an unusual case of colitis

An unusual case of colitisAn unusual case of colitis

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

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

Past Medical/Surgical HxPast Medical/Surgical Hx

PMHx/PSHx: Cholecystectomy

Meds: Nil

Allergies: NKDA

FHx: Nil

SHxSHx

Married, no childrenNon-smokerNon drinker

O/EO/E

HR: 116 bpm, regularBP: 120/64 mmHgRR: 20/minT: 36.3 CSats: 98% RA

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

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

RadiologyRadiology

CXR showed prominent bowel loop beneath left hemidiaphragm

PFA – grossly distended loops of bowel

DdxDdx

Colitis (infective vs inflammatory)

Gastroenteritis

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

CT abdomenCT abdomen

Oedematous, fluid filled right colonFree fluid in abdomen and loculated

collection in pouch of DouglasBilateral ovarian cystsBilateral pleural effusions

Flexi sigmoidoscopyFlexi sigmoidoscopy

Normal mucosaNo distal colitisFull colonoscopy not performed due to risk

of perforation

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

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

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.

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

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

IntroductionIntroduction

Aetiology of colitis:

1. Inflammatory- Ulcerative colitis- Crohn’s disease - Indeterminate colitis

2. Ischaemic

IntroductionIntroduction3. Infective:-Enterotoxigenic E. coli-Shigella-Salmonella-Campylobacter-C. difficile-Yersinia enterocolitica

4. Radiation

Clostridium perfringens colitisClostridium perfringens colitis

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

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.

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

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.

Medical studentsMedical students

Remember the aetiology of colitisDifferential diagnosis of lower abdominal

pain & distensionTreatment for C. perfringens colitis