Organ-Preserving Strategies in the Management of Fulminant Clostridium difficile Colitis

  • Ari Grinspan
  • Marylise Boutros


The current gold standard treatment for fulminant Clostridium difficile colitis (FCDC) is total abdominal colectomy with end ileostomy. Due to the radical nature of this operation, it is often left as a last resort and results in significant morbidity and mortality. It has become apparent that earlier time to operation is key to improving outcomes. Given the importance of early intervention and reduction in surgical stress, minimally invasive colon preserving therapies and non-operative interventions have emerged as attractive options.


Clostridium difficile Total abdominal colectomy Loop ileostomy Colonic lavage Laparoscopy Minimally invasive 


  1. 1.
    Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825–34.CrossRefPubMedGoogle Scholar
  2. 2.
    Kelly CP, LaMont JT. Clostridium difficile—more difficult than ever. N Engl J Med. 2008;359(18):1932–40.CrossRefPubMedGoogle Scholar
  3. 3.
    Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S. Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg. 2013;217(5):802–12.CrossRefPubMedGoogle Scholar
  4. 4.
    Hall AJ, Curns AT, McDonald LC, Parashar UD, Lopman BA. The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999–2007. Clin Infect Dis. 2012;55(2):216–23.CrossRefPubMedGoogle Scholar
  5. 5.
    Bhangu A, Nepogodiev D, Gupta A, Torrance A, Singh P, Collaborative WMR. Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis. Br J Surg. 2012;99(11):1501–13.CrossRefPubMedGoogle Scholar
  6. 6.
    Butala P, Divino CM. Surgical aspects of fulminant Clostridium difficile colitis. Am J Surg. 2010;200(1):131–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Stewart D, Hollenbeak C, Wilson M. Is colectomy for fulminant Clostridium difficile colitis life saving? A systematic review. Colorectal Dis. 2013;15(7):798–804.CrossRefPubMedGoogle Scholar
  8. 8.
    McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1–e48.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kautza B, Zuckerbraun BS. The surgical management of complicated Clostridium Difficile infection: alternatives to colectomy. Surg Infect (Larchmt). 2016;17(3):337–42.CrossRefGoogle Scholar
  10. 10.
    Malamood M, Nellis E, Ehrlich AC, Friedenberg FK. Vancomycin enemas as adjunctive therapy for Clostridium difficile infection. J Clin Med Res. 2015;7(6):422.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    McPherson S, Rees CJ, Ellis R, Soo S, Panter SJ. Intravenous immunoglobulin for the treatment of severe, refractory, and recurrent Clostridium difficile diarrhea. Dis Colon Rectum. 2006;49(5):640–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Salcedo J, Keates S, Pothoulakis C, Warny M, Castagliuolo I, LaMont J, et al. Intravenous immunoglobulin therapy for severe Clostridium difficile colitis. Gut. 1997;41(3):366–70.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Herpers BL, Vlaminckx B, Burkhardt O, Blom H, Biemond-Moeniralam HS, Hornef M, et al. Intravenous tigecycline as adjunctive or alternative therapy for severe refractory Clostridium difficile infection. Clin Infect Dis. 2009;48(12):1732–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Dudukgian H, Sie E, Gonzalez-Ruiz C, Etzioni DA, Kaiser AM. C. difficile colitis—predictors of fatal outcome. J Gastrointest Surg. 2010;14(2):315–22.CrossRefPubMedGoogle Scholar
  15. 15.
    Byrn JC, Maun DC, Gingold DS, Baril DT, Ozao JJ, Divino CM. Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. Arch Surg. 2008;143(2):150–4; discussion 5.CrossRefPubMedGoogle Scholar
  16. 16.
    Pepin J, Vo TT, Boutros M, Marcotte E, Dial S, Dube S, et al. Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection. Dis Colon Rectum. 2009;52(3):400–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Dallas KB, Condren A, Divino CM. Life after colectomy for fulminant Clostridium difficile colitis: a 7-year follow up study. Am J Surg. 2014;207(4):533–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Sailhamer EA, Carson K, Chang Y, Zacharias N, Spaniolas K, Tabbara M, et al. Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality. Arch Surg. 2009;144(5):433–9; discussion 9–40.CrossRefPubMedGoogle Scholar
