Table 2.
Previous studies analyzing surgical management of fulminant Clostridium difficile colitis
| Article | Indications for surgical consultation and operative management | Notes |
| Carchman et al[6] | Indications for Surgical Consultation in Patients with Known or Suspected | Strength/quality of evidence, B-III |
| Review | CDAD | |
| Ileus/significant abdominal distension | ||
| Admission to intensive care unit | ||
| Hypotension (+/- vasopressors) | ||
| Mental status changes | ||
| WBC counts ≥ 35 × 109 /μL | ||
| Serum lactate ≥ 2.2 mmol/L | ||
| Any evidence of end-organ failure | ||
| Age ≥ 80 yr with severe CDAD criteria | ||
| Immunosuppression with severe CDAD criteria | Strength/quality of evidence, B-II | |
| Indications for Operative Management in Patients with CDAD | ||
| Diagnosis of C. difficile colitis as determined by one of the following: | ||
| Positive toxin assay result | ||
| Endoscopic findings (pseudomembranes) | ||
| CT scan findings (pancolitis +/- ascites) | ||
| Plus any one of the following criteria: | ||
| Peritonitis | ||
| Perforation | ||
| Worsening abdominal distension/pain | ||
| Sepsis | ||
| Intubation | ||
| Vasopressor requirement | ||
| Mental status changes | ||
| Unexplained clinical deterioration | ||
| Renal failure | ||
| Lactate level > 5 mmol/L | ||
| WBC count ≥ 50 × 109/μL | ||
| Abdominal compartment syndrome | ||
| Failure to improve with standard therapy within 5 d as determined by resolving symptoms and physical examination, resolving WBC per band count | ||
| Osman et al[14] | Summary of the clinical, laboratory, and radiologic features of fulminant C. difficile colitis | Severe, complicated CDAD synonymous with fulminant CDAD is considered to be indication for operative management by these authors. |
| Original article | Clinical: | |
| History of diarrhea following antibiotic use | ||
| Systemic toxicity | ||
| Pyrexia ≥ 38 °C | ||
| Tachycardia > 100 beats/min | ||
| Hypotension: BP < 90 mmHg | ||
| Abdominal signs of Peritonitis | ||
| Generalized abdominal pain | ||
| Tenderness | ||
| Abdominal distension | ||
| Rebound tenderness | ||
| Organ failure and requirement for vasopressor therapy | ||
| Laboratory and Radiologic: | ||
| Increasing leukocytosis > 16 × 109 /L | ||
| Lactate > 2.2 mmol/L | ||
| Hypoalbuminemia < 30 g/L | ||
| Radiologic evidence of toxic megacolon (abdominal X-ray or CT) | ||
| Free air under the diaphragm | ||
| Butala et al[15] | Prognosticators for development of fulminant colitis | Strength/quality of evidence, B |
| Review | Age > 65 yr | |
| Lactate between 2.2-4.9 mmol/L | ||
| WBC count > 16000/μL-surgery within 30 d | ||
| History of Inflammatory bowel disease | ||
| Treatment with intravenous immunoglobulin | ||
| Colitis associated with signs of organ dysfunction | ||
| Girotra et al[16] | Summary of red flags for development of fulminant Clostridium difficle colitis | |
| Original article | Age > 70 yr | |
| Presenting symptoms: Triad of abdominal pain, diarrhea, and distension | ||
| Signs: Tachycardia (heart rate > 100 beats/min), tachypnea (respiratory rate > 20 respirations/min),or hypotension (systolic BP < 90 mmHg) | ||
| Recent C. difficile infection | ||
| Use of antiperistaltic medications (narcotics or anticholinergics) | ||
| White blood cell count > 18000/mm3 | ||
| Radiology studies suggestive of megacolon or perforation |
C. difficile: Clostridium difficile; CDI: Clostridium difficile infection; CDAD: Clostridium difficile associated disease; WBC: White blood cell.