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

  • Case Reports
  • Published:
Diseases of the Colon & Rectum

Purpose

Clostridium difficile enteritis is a rare infection, with less than a dozen cases reported in the literature. We present a case of a patient with total proctocolectomy and ileostomy, developing Clostridium difficile infection of small bowel. We discuss the role of Clostridium difficile toxins and review previously reported cases of Clostridium difficile enteritis after total colectomy.

Methods

A 65-year-old male with a history of total proctocolectomy and ileostomy 30 years previously had purulent ileostomy drainage and septic shock. The patient was recently treated with intravenous piperacillin, tazobactam, and levofloxacin for aspiration pneumonia in the previous admission. Ileostomy stool cultures tested positive for Clostridium difficile toxin A, and the patient was promptly treated with intravenous metronidazole.

Results

The patient was aggressively resuscitated and treated, recovered from the enteritis and shock, but died of pulmonary complications after a prolonged hospitalization.

Conclusions

Review of previously reported cases of Clostridium difficile enteritis showed a high mortality rate. We attribute this to delayed diagnosis secondary to rarity of this illness. Some patients were diagnosed only after pseudomembranes in small-bowel segments were found at autopsy. This rare disease entity is firmly established among the differential diagnosis to clinicians treating patients with total proctocolectomy.

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References

  1. RH George JM Symonds F Dimock et al. (1978) ArticleTitleIdentification of Clostridium difficile as a cause of pseudomembranous colitis BMJ 1 695 Occurrence Handle630301 Occurrence Handle1:STN:280:DyaE1c7isVynsQ%3D%3D Occurrence Handle10.1136/bmj.1.6114.695

    Article  PubMed  CAS  Google Scholar 

  2. C Pothoulakis G Triadafilopoulos M Clark C Franzblau JT LaMont (1986) ArticleTitle Clostridium difficile cytotoxin inhibits protein synthesis in fibroblasts and intestinal mucosa Gastroenterology 91 1147–1153 Occurrence Handle3758606 Occurrence Handle1:CAS:528:DyaL28XmtVCntb0%3D

    PubMed  CAS  Google Scholar 

  3. M Riegler R Sedivy C Pothoulakis et al. (1995) ArticleTitle Clostridium difficile toxin B is more potent than toxin A in damaging human colonic epithelium in vitro J Clin Invest 95 2004–2011 Occurrence Handle7738167 Occurrence Handle1:CAS:528:DyaK2MXltlWrtrw%3D Occurrence Handle10.1172/JCI117885

    Article  PubMed  CAS  Google Scholar 

  4. LV McFarland GW Elmer WE Stamm ME Mulligan (1991) ArticleTitleCorrelation of immunoblot type, enterotoxin production, and cytotoxin production with clinical manifestations of Clostridium difficile infection in a cohort of hospitalized patients Infect Immun 59 2456–2462 Occurrence Handle2050409 Occurrence Handle1:STN:280:DyaK3M3mslKhtA%3D%3D

    PubMed  CAS  Google Scholar 

  5. G Triadafilopoulos C Pothoulakis MJ O’Brien JT LaMont (1987) ArticleTitleDifferential effects of Clostridium difficile toxins A and B on rabbit ileum Gastroenterology 93 273–279 Occurrence Handle3596162 Occurrence Handle1:CAS:528:DyaL2sXltFSktLk%3D

    PubMed  CAS  Google Scholar 

  6. DM Lyerly KE Saum DK MacDonald TD Wilkins (1985) ArticleTitleEffects of Clostridium difficile toxins given intragastrically to animals Infect Immun 47 349–352 Occurrence Handle3917975 Occurrence Handle1:CAS:528:DyaL2MXhtVOrtbc%3D

    PubMed  CAS  Google Scholar 

  7. L Kyne M Warny A Qamar CP Kelly (2000) ArticleTitleAsymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A N Engl J Med 342 390–397 Occurrence Handle10666429 Occurrence Handle10.1056/NEJM200002103420604 Occurrence Handle1:STN:280:DC%2BD3c7hs12mtg%3D%3D

    Article  PubMed  CAS  Google Scholar 

  8. GP Testore F Nardi S Babudieri M Giuliano R Rosa ParticleDi G Panichi (1986) ArticleTitleIsolation of Clostridium difficile from human jejunum: identification of a reservoir for disease? J Clin Pathol 39 861–862 Occurrence Handle3745477 Occurrence Handle1:STN:280:DyaL28zgsFShtw%3D%3D

    PubMed  CAS  Google Scholar 

  9. RH Taylor SP Borriello AJ Taylor (1981) ArticleTitleIsolation of Clostridium difficile from the small bowel BMJ 283 412 Occurrence Handle6789993 Occurrence Handle1:STN:280:DyaL3M3lslGqtA%3D%3D

    PubMed  CAS  Google Scholar 

  10. R Apel Z Cohen CW Andrews SuffixJr R McLeod H Steinhart RD Odze (1994) ArticleTitleProspective evaluation of early morphological changes in pelvic ileal pouches Gastroenterology 107 435–443 Occurrence Handle8039620 Occurrence Handle1:STN:280:DyaK2czhsVWhsQ%3D%3D

