Clostridioides Difficile Colitis

Question 1

hypervirulent strains

Answer 1

NAP1/ BI/ 027
> increased toxin production and subsequently a more severe clinical Course

Question 2

C. difficile

Answer 2

anaerobic toxin-producing gram-positive bacillus
> spore form (outside the colon)
> vegetative forms.

Two exotoxins (toxin A and toxin B) > colitis and diarrhea.

Ingestion of spores of C. difficile via a fecal-oral route is a common cause of transmissibility

Question 3

RF

Answer 3

• Antibiotic use
  > occur up to 3 months after antibiotic discontinuation. > disruption of colonic microbiota
  > clindamycin was the first antibiotic to be associated with CDI
• advanced age
• immunosuppression
• inflammatory bowel disease (IBD)
• gastrointestinal surgery
• length of hospitalization

Question 4

Disease Severity and Recommended Treatment

Answer 4

Nonsevere disease :

Leukocytosis, WBC ≤ 15,000 or serum creatinine < 1.5 mg/ dL

Vancomycin 125 mg PO QID  ×  10d
OR
fidaxomicin 200 mg PO BID  ×  10d

Use metronidazole 500 mg PO TID if none of the above available

Question 5

Severe disease

Answer 5

Leukocytosis WBC ≥ 15,000 or serum creatinine > 1.5 mg/ dL

Vancomycin 125 mg PO QID  ×  10d
OR
fidaxomicin 200 mg PO BID  ×  10d

Question 6

Fulminant

Answer 6

Hypotension/ shock,ileus, or megacolon

Vancomycin 500 mg QID PO/ PT (consider adding rectal vancomycin if ileus)   +  IV metronidazole (500 mg q8h)

Question 7

Recurrent disease

Answer 7

Pulse-tapered vancomycin regimen
or
fidaxomicin regimen is recommended.

Fidaxomicin, vancomycin with or without rifaximin, and fecal microbiota transplant (FMT) are used for second or subsequent recurrences.

With recurrences presenting with fulminant disease, in addition to the antibiotic regimen administered, some advocate for the addition of FMT.

Question 8

Testing is recommended for patients with

Answer 8

unexplained new onset diarrhea (3 stools/ day) especially in the presence of risk factors for CDI.

• Patients should be placed on preemptive isolation while awaiting results.
• Hand hygiene with soap and water is superior to alcohol-based hand-hygiene products for spores
• contact precautions including gloves and gowns.

Question 9

Lab Test

Answer 9

• laboratory protocols recommend that only liquid or loose stool samples be tested.
• Stool toxin tests > glutamate dehydrogenase (GDH) assay or nucleic acid amplification tests (NAAT) assay followed by toxin-recognition to help differentiate between asymptomatic carriers and patients with the disease.

Question 10

Endoscopy

Answer 10

• Pseudomembranes > raised white and yellow plaques and consist of toxin-induced ulcers with inflammatory cells and mucous
• Confirmatory endoscopy with flexible or rigid sigmoidoscopy > exclude other causes of colitis such as cytomegalovirus infection, graft-versus-host disease, IBD exacerbation, or ischemic colitis.
• Endoscopic confirmation > used in cases where a decision on surgical management needs to be expediently made

Question 11

Abdominal plain film

Answer 11

Classically, plain films were used to assess for “thumb printing” secondary to submucosal edema or toxic megacolon with colonic distention.

Question 12

CT

Answer 12

in severe or fulminant disease include

> pancolitis with significant colonic thickening and ascites

> If contrast is given > seen trapped between the edematous haustral folds (accordion sign)

> Evidence of complications such as bowel perforation, toxic megacolon, and ischemia

John L. Cameron; Andrew M. Cameron. Current Surgical Therapy (p. 205). Elsevier Health Sciences. Kindle Edition.

