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Rectal Sparing in Antibiotic-Associated Pseudomembranous Colitis: A Prospective Study
Abstract
A prospective study of 22 patients with antibiotic-associated pseudomembranous colitis demonstrated that the most distal location of the pseudomembranes was noted from 0 to 25 cm from the anus in 17 patients, from 25 to 60 cm from the anus in 3 patients, and greater than 60 cm from the anus in only 2 patients. These data suggest that the pseudomembranes will be noted by the rigid sigmoidoscope in 77% of the patients and by the flexible sigmoidoscope in 91% of the patients. Colonoscopic examination beyond 60 cm from the anus was necessary for the diagnosis of pseudomembranous colitis in 2 (9%) patients.
... S. aureus was the suspected pathogen and standard treatment became oral vancomycin [24]. Tedesco et al. described "clindamycin colitis" in 1974 utilizing culture and endoscopy to diagnose pseudomembranous colitis associated with antibiotic use after 21% of patients given clindamycin developed diarrhea and 10% developed pseudomembranous colitis [25]. Incidentally, S. aureus did not grow from stool cultures from any of the patients. ...
... Although there are many causes of pseudomembranous colitis, the majority of cases since the late 1970s have been caused by C. difficile infection. Pseudomembranous colitis is limited to the proximal colon in 20-30% of cases and may therefore be missed by sigmoidoscopy, providing more credence to performing a complete colonoscopy to identify anatomic lesions [25,34]. With the current availability of C. difficile toxin assays, colonoscopy is rarely necessary. ...
... difficile) infections may vary from mild diarrhea to life-threatening pseudomembranous colitis (PMC), which may localize from the proximal colon to the rectum [1] . Localized forms of PMC have been reported to compromise the transverse and right colon [2] , but to the best of our knowledge, we have not found cases with exclusive localization of PMC over polyps. Below, we report a case with the pseudomembranes only covering the surface of adenomatous polyps. ...
... The term PMC is nonspecific and describes an acute mucosal injury characterized by an endoscopic pattern of numerous, discrete and small (2-5 mm), raised, round and yellowish plaques (pseudomembranes) distributed over an erythematous but unulcerated mucosa [1] . The rectum is frequently involved, but in a few cases the sigmoid and/or right colon is compromised [2] . The histological pattern is characterized by a neutrophil-rich edema fluid in the lamina propria that bursts through tiny breeches to the surface epithelium, like a volcanic eruption, to form a characteristic punctate inflammatory pseudomembrane [1,3] . ...
The most frequent cause of pseudomembranous colitis is Clostridium difficile (C. difficile) infection. This type of colitis is characterized by an endoscopic pattern of numerous small, yellowish or whitish plaques diffusely distributed, which typically compromises the rectum extending to proximal colon. Occasionally, the pseudomembranes compromise only the transverse or right colon, but their exclusive localization over polyps has not been reported. In this case report we have described a patient with symptoms compatible with C. difficile infection and positive for C. difficile toxigenic culture. Colonoscopy examination showed two small polyps with a whitish surface, and histopathological analysis confirmed them to be pseudomembranes over tubular adenomas. The rest of the colonic mucosa was normal and no other cause was demonstrated. We suggest that this particular distribution might be due to a higher affinity for dysplastic cells such as adenomatous polyps of colon by C. difficile and/or its toxins.
... Compared to R20291 spore gavage, intrarectal instillation of 50 mg of TcdB caused a similar degree of distal inflammation (Fig. 1). The distal colon is most often affected in human disease, but the largest amount of inflammation in spore-gavaged mice is in the cecum (37,38). Therefore, another strength of intrarectal instillation is to model distal colitis. ...