    PubMed  CAS  Google Scholar 

  11. A Vince F O’Grady AM Dawson (1973) ArticleTitleThe development of ileostomy flora J Infect Dis 128 638–641 Occurrence Handle4768914 Occurrence Handle1:STN:280:DyaE2c%2FntFOnsA%3D%3D

    PubMed  CAS  Google Scholar 

  12. DP Kuntz MJ Shortsleeve PA Kantrowitz GP Gauvin (1993) ArticleTitle Clostridium difficile enteritis. A cause of intramural gas Dig Dis Sci 38 1942–1944 Occurrence Handle8404420 Occurrence Handle10.1007/BF01296124 Occurrence Handle1:STN:280:DyaK2c%2FgvVCitA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  13. HF Yee SuffixJr RS Brown SuffixJr JW Ostroff (1996) ArticleTitleFatal Clostridium difficile enteritis after total abdominal colectomy J Clin Gastroenterol 22 45–47 Occurrence Handle8776096 Occurrence Handle10.1097/00004836-199601000-00013

    Article  PubMed  Google Scholar 

  14. Z Vesoulis G Williams B Matthews (2000) ArticleTitlePseudomembranous enteritis after proctocolectomy: report of a case Dis Colon Rectum 43 551–554 Occurrence Handle10789757 Occurrence Handle10.1007/BF02237205 Occurrence Handle1:STN:280:DC%2BD3c3kvVKiuw%3D%3D

    Article  PubMed  CAS  Google Scholar 

  15. JF Freiler SJ Durning PT Ender (2001) ArticleTitle Clostridium difficile small bowel enteritis occurring after total colectomy Clin Infect Dis 33 1429–1431 Occurrence Handle11565085 Occurrence Handle10.1086/322675 Occurrence Handle1:STN:280:DC%2BD3MrhslarsQ%3D%3D

    Article  PubMed  CAS  Google Scholar 

  16. JT LaMont YM Trnka (1980) ArticleTitleTherapeutic implications of Clostridium difficile toxin during relapse of chronic inflammatory bowel disease Lancet 1 381–383 Occurrence Handle6101841 Occurrence Handle10.1016/S0140-6736(80)90939-3 Occurrence Handle1:STN:280:DyaL3c7hvFGmsw%3D%3D

    Article  PubMed  CAS  Google Scholar 

  17. JS Hyams MM Berman H Helgason (1981) ArticleTitleNonantibiotic-associated enterocolitis by Clostridium difficile in an infant J Pediatr 99 750–752 Occurrence Handle7299553 Occurrence Handle10.1016/S0022-3476(81)80402-7 Occurrence Handle1:STN:280:DyaL38%2FlsFSntA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  18. JR Shortland RC Spencer JL Williams (1983) ArticleTitlePseudomembranous colitis associated with changes in an ileal conduit J Clin Pathol 36 1184–1187 Occurrence Handle6619315 Occurrence Handle1:STN:280:DyaL2c%2FgvVGrsA%3D%3D

    PubMed  CAS  Google Scholar 

  19. GP Testore A Pantosti G Panichi et al. (1984) ArticleTitlePseudomembranous enteritis associated with Clostridium difficile Ital J Gastroenterol 16 229–230

    Google Scholar 

  20. B Tsutaoka J Hansen D Johnson M Holodniy (1994) ArticleTitleAntibiotic-associated pseudomembranous enteritis due to Clostridium difficile Clin Infect Dis 18 982–984 Occurrence Handle8086563 Occurrence Handle1:STN:280:DyaK2czmvV2ltg%3D%3D

    PubMed  CAS  Google Scholar 

  21. KA Kralovich J Sacksner RA Karmy-Jones JC Eggenberger (1997) ArticleTitlePseudomembranous colitis with associated fulminant ileitis in the defunctionalized limb of a jejunal-ileal bypass: report of a case Dis Colon Rectum 40 622–624 Occurrence Handle9152196 Occurrence Handle10.1007/BF02055391 Occurrence Handle1:STN:280:DyaK2s3ps1OhtQ%3D%3D

    Article  PubMed  CAS  Google Scholar 

  22. BL Miles JA Siders SD Allen (1988) ArticleTitleEvaluation of a commercial latex test for Clostridium difficile for reactivity with C difficile and cross-reactions with other bacteria J Clin Microbiol 26 2452–2455 Occurrence Handle3235677 Occurrence Handle1:STN:280:DyaL1M7nsFCitA%3D%3D

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Graduate Hospital, 1800 Lombard Street, Pepper Pavilion, Suite 1101, Philadelphia, Pennsylvania, 19146, USA

    Kiup A. Kim M.D., Philip Wry M.D., Eugene Hughes Jr. M.D., Jeffrey Butcher M.D. & Donna Barbot M.D.

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  1. Kiup A. Kim M.D.
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  2. Philip Wry M.D.
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  3. Eugene Hughes Jr. M.D.
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  4. Jeffrey Butcher M.D.
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  5. Donna Barbot M.D.
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Kim, K.A., Wry, P., Hughes, E. et al. Clostridium difficile Small-Bowel Enteritis After Total Proctocolectomy: A Rare But Fatal, Easily Missed Diagnosis. Report of a Case. Dis Colon Rectum 50, 920–923 (2007). https://doi.org/10.1007/s10350-006-0784-y

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