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An unusual case of colitisAn unusual case of colitis
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DM, 55yoDM, 55yo
Previously well woman was referred by GP for lower abdominal pain and vomiting
Noticed increasing flatus 5/7 priorLoose BM x 3/7 relieved by immodiumCrampy abdominal pain ++Multiple episodes of N+V
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HistoryHistory
Nil anorexia/weight lossNo recent exposure to C.difficile or
gastroenteritis No recent travelLast antibiotic use was 6/12 ago –
flucloxacillin & amoxicillin for paronychia
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Past Medical/Surgical HxPast Medical/Surgical Hx
PMHx/PSHx: Cholecystectomy
Meds: Nil
Allergies: NKDA
FHx: Nil
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SHxSHx
Married, no childrenNon-smokerNon drinker
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O/EO/E
HR: 116 bpm, regularBP: 120/64 mmHgRR: 20/minT: 36.3 CSats: 98% RA
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O/EO/E
Normal heart and chest exams
Abdomen: Moderately distended Soft Generalised tenderness maximal over lower
abdomen. Guarding present over same area Tinkling BS PR normal
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Blood investigationsBlood investigations
Hb: 11.3 WCC: 9.26 Urea: 8.3 Na: 131 K: 3.4 Cr: 8.6 CRP: 541
Bili : 8 ALT : <10 Alk Phos : 20 Amylase : 29
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RadiologyRadiology
CXR showed prominent bowel loop beneath left hemidiaphragm
PFA – grossly distended loops of bowel
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DdxDdx
Colitis (infective vs inflammatory)
Gastroenteritis
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Initial managementInitial management
Aggressive fluid resuscitationNGTClose monitoring of fluid balanceIV hydrocortisone, IV ciprofloxacin, IV
metronidazole and oral vancomycinUrgent CT abdomen done on 17/6/9
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CT abdomenCT abdomen
Oedematous, fluid filled right colonFree fluid in abdomen and loculated
collection in pouch of DouglasBilateral ovarian cystsBilateral pleural effusions
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Flexi sigmoidoscopyFlexi sigmoidoscopy
Normal mucosaNo distal colitisFull colonoscopy not performed due to risk
of perforation
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CourseCourse in hospital in hospital
Within 24 hours of admission, patient developed tachypnoea, RR: 26 and raised JVP. Coarse bibasal creps. BP: 137/89, HR: 100 bpm
R/v by respiratory team – Acute Lung InjuryTransferred to ICU
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Microbiology and IDMicrobiology and ID
C. diff toxin negative?infective vs inflammatory processDecision: treat until C. diff can be r/oIV metronidazole, PO vancomycin for
C.difficile IV piperacillin/tazobactam in case of
abdominal sepsis
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Microbiology and IDMicrobiology and ID
Day 9 post admission, Clostridium perfringens was isolated from 3 faeces samples taken on 17/6/9
Clindamycin was added on to antimicrobial therapy.
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Course in hospital Course in hospital
Patient showed definite improvement clinically while on clindamycin
Abdominal pain was settling, but abdomen was getting progressively distended with ascites
Weight– 80kg. Abdominal girth - 105cm
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DischargeDischargePatient improved clinically with good
nutrition and appropiate antibiotics.
Discharged to convalescence f/u in OPD. Abdo girth 92cm. Weight 60kg.
Provisional final diagnosis: Acute colitis possibly secondary to Clostridium perfrigens
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IntroductionIntroduction
Aetiology of colitis:
1. Inflammatory- Ulcerative colitis- Crohn’s disease - Indeterminate colitis
2. Ischaemic
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IntroductionIntroduction3. Infective:-Enterotoxigenic E. coli-Shigella-Salmonella-Campylobacter-C. difficile-Yersinia enterocolitica
4. Radiation
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Clostridium perfringens colitisClostridium perfringens colitis
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Clostridium perfringens colitisClostridium perfringens colitis
C. perfringens produces at least 17 types of exotoxins (Type A, Type B, Type C etc)
250,000 cases of mild, self limiting gastroenteritis in the US caused by C perfringens Type A
‘Pigbel’ disease – necrotising enteritis associated with C perfringens Type C in severely protein deprived population in the Pacific – often fatal
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Sobel J et al. Necrotizing enterocolitis associated with clostridium perfringens type A in previously healthy north american adults. J Am Coll Surg. 2005 Jul;201(1):48-56.
Bos J et al. Fatal necrotizing colitis following a foodborne outbreak of enterotoxigenic Clostridium perfringens type A infection. Clin Infect Dis. 2005 May 15;40(10):e78-83. Epub 2005 Apr 14.
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Disease process: 1. Ingestion of food containing preformed toxins, 2. overgrowth of C. perfringens post antibiotic therapy1 or sporadically leading to disease in susceptible hosts
Diagnosis: C. perfringens growth in culture and isolation of toxin
Treatment: Metronidazole +/- clindamycin
1. Borriello SP, Larson HE, Welch AR, Barclay F, Enterotoxigenic Clostridium perfringens: a possible cause of antibiotic associated diarrhoea. Lancet 1984;1:305-7
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Future?Future?
Siggers RH et al. Early administration of probiotics alters bacterial colonization and limits diet-induced gut dysfunction and severity of necrotizing enterocolitis in preterm pigs. J Nutr. 2008 Aug;138(8):1437-44.
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Medical studentsMedical students
Remember the aetiology of colitisDifferential diagnosis of lower abdominal
pain & distensionTreatment for C. perfringens colitis