22, 64%). Conclusion. While not recommended as a primary screening tool, lower GI endoscopy can add valuable information in CDI when other colonic pathologies may exist, studies are inconclusive, or clinical status worsens.

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“…We performed the NAATs (Xpert) and toxin B EIA test, and both tests were positive; thus, we believe that CDI was most likely present. However, we used enteroscopy as another diagnostic tool in this patient because we thought that he might have other causes for the severe diarrhea, which is consistent with the indications for enteroscopy in patients with CDI[8]. According to the ESCMID guidelines[9], pseudomembranous colitis can support the diagnosis of severe CDI in our case.…”

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“…При этом следует подчеркнуть, что колоноскопия для поиска псевдомембран и получения образца стула не является необходимой для постановки или подтверждения диагноза в большинстве эпизодов и может даже быть связана с повышенным риском осложне-Пробиотики • Клинические исследования • ний [4]. Однако она может быть полезна в условиях ассоциированной патологии толстой кишки, неубедительных лабораторных анализов, при подозрении на наличие кишечной непроходимости, когда образец кала недоступен, или при остром ухудшении состояния для определения дальнейшей тактики ведения больного и необходимости срочного хирургического вмешательства [32]. О классическом «псевдомембранозном колите» сообщается примерно в половине случаев CDI, при которых проводится эндоскопия, что ограничивает использование этого метода исследования в качестве раннего теста для подтверждения CDI [32].…”

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“…However, patients with a complicated clinical picture who have findings such as colon wall thickening or “mucosal thumbprinting” on abdominal CT are indicative of CDI with a high positive predictive value for infection and should be considered for treatment 29 . Lower endoscopic studies like flexible sigmoidoscopy are generally not recommended but can be useful in the settings of a coexisting colonic pathology, inconclusive lab tests, colonic ileus where stool sample is not available, or acute worsening symptoms when rapid diagnosis is important to determine the need for urgent surgical intervention 30 . The classic “pseudomembranous colitis” has been reported in about half of CDI cases undergoing endoscopy, thus limiting its use as a test of choice for the confirmation of CDI 30 .…”

“…Lower endoscopic studies like flexible sigmoidoscopy are generally not recommended but can be useful in the settings of a coexisting colonic pathology, inconclusive lab tests, colonic ileus where stool sample is not available, or acute worsening symptoms when rapid diagnosis is important to determine the need for urgent surgical intervention 30 . The classic “pseudomembranous colitis” has been reported in about half of CDI cases undergoing endoscopy, thus limiting its use as a test of choice for the confirmation of CDI 30 .…”