Clostridioides difficile is linked to nearly 225,000 antibiotic-associated diarrheal infections and almost 13,000 deaths per year in the United States. Pathogenic strains of C. difficile produce toxin A (TcdA) and toxin B (TcdB), which can directly kill cells and induce an inflammatory response in the colonic mucosa. Hirota, et al. first introduced the intrarectal instillation model of intoxication using TcdA and TcdB purified from VPI 10463 and 630 C. difficile strains. Here, we expand this technique by instilling purified, recombinant TcdA and TcdB, which allows for the interrogation of how specifically mutated toxins affect tissue. Mouse colons were processed and stained with hematoxylin and eosin (H&E) for blinded evaluation and scoring by a board-certified gastrointestinal pathologist. The amount of TcdA or TcdB needed to produce damage was lower than previously reported in vivo and ex vivo Furthermore, TcdB mutants lacking either endosomal pore-formation or glucosyltransferase activity resemble sham negative controls. Immunofluorescent staining revealed how TcdB initially damages colonic tissue by altering the epithelial architecture closest to the lumen. Tissue sections were also immunostained for markers of acute inflammatory infiltration. These staining patterns were compared with slides from a human C. difficile infection (CDI). The intrarectal instillation mouse model with purified recombinant TcdA and/or TcdB provides the flexibility needed to better understand structure/function relationships across different stages of CDI pathogenesis.
... PMC may spare the rectum in approximately 10% of patients, so colonoscopy is preferred. [68][69][70][71] Pseudomembranes appear as tightly adherent, raised yellow or offwhite plaques up to 2 cm in diameter, which may be covered with mucus, often with intervening normal looking colonic mucosa. 72 Histopathological findings include the typical "summit" or "volcano" lesion with an erupting "pseudomembrane" of inflammatory cell infiltrate and debris with focal mucosal necrosis. ...
There have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease, attributed to the emergence of a fluoroquinolone-resistant "hypervirulent" strain, ribotype 027. C. difficile is now the most common pathogen causing hospital-acquired infection in U.S. hospitals, and community-acquired infections are increasing. The diagnosis of CDI is based on a combination of signs and symptoms, confirmed by laboratory tests. Clinical manifestations of CDI can range from asymptomatic colonization to severe pseudomembranous colitis and death. Many aspects of laboratory diagnosis of CDI remain contentious. Toxin enzyme immunoassays are too insensitive to be used alone, while nucleic acid amplification tests have emerged as an option, either as a stand-alone test or as part of a multitest algorithm. Oral vancomycin and metronidazole have been the recommended antimicrobial therapy options, and fidaxomicin is an effective new alternative. There is ongoing concern regarding the potential inferiority of metronidazole, in particular for severe CDI. Management of severe CDI and recurrent CDI continue to represent major treatment challenges. Biological therapies for the restoration of the intestinal microbiota (e.g., fecal microbiota transplantation) and monoclonal antibody therapy are promising approaches for CDI management, in particular troublesome recurrent CDI. This review will concentrate on the diagnosis and management of CDI in adults.
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... En estos dos grupos cobra mayor importancia el diagnóstico microbiológico, dado que en muy pocos casos va a ayudar la endoscopia, salvo para descartar otro tipo de entidades o infecciones como citomegalovirus. La colitis pseudomembranosa afecta principalmente al recto y al sigmoides, pero en hasta 15 a 20% de los casos las lesiones se observan a nivel más proximal 69 . Por este motivo, aunque el colon izquierdo sea normal en la endoscopia, y si existe una alta sospecha clínica de colitis 70 . ...
Clostridium difficile es la causa más común de diarrea infecciosa en instituciones sanitarias de adultos. Estudios recientes han mostrado un incremento en la incidencia, gravedad y recurrencia de la infección por C. difficile (ICD).Factores asociados al paciente y a la atención sanitaria contribuyen a establecer la colonización y en algunos casos la posterior progresión a enfermedad sintomática. La disponibilidad de nuevas técnicas microbiológicas ha contribuido en gran medida a mejorar el manejo de estos pacientes. Se muestra un algoritmo diagnóstico ante la sospecha de ICD basándose en la evidencia actual sobre la rentabilidad de métodos microbiológicos y radiológicos. Ante la confirmación clínica de ICD la primera medida y la más eficaz es la retirada del tratamiento antimicrobiano que tenga el paciente, si es posible. El tratamiento antimicrobiano de la ICD se basa en tres agentes clásicos, metronidazol, vancomicina y teicoplanina, y uno de reciente incorporación, fidaxomicina. En los cuadros graves se deberán instaurar medidas de soporte y monitorización adecuadas y pueden ser subsidiarios de tratamiento quirúrgico. Las estrategias de prevención y control de la infección permiten interrumpir el mecanismo de transmisión. Este manuscrito revisa la evidencia actualsobre el abordaje de esta entidad desde un punto de vista multidisciplinario.
