PubMed literature search for C. difficile
enteritis was performed and revealed 26 cases from 1980–2008 ()
There was significant age variability, with a range of 18 to 83 years of age
(mean 50.3). Sixteen of the 26 patients had inflammatory bowel disease (IBD), thirteen
patients had ulcerative colitis, and three had Crohn's disease. Ten patients
had total colectomies and six underwent IPAA. All but three patients had
altered intestinal anatomy. Twenty four patients had recent hospitalization
and/or operation as well as recent antibiotic use. Thirteen patients were
septic and required ICU admission. In all 26 cases, the stool assays were positive
for C. difficile
toxin. Diagnosis of small bowel involvement was made
based on biopsy,
pathology, or autopsy results. Only seven patients were evaluated endoscopically.
Four underwent flexible sigmoidoscopy, and three of those had pseudomembranes.
Of the patients with IPAA, only two were examined endoscopically and no
pseudomembranes were visualized. One patient had an esophagogastroduodenoscopy
(EGD) which demonstrated pseudomembranes in the duodenum. Treatment in all but two
patients included metronidazole or vancomycin, or a combination of both. Two
patients were resistant to metronidazole. Fourteen of the 26 underwent operative
intervention. Mortality rate was 35%.
reported cases of small bowel C. difficile.
Our patient was
similar to the previously reported cases of
C. difficile enteritis in that he had a history of IBD, recent surgery,
and antibiotic use. He required ICU admission secondary to sepsis, but he did
not require operative intervention. Unlike any of the previously reported
cases, our patient's pouch endoscopy revealed pseudomembranes, facilitating
timely intervention and his ultimate recovery.
C. difficile enteritis appears to have a
fulminant course, with high risk of sepsis, need for operation, and mortality.
It is unclear why the disease course is more severe than in colitis. Increased
small bowel permeability is one potential explanation. Delay in diagnosis and
treatment may play a role as well.
The clinical presentation
can be similar for both enteritis and colitis. Symptoms include diarrhea,
dehydration, and increased ileostomy output. Unlike colitis, enteritis more
commonly presents with systemic manifestations such as fever, hypotension,
leukocytosis and thrombocytosis [3
], and occasionally with peritonitis
or bowel perforation [7
enteritis may be difficult to
differentiate from other inflammatory processes, and requires high degree of
suspicion to make the diagnosis.
has also been implicated as a cause of chronic pouchitis in patients with IPAA [16
and should be suspected in this setting. Given the higher risk that IBD
patients may have for developing
enteritis, it is important to be able to differentiate it from an exacerbation
of IBD. Diagnosis is made by identifying
A or B in the stool. Similarly, endoscopy should be utilized in patients with
suspected small bowel involvement even with history of prior colectomy. This
may facilitate differentiation between Crohn's enteritis, pouchitis, and
As with our
patient, most cases will respond to treatment with metronidazole or vancomycin.
However, more virulent and resistant strains have been reported [23
Some patients will need emergent surgical resection of any perforated or
gangrenous bowel if they fail to respond to medical treatment.
C. difficile enteritis is emerging with increased
frequency and can have devastating results. Patients with IBD and prior
colectomy are at increased risk. Prompt identification of the organism via
stool culture and endoscopy may result in more favorable outcomes.