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Clostridium difficile enteritis: An early post-operative complication in IBD patients following colectomy
Sarah J. Lundeen1, Mary F. Otterson1, Gordon L. Telford1, David G. Binion2, William J. Peppard3; 1Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; 2Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; 3Froedtert Memorial Lutheran Hospital, Milwaukee, WI

Introduction: Clostridium difficile (C diff) is known to cause severe colitis, and is the leading cause of hospital-acquired diarrhea in the United States. However, C diff associated small bowel enteritis is a rare complication, with only 19 case reports in the literature (1979-2000), but is associated with mortality rates as high as 73%. C diff has increased in incidence with a marked increase among patients with inflammatory bowel disease (IBD). We report a series of 5 patients(2004-2005), all treated at our tertiary IBD referral center that experienced severe enteritis. C diff toxins were detected in the ileostomy effluent of all patients in the early post-operative time frame(< 90 days). We report the demographics, presentation, management and disposition in this cohort of patients. Results: Five patients were identified that developed C diff enteritis following total abdominal colectomy and ileostomy. All received a dose of preoperative antibiotics. 2 patients underwent ileal pouch and loop ileostomy. All 5 patients had a final pathology of ulcerative colitis (4 female, 1 male). Four/5 patients had C diff colitis prior to colectomy. Presenting symptoms were high volume watery ileostomy output followed by ileus in 5/5 patients; 4/5 presented with fever and elevated WBC. 4/5 developed complications which resulted in further surgery or prolonged hospitalization. These included 2 readmissions with fever and dehydration, 1 reoperation to bypass strictured small bowel, 1 patient was transferred to the ICU for the management of hemodynamic instability. Patients diagnosed with C. diff enteritis were treated with intravenous hydration and metronidazole until able to take oral vancomycin. One patient was treated with vancomycin alone due to intolerance and one patient was treated with mentronidazole alone. None of the 5 patients died, and all have resumed education or employment. Discussion: Despite the historical rarity of C diff enteritis, incidence is rising. Clinicians should have a high suspicion of C diff enteritis, especially in patients with a history of IBD and C diff colitis prior to colectomy. Although published rates of mortality approached 2/3, there were no deaths in our series of 5 patients. Our favorable outcomes may be attributed in part to rapid diagnosis and aggressive treatment of the C diff enteritis.


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