CD colonisation of the colon is common in patients following treatment with broad-spectrum antibiotics. Pseudomembranous colitis is generally confined to the colon with a demarcation at the ileocaecal valve.2
Although CD has been described in jejunal aspirates,3
small bowel involvement occurring in patients with an ileostomy remote from the time of the colectomy for inflammatory bowel disease is rare.4–7
A literature search revealed 15 case reports of CD enteritis with prior abdominal surgery in 11 of 15 cases.1 7
An additional series described 12 cases of CD enteritis; 6 with an ileostomy, of whom only 1 had underlying inflammatory bowel disease.8
This patient developed CD infection within 2 weeks of surgery. There are only six reported cases of ileostomy CD diarrhoea following inflammatory bowel disease, including one patient who developed a postoperative CD infection.4–9
Risk factors for CD enteritis include old age, recent admission to hospital and recent antibiotics. Our case is only the fifth patient described with CD enteritis occurring at least 1 year after the creation of the stoma in inflammatory bowel disease.
Susceptibility to CD infection in the small bowel may be due to morphological changes such as colonic-type metaplasia and partial villous atrophy,10
or an altered bacterial flora that resembles faecal flora following an ileostomy.11
The long time interval between the original operation and CD infection supports this. The trigger in this case was likely to have been the broad-spectrum antibiotics used prior to the onset of diarrhoea leading to hospital-acquired CD infection. The rate of nosocomial CD infection in this institution is 0.13% of admissions. Symptoms include fever, diarrhoea, nausea, vomiting and abdominal pain. Diagnosis is confirmed by toxin assays. The absence of CD toxin at presentation may be due to a false-negative result but highlights the need of repeat testing if the index of suspicion is high. Clinical management is similar to that of CD infection with an intact colon. CD infection is associated with increased mortality, particularly in patients with advanced age and co-morbidities. We suspect that the CD enteritis was a manifestation of her poor overall health and was, therefore, a contributory factor rather than a cause of her death.
The clinical entity of CD infection in an ileostomy is rare and not well-known even among gastroenterologists. This may be a rarity but the high profile of CD within the community warrants all clinicians to consider this even in patients who do not have a colon.
- CD can cause infection of the small bowel.
- CD enteritis can occur many years after a colectomy.
- CD toxin should be requested and repeated if there is an unexplained increase in ileostomy effluent.
- CD enteritis can be fatal.