Clostridium difficile ileitis in a patient, after total colectomy

Abstract

This is a case of a 63-year-old, post total colectomy patient, who presented to the hospital with watery diarrhoea, abdominal cramping and fevers. On admission, the patient was haemodynamically stable and febrile. Clostridium difficile PCR was sent and tested positive. CT of the abdomen revealed diffuse thickening of the distal small bowel to the level of the anastomosis and mesenteric oedema consistent with infectious enteritis. The patient was started on vancomycin orally as well as flagyl intravenously. Because of an ileus, he initially was treated with bowel rest and a NG tube. Surgical consult was obtained early with no intervention. The patient's symptoms progressively resolved over the next 7 days of hospitalisation, and he was discharged home.

Background

Clostridium difficile causes severe infection, especially in the older population and in those who are diagnosed late in the disease progression. It is common to assume that C. difficile infection causes colitis—but it is disregarded in cases of total colectomy. Because of lack of clinical suspicion, diagnosis of C. difficile enteritis or ileitis is delayed, which in turn causes poor outcomes.

Case presentation

This is a case of a 63-year-old white male with stage II A (T4a, NO), who had undergone colon adenocarcinoma s/p complete colectomy (with ileorectal anastamosis) 4 months prior to admission; he had completed two cycles of capecitabine. The patient presented to the hospital after 1 week of watery diarrhoea. He reported eight episodes of watery diarrhoea a day associated with diffuse abdominal cramping and subjective fevers, however, no blood was seen in the stool. Of note, in the preceding 2 weeks, the patient had been treated with levofloxacin orally for 7 days because of a complaint of cough and productive cough. On admission, the patient was haemodynamically stable, however, he spiked a fever of 102.5F. His WBC was 5.1, albumin was normal, creatinine was 1.4 (from baseline 1.1) and lactic acid was 1.9. C. difficile PCR toxin B gene (tcdB) was positive. The patient's stool cultures were negative, as was an examination for ova and parasites. Abdominal X-ray showed distended loops of small bowel, concerning for early ileus or small bowel obstruction. CT of the abdomen revealed diffuse thickening of the distal small bowel to the level of the anastomosis (figure 1), and mesenteric oedema, consistent with infectious enteritis (figure 2). The patient was started on vancomycin 500 mg q6H orally as well as metronidazole 500 mg q8H intravenously. Because of an ileus, he initially was treated with bowel rest and a NG tube. Surgical consult was obtained early with no intervention. The patient's symptoms progressively resolved over the next 7 days, and he was discharged home to finish a total of 14 days of orally vancomycin.

Figure 1.

Inflammation of terminal ileum and anastomotic site.

Figure 2.

Mesenteric stranding reflective of inflammation of the small bowel loops.

Investigations

C. difficile PCR tcdB was chosen as the modality of the test choice as it proves the presence of a toxin gene and the potential for C. difficile organism to cause colitis. In conjuncture with imaging, CT of the abdomen, and clinical signs and symptoms, confirmed the diagnosis. A C. difficile culture was not performed. Additionally, the criteria for mild-to-moderate versus severe C. difficile disease include assessment of WBC, lactate and serum albumin, which was also performed. Stool cultures in this case proved neither Salmonella, Campylobacter nor Shigella to be the possible causes of the diarrhoea. Additionally, the lack of ova and parasites excluded the possibility of parasitic disease as the potential cause of the diarrhoea.

Differential diagnosis

Differential diagnosis in this case included common causes of acute infectious diarrhoea: E. coli, Shigella, Salmonella and Campylobacter, involving the remaining bowel loops. Possibility of a parasitic cause was also discussed, however, it was consistent with neither clinical presentation nor with time course. Given the fevers, raised inflammatory markers and abdominal imaging findings, diagnosis of enteritis versus ileitis was made. The stool studies excluded all potential causes, with the exception of positive toxin B for C. difficile.

Treatment

Treatment options are currently limited to two active agents: metronidazole orally versus intravenously and vancomycin orally. Severe disease is treated with a combination of these two agents. In this case, given the high risk of complications, the patient was treated with intravenous metronidazole in addition to orally vancomycin 500 mg q6H, which was narrowed to orally vancomycin for the remaining 14 days of therapy.

Outcome and follow-up

The patient recovered completely.

Discussion

In the past 15 years, there have been case reports presenting patients with prior colectomy for inflammatory bowel disease with pathological findings in the small bowel similar to pseudomembranous colitis, treated successfully with metronidazole.¹ Small bowel enteritis was postulated as a true diagnosis in the series of nine prior cases, with a direct link to poor outcomes, especially in the elderly.² Ileal perforation was also prescribed as a complication of C. difficile ileitis.³ Another case of septic shock in a patient postcolectomy in years prior, in the setting of broad spectrum antibiotics, was linked to C. difficile enteritis through positive toxin testing and successfully treated with metronidazole.⁴ One case described failure of metronidazole in C. difficile enteritis but prompt resolution of the diarrhoea with orally vancomycin.⁵ Another case series proposed that C. difficile infection should be a suspect in unexplained high ileostomy output in cases post total proctocolectomy.⁶ Also, reports of other extracolonic manifestations of C. difficile have been described including soft tissue, prosthetic material, as well as bone and joint infections.⁷ Overall, there have been about 25 cases in the prior literature describing C. difficile ileitis or enteritis.

Learning points.

• Diagnosis of small bowel Clostridium difficile infection continues to get delayed given lack of clinical suspicion.

• Adaptive changes that progressively transform gastrointestinal mucosa postresection to resemble colonic mucosa make C. difficile infection of the remaining bowel more likely.⁸

• The link between antibiotic use and alteration in normal bowel flora has been implicated in cases of colonic C. difficile and is also considerable in cases of ileitis or enteritis caused by C. difficile.⁴

• Chemotherapy (with methotrexate, doxorubicin, cyclophosphamide and 5-fluorouracil) is a known risk factor for colonic C. difficile and we postulate that it remains a risk factor in ileitis or enteritis caused by C. difficile.⁹ In this case, 5-FU was used in the months preceding the diarrhoea.