Question 13

Medical Tx

Answer 13

• Stop inciting antibiotics
• Vancomycin or fidaxomicin have been found to be superior to metronidazole
• First recurrence > pulse-tapered vancomycin regimen or fidaxomicin regimen

> Fidaxomicin, vancomycin with or without rifaximin, and fecal microbiota transplant (FMT) are used for second or subsequent recurrences.

Question 19

probiotics role ?

Answer 19

Can decrease the occurrence of CDI
But no role in the treatment of the disease.

Question 19

Indications for Surgical Management

Answer 19

• Colonic perforation
• Full-thickness ischemia
• Peritonitis, worsening abdominal exam despite adequate medical treatment
• Abdominal compartment syndrome
• Hemodynamic instability with ongoing or increasing need for vasopressor support
• Need for intubation and mechanical ventilation
• Worsening end-organ failure (especially renal failure)

Question 19

Gold standard operation for patients with fulminant C. difficile colitis (FCDC)

Answer 19

open total abdominal colectomy (TAC) with an end ileostomy

segmental colectomy is not recommended even if the colitis appears to be limited

Question 19

Patients with severe colitis, Medical Tx

Answer 19

• large bore intravenous access
• measurements of intake and output
• Acute kidney injury is a common complication
• kept fasting with complete bowel rest until their symptoms improve
• serial clinical examinations
  > vital signs, abdominal examination, and laboratory investigations
• Prompt recognition of complications

Question 20

what is The distal extent of the resection, and what if friable ?

Answer 20

• Upon entry into the abdominal cavity
• profuse ascites is encountered
• The colon usually dilated and edematous
• normal serosal surface, as this is a mucosal disease.
• The distal extent of the resection is at the rectosigmoid junction
• If the rectosigmoid appears too friable and there is heightened concern for rectal stump blowout, the surgeon can consider a more proximal transection to allow delivery of a distal stapled end of more proximal sigmoid as a mucous fistula.
• It is our preference to place a Malecot rectal catheter in the rectal stump for the first few postoperative days to allow decompression while healing.

Question 21

When to do Anastomosis ?

Answer 21

• ileorectal anastomosis can be performed if the patient has returned to a functional baseline.
• at 3 to 6 months postoperatively.
• Many patients do not reach a level of fitness suitable to endure another extensive operation for restoration of gastrointestinal continuity with an ileorectal anastomosis.

Question 22

What is diverting loop ileostomy (DLI) with colonic lavage

Answer 22

• colonic lavage with warm polyethylene glycol solution and postoperative antegrade installation of vancomycin flashes by the ileostomy

Question 23

diverting loop ileostomy (DLI) with colonic lavage Vs TAC

Answer 23

• Decreased 30-day postoperative mortality
• Increased ileostomy closure rates at six months.
• minority of patients in the DLI group required conversion to a TAC > due to abdominal compartment syndrome or for failure of improvement.
  -Slower resolve of systemic inflammatory response

Recent Study :
- no difference in postoperative morbidity or mortality
- higher gastrointestinal restoration rates for patients with DLI.

Question 24

When to consider it

Answer 24

1- Patients with severe disease early in their disease course
2- Do not have any complications (perforation, ischemia, or toxic megacolon)

• must be cautious that patients need close follow-up as the diseased colon is still in situ

Question 25

Technical Details and Tips

Answer 25

1

Question 26

Technical Details and Tips

Answer 26

2

Question 27

Important RF to keep an eye on ?

Answer 27

• IBD > ulcerative colitis
• more likely to need surgical intervention
• longer length of stay and increased mortality with CDI
• CDI can mimic IBD flares > considered in patients with worsening, smoldering, or relapsing IBD.
• monitored closely and have a lower threshold for early surgical intervention.

Question 28

rare cause of Pouchitis

Answer 28

• CDI enteritis is a very rare event
• can occur after TAC with end ileostomy or following ileal pouch anal anastomosis
• should be excluded in the event of a high-output ileostomy with SIRS.