Pseudomembranous enteritis after proctocolectomy

Abstract

Intestinal pseudomembrane formation, sometimes a manifestation of antibiotic-associated diarrheal illnesses, is typically limited to the colon but rarely may affect the small bowel. A 56-year-old female taking antibiotics, who had undergone proctocolectomy for idiopathic inflammatory bowel disease, presented with septic shock and hypotension. A partial small-bowel resection revealed extensive mucosal pseudomembranes, which were cultured positive for Clostridium difficile. Intestinal drainage contents from an ileostomy were enzyme immunoassay positive for C. difficile toxin A. Gross and histopathologic features of the small-bowel resection specimen were similar to those characteristic of pseudomembranous colitis. The patient was treated successfully with metronidazole. These findings suggest a reservoir for C. difficile also exists in the small intestine and that conditions for enhanced mucosal susceptibility to C. difficile overgrowth may occur in the small-bowel environment of antibiotic-treated patients after colectomy. Pseudomembranous enteritis should be a consideration in those patients who present with purulent ostomy drainage, abdominal pain, fever, leukocytosis, or symptoms of septic shock.

Clostridium Difficile Infection—An Unusual Cause of Refractory Pouchitis: Report of a Case

“…three reports describing the isolation of C. difficile from the small intestine in patients who survived the infective episode, [6][7][8] with four other reports from patients who died shortly after the diagnosis was made. [9][10][11][12] Taylor et al 6 described a patient with a history of unexplained diarrhea, in whom jejunal aspirates and culture yielded C. difficile.…”

“…8 A partial smallbowel resection revealed extensive pseudomembranes, which were cultured positive for C. difficile. She had recently received antibiotics for a urinary tract infection.…”

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

“…Among all the reported incidences of C. difficile enteritis, the mortality rate is 63 percent (7/11 deaths, including this report). [12][13][14][15][16][17][18][19][20][21][22] The mortality rate for C. difficile enteritis in patients with total colectomy is 60 percent (3/5, including this report). This high mortality rate is to the result of delayed diagnosis secondary to rarity of this illness.…”

Recurrence of Clostridium difficile infection after total colectomy in an allogeneic stem cell transplant patient

“…The infection is almost always limited to the colon, but there have been rare case reports of C. difficile enteritis. [2][3][4][5] We present an allogeneic transplant recipient with chronic GvHD who developed recurrent C. difficile infection after total colectomy.…”

“…Although total colectomy is intended to be curative, there have been rare reported cases of C. difficile enteritis after a total colectomy. [2][3][4][5] These reports suggest that the small bowel flora can also be altered by antibiotic use. C. difficile can infect the small bowel after a colectomy and manifest as infection like the colon, resulting in comparable symptoms.…”