... Overall, pseudomembranes have been detected in 41% of cases of CDAD [45] . Distal involvement of the colon is most common, making flexible sigmoidoscopy a reasonable initial test although in one series, false negative rate due to proximal involvement with rectal sparing was reported in 10% of cases [46] . Histologically, the pseudomembranes, composed of fibrin, mucus, epithelial and inflammatory cells appear as "clouds" rising from points of superficial ulcerations. ...
Clostridium difficile infection (CDI) presents a rapidly evolving challenge in the battle against hospital-acquired infections. Recent advances in CDI diagnosis and management include rapid changes in diagnostic approach with the introduction of newer tests, such as detection of glutamate dehydrogenase in stool and polymerase chain reaction to detect the gene for toxin production, which will soon revolutionize the diagnostic approach to CDI. New medications and multiple medical society guidelines have introduced changing concepts in the definitions of severity of CDI and the choice of therapeutic agents, while rapid expansion of data on the efficacy of fecal microbiota transplantation heralds a revolutionary change in the management of patients suffering multiple relapses of CDI. Through a comprehensive review of current medical literature, this article aims to offer an intensive review of the current state of CDI diagnosis, discuss the strengths and limitations of available laboratory tests, compare both current and future treatments options and offer recommendations for best practice strategies.
... This test is typically reserved for patients who are severely ill and need rapid assessment to determine if they have a potential infection due to C difficile. 6,33,[36][37][38][39] Radiologic tests, chiefly CT scan of the abdomen and pelvis may be used to support a diagnosis of C difficile colitis. Radiological findings suggestive of C difficile colitis include pericolonic stranding, an accordion sign (high-attenuation oral contrast in the colonic lumen alternating with low-attenuating inflamed mucosa), and the double-halo or target sign (varying degrees of attenuation of the intravenous [IV] contrast material in the mucosa caused by submucosal inflammation and hyperemia). ...
Clostridium difficile is an anaerobic, spore-forming, gram-positive bacillus that can produce severe colitis resulting in death. There has been an overall increase in the incidence of Clostridium difficile-associated disease and, particularly, an increase in the more virulent forms of the disease. Treatment of severe C difficile infection includes management of severe sepsis and shock, pathogen-directed antibiotic therapy, and, in selected cases, surgical intervention. Ultimately, prevention is the key to limiting the devastating effects of this microorganism.
... En estos dos grupos cobra mayor importancia el diagnóstico microbiológico, dado que en muy pocos casos va a ayudar la endoscopia, salvo para descartar otro tipo de entidades o infecciones como citomegalovirus. La colitis pseudomembranosa afecta principalmente al recto y al sigmoides, pero en hasta 15 a 20% de los casos las lesiones se observan a nivel más proximal 69 . Por este motivo, aunque el colon izquierdo sea normal en la endoscopia, y si existe una alta sospecha clínica de colitis 70 . ...
Clostridium difficile is the most common cause of infectious diarrhea in adults healthcare institutions. Recent studies have shown an increase in the incidence, severity and recurrence of C. difficile infection (CDI). Factors associated with the patient and medical care provided contribute to establishing colonization and, in some cases, subsequent progression to symptomatic disease. The availability of new microbiological techniques has contributed greatly to improving care for these patients. A diagnostic algorithm is provided for cases in which CDI is suspected based on current evidence regarding the effectiveness of microbiological and radiological methods. In cases in which CDI is confirmed, the first and most effective measure is the withdrawal of any antibiotic treatment the patient is receiving, if possible. The antimicrobial treatment of CDI is based on three classic agents: metronidazole, vancomycin and teicoplanin, along with the recent addition of fidaxomicin. Patients presenting serious symptoms, in addition to appropriate support and monitoring measures, may require surgical treatment. Infection prevention and control strategies can interrupt the transmission mechanism. This manuscript reviews current evidence on the approach of this entity from a multidisciplinary point of view.
... However, there are reports of rectal or rectosigmoid sparing PMC occuring in as many as 23% to 69% of patients. 16,17 Normal mucosal appearance or nonspecific proctosigmoiditis may be the sigmoidoscopic finding but pseudomembrane can be found in ascending colon as occurred in our case. Therefore, total colonoscopy should be performed to confirm the diagnosis of PMC, if sigmoidoscopy is inconclusive. ...