  19. 19.
    Ali SO, Welch JP, Dring RJ. Early surgical intervention for fulminant pseudomembranous colitis. Am Surg. 2008;74(1):20–6.PubMedGoogle Scholar
  20. 20.
    Ferrada P, Callcut R, Zielinski MD, Bruns B, Yeh DD, Zakrison TL, et al. Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile–associated disease: an Eastern Association for the Surgery of Trauma multicenter trial. J Trauma Acute Care Surg. 2017;83(1):36–40.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Seder CW, Villalba MR, Robbins J, Ivascu FA, Carpenter CF, Dietrich M. Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience. Am J Surg. 2009;197(3):302–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Lamontagne F, Labbe AC, Haeck O, Lesur O, Lalancette M, Patino C, et al. Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg. 2007;245(2):267–72.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Dallal RM, Harbrecht BG, Boujoukas AJ, Sirio CA, Farkas LM, Lee KK, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235(3):363–72.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Miller AT, Tabrizian P, Greenstein AJ, Dikman A, Byrn J, Divino C. Long-term follow-up of patients with fulminant Clostridium difficile colitis. J Gastrointest Surg. 2009;13(5):956–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Markelov A, Livert D, Kohli H. Predictors of fatal outcome after colectomy for fulminant Clostridium difficile colitis: a 10-year experience. Am Surg. 2011;77(8):977–80.PubMedGoogle Scholar
  26. 26.
    Stokes AL, Bible A, Hollenbeak CS, Stewart DB Sr. Clostridium difficile infection is associated with lower inpatient mortality when managed by GI surgeons. Dis Colon Rectum. 2016;59(9):855–61.CrossRefPubMedGoogle Scholar
  27. 27.
    Neal MD, Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS. Diverting loop ileostomy and colonic lavage: an alternative to total abdominal colectomy for the treatment of severe, complicated Clostridium difficile associated disease. Ann Surg. 2011;254(3):423–7; discussion 7–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Hall JF, Berger D. Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management. Am J Surg. 2008;196(3):384–8.CrossRefPubMedGoogle Scholar
  29. 29. Loop ileostomy with colonic lavage for fulminant Clostridium difficile colitis. 2017. Available from:
  30. 30.
    Turnbull RB Jr, Hawk WA, Weakley FL. Surgical treatment of toxic megacolon. Ileostomy and colostomy to prepare patients for colectomy. Am J Surg. 1971;122(3):325–31.CrossRefPubMedGoogle Scholar
  31. 31. Intestinal lavage for the treatment of severe C. difficile infections. 2015. Available from:
  32. 32.
    Eiseman Á, Silen W, Bascom G, Kauvar A. Fecal enema as an adjunct in the treatment of pseudomembranous enterocolitis. Surgery. 1958;44(5):854–9.PubMedGoogle Scholar
  33. 33.
    Van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013;368(5):407–15.CrossRefPubMedGoogle Scholar
  34. 34.
    Kassam Z, Lee CH, Yuan Y, Hunt RH. Fecal microbiota transplantation for Clostridium difficile infection: systematic review and meta-analysis. Am J Gastroenterol. 2013;108(4):500.CrossRefPubMedGoogle Scholar
  35. 35.
    Cammarota G, Masucci L, Ianiro G, Bibbò S, Dinoi G, Costamagna G, et al. Randomised clinical trial: faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection. Aliment Pharmacol Ther. 2015;41(9):835–43.CrossRefPubMedGoogle Scholar
  36. 36.
    Kelly CR, Khoruts A, Staley C, Sadowsky MJ, Abd M, Alani M, et al. Effect of fecal microbiota transplantation on recurrence in multiply recurrent Clostridium difficile infection: a randomized trial. Ann Intern Med. 2016;165(9):609–16.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478–98; quiz 99.CrossRefPubMedGoogle Scholar
  38. 38.
