Clostridium difficile enteritis after colectomy

Rosenfeld GA, Freeman H, Brown M, Steinbrecher UP. Severe and extensive
enteritis following colectomy for ulcerative colitis. Can J Gastroenterol. 2012

“Ulcerative colitis is an inflammatory condition usually confined to the colonic mucosa. However, inflammatory changes have been recorded in the small bowel with ulcerative colitis, specifically in ileal pouch mucosa after colectomy (ie, ‘pouchitis’) or in the terminal ileum with severe pancolitis (ie, ‘backwash ileitis’). There have also been rare previous reports of a more diffuse and distinctive form of diffuse and extensive enteritis following total colectomy that responded to steroids or calcineurin inhibitor use (1–3). Rarely, a fatal form of diffuse enteritis following colectomy has been described (4,5). We report a dramatic presentation of severe steroid-resistant panenteritis in a patient three months after total colectomy for severe ulcerative colitis that responded to tacrolimus.”

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Kim JH, Muder RR. Clostridium difficile enteritis: a review and pooled analysis of the cases. Anaerobe. 2011 Apr;17(2):52-5.

“C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years. Surgically altered intestinal anatomies, advanced age, predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Recognition of C. difficile infection not only in the colon but also in the small bowel may lead to improved outcomes.”

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Causey MW, Spencer MP, Steele SR. Clostridium difficile enteritis after
colectomy. Am Surg. 2009 Dec;75(12):1203-6.

“Clostridium difficile infection of the colon is, unfortunately, a relatively common occurrence that typically follows treatment with antibiotics; however, C. difficile infection of the small bowel is a much more rare phenomenon with only 19 cases reported to date. We present three cases of isolated C. difficile enteritis after colectomy. Although all three patients were identified early and successfully treated with medical management without the need for surgical intervention, previous authors have suggested a much higher morbidity and mortality rate with this infection. This article reviews the current available literature on C. difficile enteritis to highlight this potentially serious condition in postoperative colectomy patients who present with low-grade fevers, abdominal or pelvic pain, and increased ileostomy output.”

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Corporaal S, Karrenbeld A, van der Linde K, Voskuil JH, Kleibeuker JH,
Dijkstra G. Diffuse enteritis after colectomy for ulcerative colitis: two case
reports and review of the literature. Eur J Gastroenterol Hepatol. 2009

Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn’s disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn’s disease and may be associated with UC and colectomy.

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Lundeen SJ, Otterson MF, Binion DG, Carman ET, Peppard WJ. Clostridium
difficile enteritis: an early postoperative complication in inflammatory bowel
disease patients after colectomy. J Gastrointest Surg. 2007 Feb;11(2):138-42.

“Clostridium difficile, the leading cause of hospital-acquired diarrhea, is known to cause severe colitis. C. difficile small bowel enteritis is rare (14 case reports) with mortality rates ranging from 60 to 83%. C. difficile has increased in incidence particularly among patients with inflammatory bowel disease. This case series of six patients from 2004 to 2006 is the largest in the literature. All patients received antibiotics before colectomies for ulcerative colitis and developed severe enteritis that was C. difficile toxin positive. Three patients underwent ileal pouch anal anastomosis and loop ileostomy. Four of the six patients had C. difficile colitis before colectomy. Presenting symptoms were high volume watery ileostomy output followed by ileus in five of six patients. Four of the six patients presented with fever and elevated WBC. Five of the six developed complications requiring further surgery or prolonged hospitalization. Patients were treated with intravenous hydration and metronidazole then converted to oral metronidazole and/or vancomycin. None of the patients died. A high suspicion of C. difficile enteritis in patients with inflammatory bowel disease and history of C. difficile colitis may lead to more rapid diagnosis, aggressive treatment, and improved outcomes for patients with C. difficile enteritis.”

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More PubMed results on C. Diff enteritis after colectomy.

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