Pseudomembranous colitis (PMC) is known to be associated with antibiotic treatment, but is not commonly related to antitubercular (anti-TB) agent, rifampin. PMC is frequently localized to rectum and sigmoid colon, which can be diagnosed with sigmoidoscopy. We report a case of rifampin-induced PMC with rectosigmoid sparing in a pulmonary tuberculosis patient. An 81-year-old man using anti-TB agents was admitted with a 30-day history of severe diarrhea and general weakness. On colonoscopy, nonspecific findings such as mucosal edema and erosion were found in sigmoid colon, whereas multiple yellowish plaques were confined to cecal mucosa only. Biopsy specimen of the cecum was compatible with PMC. Metronidazole was started orally, and the anti-TB medications excluding rifampin were readministerred. His symptoms remarkably improved within a few days without recurrence. Awareness of rectosigmoid sparing PMC in patients who develop diarrhea during anti-TB treatment should encourage early total colonoscopy.
... Although sigmoidoscopy can be helpful, it is important to remember that pseudomembranes can be restricted to the proximal colon (Tedesco et al., 1982), or be completely missing. ...
Clostridium difficile is a well recognized pathogen of humans and animals. Although C. difficile was first identified over 70 years ago, much remains unknown in regards to the primary source of human acquisition and its pathobiology. These deficits in our knowledge have been intensified by dramatic increases in both the frequency and severity of disease in humans over the last decade. The changes in C. difficile epidemiology might be due to the emergence of a hypervirulent stain of C. difficile, ageing of the population, altered risk of developing infection with newer medications, and/or increased exposure to C. difficile outside of hospitals. In recent years, there have been numerous reports documenting C. difficile contamination of various foods, and reports of similarities between strains that infect animals and strains that infect humans as well. The purposes of this review are to highlight the many challenges to diagnosing, treating, and preventing C. difficile infection in humans, and to stress that collaboration between human and veterinary researchers is needed to control this pathogen.
Clostridioides (formerly Clostridium ) difficile is a major cause of nocosomial infection in the USA and worldwide. It has a wide spectrum of presentation, ranging from an asymptomatic carrier state to fulminant colitis. Pseudomembranous colitis is a manifestation of severe C. difficile infection (CDI), typically with progressive symptoms including watery diarrhoea, abdominal cramping and fevers and elevated white cell count and/or creatinine. It is diagnosed on three levels, including clinical assessment, stool assays and visualisation of the colonic mucosa. Laboratories will reject stools that do not meet criteria for testing. In the era of molecular testing for the presence of toxigenic C. difficile DNA, which only indicates the potential for infection, it is vital to use clinical evaluation in the diagnosis of CDI. We present an atypical case of pseudomembranous colitis affecting the right colon in a patient whose stools were rejected multiple times for C. difficile testing.
Clostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care-associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to infection prevention. This article provides updated recommendations regarding the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.
Enteric infections are a major cause of morbidity and mortality worldwide including 800 000 deaths, or 10.5% of all childhood deaths under 5 years of age. This chapter provides an overview of diagnostic considerations for all patients with diarrhea focusing on microbiological assessments, specific and nonspecific therapies, and general preventive measures. We then discuss the history, epidemiology, pathogenesis, clinical aspects, complications, diagnosis, and treatment of a diversity of bacterial and viral gastrointestinal pathogens including tradition and emerging pathogens.
IntroductionInfectious diarrheaAIDS enteropathySexually transmitted diseases causing colitisIdiopathic diarrhea and miscellaneous
Clostridium (C.) difficile is a typical representative of the genus Clostridium. After colonization of the intestinal tract, toxigenic C. difficile strains are capable to produce two exotoxins, enterotoxin (toxin A) and cytotoxin (toxin B), which cause diarrhea and colitis. Toxin A binds to specific carbohydrate receptors on the surface of intestinal cells and this is the beginning of damages in the intestinal tract which include destruction of the villi epithelium, limiting membrane, intercellular connections (zonula occludens) and surface of the mucosa. If only toxin B is injected into intestinal cells, it does not cause damage nor increased fluids secretion. Probably, the reason for this is the inability of the toxin to bind to the cell membrane receptor in the intestinal tract under normal physiological conditions. Toxigenic strains of C. difficile can be found in the intestines of healthy people, without any symptoms or clinical signs (asymptomatic colonization). However, in people with risk factors, they can cause diarrhea of varying severity and life-threatening pseudomembranous colitis. These diseases are known as C. difficile associated disease - CDAD.