    Fischer M, Sipe B, Rogers N, Cook G, Robb B, Vuppalanchi R, et al. Faecal microbiota transplantation plus selected use of vancomycin for severe-complicated Clostridium difficile infection: description of a protocol with high success rate. Aliment Pharmacol Ther. 2015;42(4):470–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Ianiro G, Masucci L, Quaranta G, Simonelli C, Lopetuso L, Sanguinetti M, et al. Randomised clinical trial: faecal microbiota transplantation by colonoscopy plus vancomycin for the treatment of severe refractory Clostridium difficile infection—single versus multiple infusions. Aliment Pharmacol Ther. 2018;48(2):152–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Aroniadis OC, Brandt LJ, Greenberg A, Borody T, Kelly CR, Mellow M, et al. Long-term follow-up study of fecal microbiota transplantation for severe and/or complicated Clostridium difficile infection. J Clin Gastroenterol. 2016;50(5):398–402.PubMedGoogle Scholar
  41. 41.
    Zainah H, Hassan M, Shiekh-Sroujieh L, Hassan S, Alangaden G, Ramesh M. Intestinal microbiota transplantation, a simple and effective treatment for severe and refractory Clostridium difficile infection. Dig Dis Sci. 2015;60(1):181–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Hocquart M, Lagier JC, Cassir N, Saidani N, Eldin C, Kerbaj J, et al. Early fecal microbiota transplantation improves survival in severe Clostridium difficile infections. Clin Infect Dis. 2018;66(5):645–50.CrossRefPubMedGoogle Scholar
  43. 43.
    Shogbesan O, Poudel DR, Victor S, Jehangir A, Fadahunsi O, Shogbesan G, et al. A systematic review of the efficacy and safety of fecal microbiota transplant for Clostridium difficile infection in immunocompromised patients. Can J Gastroenterol Hepatol. 2018;2018:1394379.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Kelly CR, Ihunnah C, Fischer M, Khoruts A, Surawicz C, Afzali A, et al. Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients. Am J Gastroenterol. 2014;109(7):1065.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Lin SC, Alonso CD, Moss AC. Fecal microbiota transplantation for recurrent Clostridium difficile infection in patients with solid organ transplants: an institutional experience and review of the literature. Transpl Infect Dis. 2018;20:e12967.CrossRefPubMedGoogle Scholar
  46. 46.
    Leffler DA, Lamont JT. Clostridium difficile infection. N Engl J Med. 2015;372(16):1539–48.CrossRefPubMedGoogle Scholar
  47. 47.
    Brandt LJ. American Journal of Gastroenterology Lecture: intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. difficile infection. Am J Gastroenterol. 2013;108(2):177.CrossRefPubMedGoogle Scholar
  48. 48.
    Allegretti JR, Kearney S, Li N, Bogart E, Bullock K, Gerber GK, et al. Recurrent Clostridium difficile infection associates with distinct bile acid and microbiome profiles. Aliment Pharmacol Ther. 2016;43(11):1142–53.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Khoruts A, Sadowsky MJ. Understanding the mechanisms of faecal microbiota transplantation. Nat Rev Gastroenterol Hepatol. 2016;13(9):508.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Weingarden AR, Dosa PI, DeWinter E, Steer CJ, Shaughnessy MK, Johnson JR, et al. Changes in colonic bile acid composition following fecal microbiota transplantation are sufficient to control Clostridium difficile germination and growth. PLoS One. 2016;11(1):e0147210.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Bakken JS, Borody T, Brandt LJ, Brill JV, Demarco DC, Franzos MA, et al. Treating Clostridium difficile infection with fecal microbiota transplantation. Clin Gastroenterol Hepatol. 2011;9(12):1044–9.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Wang S, Xu M, Wang W, Cao X, Piao M, Khan S, et al. Systematic review: adverse events of fecal microbiota transplantation. PLoS One. 2016;11(8):e0161174.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Fischer M, Sipe B, Cheng Y-W, Phelps E, Rogers N, Sagi S, et al. Fecal microbiota transplant in severe and severe-complicated Clostridium difficile: a promising treatment approach. Gut Microbes. 2017;8(3):289–302.CrossRefPubMedGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

Authors and Affiliations

  • Ari Grinspan
    • 1
    • 2
  • Marylise Boutros
    • 3
    • 4
  1. 1.Mount Sinai Hospital, The Dr. Henry D. Janowitz Division of GastroenterologyNew YorkUSA
  2. 2.Icahn School of Medicine at Mount Sinai, The Dr. Henry D. Janowitz Division of GastroenterologyNew YorkUSA
  3. 3.Jewish General Hospital, Division of Colorectal SurgeryMontrealCanada
  4. 4.McGill University, Department of SurgeryMontrealCanada

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