Morbus Crohn und Colitis ulcerosa sind chronisch-entzündliche, rezidivierende Darmerkrankungen, deren Ätiologie bislang nicht ausreichend geklärt ist. Insbesondere sind jene Faktoren unbekannt, die eine chronische Immunreaktion initiieren und perpetuieren.
In der klinischen Praxis steht bei Erkrankungen des Darmes die endoskopische Diagnostik meistens mit am Anfang. Im oberen Gastrointestinaltrakt erlaubt sie die Beurteilung bis etwa zum Treitz-Band, bei Einsatz spezieller längerer Endoskope auch darüber hinaus bis ins Jejunum. Koloskopisch ist die Untersuchung vom Analring bis ca. 25 cm oberhalb der Ileozäkalklappe möglich.
In the 1950’s when the era of antibiotics began the initial accounts of antibiotic-associated pseudomembranous colitis (PMC) suggested that overgrowth by Staphylococcal aureus was the responsible agent (1). A suitable animal model at that time was believed to be the chinchilla in whom it was noticed that S. aureus could be grown from the enteric ulcers that developed after feeding the animals pellets containing Chlortetracycline (2). The vogue for incriminating S. aureus in human disease waned following the demonstration that antibiotic-associated PMC occurred with or without S. aureus present and indeed S. aureus could cause diarrhoea in the absence of intestinal morphological changes (3).
A twenty-six-year old female who had been well and had no serious disease developed pseudomembranous colitis after ampicillin and cloxacillin (Viccillin-S) therapy for acute tonsilitis. Barium enema examination revealed a loss of haustration and a marked narrowing of the colon and colonoscopy showed maculae-like pseudomembrane extensive-ly. A relap:;e occurred after cessation of metronidazole (Flagyl) and it was successfully treated with Vancomycin. A possible role of allergic reaction to Viccillen S in the case was evaluated. All tests including skin reaction, rectal mucosa reaction and lymphocyte transformation to Viccillin S were negative. Laboratory findings revealed no elevation of eosinophil, I gE or immune complex in the peripheral blood. From these, it was concluded that the case developed pseudomembranous colitis without relation to allergic mechanism with Viccillin S.
Histological reaction patterns within the colon are not disease-specific but reflect mechanisms of injury and duration of disease. By correlating these patterns with known causes of colonic inflammation, we provide guidelines to enhance the diagnostic value of colonoscopic samples. Normal histological features are reviewed, and the sequence of inflammation and repair is used as the basis for appreciating pathological deviations. The common histological patterns of acute colitis with and without features of pseudomembranous or ischemic colitis and the morphological features of chronic colitis with and without crypt destruction are collated with clinical and endoscopic features to emphasize the importance of dialogue between the pathologist and gastroenterologist. Less common patterns, including eosinophilic colitis, graft-versus-host disease, chronic mucosal prolapse, por tal hypertensive colopathy, and nonspecific or idiopathic ulcer, illustrate variations in the basic reaction patterns. Difficulties in differential diagnosis are underscored, and biopsy strategies are suggested. (C) 2000 by Am. Cell. of Gastroenterology.
Background: Clostridium difficile-infection (CDI) is the predominant cause of nosocomial diarrhea. Approximately 300,000 new cases occur in hospitals in the United States each year and these rates nearly doubled between 2000 and 2003. There is also an increase in mortality and complications related to CDI. Case Report: A 54-year-old male who underwent a total hip replacement developed diarrhea 2 days postoperative; he received cefazolin as perioperative antibiotic. Clostridium difficile (CD) enzymelinked immunosorbentassay (ELISA) toxin assay was negative, and he was sent home. After three weeks, he returned to the hospital with severe abdominal pain, watery diarrhea, severe sepsis, and multiple organ failure. CD toxin ELISA was once again negative, but colonoscopy demonstrated pseu-domembranes in the transverse colon. Tissue culture assay was positive. Colectomy with end-ileos-tomy was performed and the patient had an excellent recovery. Conclusions: Perioperative antibiotic has become standard for surgical site infection prevention, but it can be associated with the development of CD colitis. Prompt diagnosis and treatment are essential for a good outcome, and timely surgical intervention should be used in patients who are unresponsive to medical therapy.
Clostridium difficile associated disease (CDAD) is responsible for 10%-20% of all cases of antibiotic associated diarrhea. CDAD has emerged as the most frequent nosocomial infection with substantial morbidity, mortality and economic burden to healthcare in the older adults since advanced age is a major risk factor for CDAD. Our review, an update and extension of many previous reviews on this topic, is aimed at discussing the epidemiology, risk factors, bacteriology, clinical manifestations, diagnostic modalities, prevention and treatment of CDAD especially in the older adults.
The colon is one structural unit with two embryological origins. The cecum and right and midtransverse colons are of midgut origin and as such are supplied by the superior mesenteric artery (SMA). The distal transverse, splenic flexure, and descending and sigmoid colon are of hindgut origin and receive blood from the inferior mesenteric artery (IMA). The entire colon starts as a midline structure that rotates during development and attaches laterally to the right and left posterior peritoneum. The right and left colonic mesenteries are obliterated, fusing to the posterior peritoneum in these regions, leaving these portions of the colon covered by peritoneum on the lateral, anterior, and medial surfaces. The transverse and sigmoid colons, in contrast, are completely covered with peritoneum and are attached by long mesenteries, allowing for great variation in the location of these structures (Fig. 51.1).
Clostridium difficile is the principal cause of infectious diarrhea in hospitalized patients. This pathogen is primarily acquired following exposure to various antibiotics. Disease due to C. difficile is usually successfully treated with either oral metronidazole or vancomycin. Surgical therapy, generally subtotal colectomy, is necessary for a small number of patients who have fulminant colitis unresponsive to medical therapy.
This chapter deals with clostridial infections that cause intestinal disease in humans and in which diarrhea is a major or significant feature of the clinical syndrome. In addition to the distinct disease syndromes, clostridia are often involved in polymicrobial infections of the gastrointestinal tract and present without specific features except for the occasional association of gas at the infected site. The production of hydrogen gas by clostridia and C. perfringens accounts for radiographic and pathologic findings associated with emphysematous cholecystitis and pneumatosis cystoides intestinalis. Clostridia cause distinct gastrointestinal syndromes in humans as a result of the action of specific toxins on the intestinal mucosa. Host factors predispose to different clinical syndromes and include: antimicrobial exposure, trypsin deficiency, and neutropenia. Clostridia are widely dispersed in the environment and the risk of developing a particular syndrome relate to the relative predominance of a particular species in that environment, such as in hospitals (C. difficile diarrhea) or the Highlands of Papua New Guinea (C. perfringens type C enteritis).. Ingestion of contaminated foods in the case of C. perfringens type A diarrhea and C. perfringens type C enteritis may also determine the type of syndrome displayed.
Inflammation of the intestines is common worldwide. Infections are the major cause whereas chronic inflammatory bowel diseases (CIBDs), drugs and other conditions are less frequent causes. Worldwide, enteric infections rank third among all causes of disease burden. The main infectious agents include a variety of viruses and bacterial agents. As endoscopy and colonoscopy are used more frequently, the pathologist is more likely to see small and large intestinal biopsies for the diagnosis of inflammatory lesions, although histology most frequently does not contribute very much to the specific diagnosis of infections. Histology is, however, very important in chronic conditions, allowing the identification of pathogens, such as cytomegalovirus, and the differential diagnosis between CIBD and drug- or infection-related conditions, such as tuberculosis and acute infectious colitis, based on the morphology of the lesions. Histological analysis is equally important for the diagnosis of inflammation in patients with a disturbed immune system, such as transplant recipients, and for the identification of rare diseases, and the diagnosis of dysplasia and complicating neoplasias.
Clostridium difficile (C. difficile) is a cytotoxin-producing anaerobic gram-positive rod that is responsible for pseudomembranous colitis (PMC). The incidence of C. difficile is increasing in ulcerative colitis (UC) and inflammatory bowel disease patients and is associated with a more severe course, a longer hospital stay, higher financial costs, a greater likelihood of colectomy, and high mortality. PMC may occur anywhere along the intestinal tract, but it is often found in the distal colon. PMC involving the proximal colon with rectosigmoid sparing is rarely reported in patients with UC. We describe the case of a 35-year-old woman in remission from UC who presented with frequent diarrhea and abdominal pain. She was treated with ciprofloxacin for infectious enterocolitis at a local hospital; however, her symptoms did not improve. A colonoscopy revealed yellow-white plaques with edematous, erythematous from the proximal ascending colon to the cecum, and feces positive for C. difficile toxin. She was treated with metronidazole (500 mg, three times a day) for two weeks, and improved rapidly. Physicians should carefully examine the entire colon via colonoscopy, and perform stool exams for C. difficile in patients with UC who have been treated with antibiotics and in those who develop prolonged diarrhea despite medical treatment.
Clostridium difficile infection is associated with broad-spectrum antibiotic therapy that alters the normal gastrointestinal flora and is the most common cause of infectious diarrhea in hospital patient [1, 2]. So it is a significant cause of morbidity and mortality among elderly hospitalized patients. Pathogenic strains of C. difficile produce two protein exotoxins, toxin A and toxin B, which cause colonic mucosal injury and inflammation [1, 3]. Infection may be asymptomatic, cause mild diarrhea, or result in severe pseudomembranous colitis (PMC). PMC is characterized by the presence of yellow or white plaques on the mucosal surface that are composed of inflammatory exudates. Risk factors for PMC include antimicrobial therapy, older age (>65 years), antineoplastic chemotherapy, length of hospital stay, and procedures or medications that alter the intestinal motility or flora [4, 5]. Antimicrobial exposure is the greatest risk factor for patients. The antibiotics most frequently implicated in predisposition to PMC include fluoroquinolones, clindamycin and broad-spectrum penicillins and cephalosporins [6]. However, any antibiotic can predispose to colonization by C. difficile, including metronidazole and vancomycin, which are the major antibiotics used to treat C. difficile infection [3]. The use of broad-spectrum antimicrobials, use of multiple antibiotic agents, and increased duration of antibiotic therapy all contribute to the incidence of PMC.
Background
As our ability to diagnosis and treat C. difficile infections (CDI) has improved over time, the role that endoscopy plays in the management of these patients has evolved.
Purpose
We reviewed the medical literature to describe the role of endoscopy in the management of CDI.
Methods
A search of Pubmed, Ovid, and the Cochrane Library was performed. Abstracts were reviewed to determine their scientific merit and relevance. The selected articles and relevant embedded references from the primary articles were also examined, with recommendations based on consensus conclusions of the data.
Results
A total of 80 articles were reviewed and analyzed for this manuscript.
Conclusion
Endoscopy once played a very prominent role in the diagnosis and management of C. difficile infections. It now serves as a tool in complicated cases to evaluate for other pathology and to asses for disease severity, while providing an therapeutic option for select patients.
Clostridium difficile causes a broad spectrum of enteric diseases in humans, ranging from mild antibiotic-associated diarrhoea to more severe pseudomembranous colitis. The authors report four cases of life-threatening pseudomembranous colitis with haemodynamic changes. Infection due to Clostridium difficile should be kept in mind whenever a patient undergoing antibiotic therapy develops a symptomatology of an acute abdomen.
This article has no abstract; the first 100 words appear below.
Presentation of Case A 7 1/2-year-old girl was admitted to the hospital because of diarrhea and arthralgia. She was well until five months previously, when dysuria developed and evidence of a urinary-tract infection was found. Ampicillin was administered, with improvement. Sixteen weeks before admission ampicillin was discontinued. The patient was subsequently well until 10 weeks before entry, when she began to have midepigastric cramps, diarrhea, and a low-grade fever. During the next few weeks her stools increased in frequency to 10 to 12 daily; they were watery and dark green and often contained mucus. Two weeks after the onset of . . .
The incidence of C. difficile infections (CDI) in the elderly continues to rise and infection is associated with increased morbidity and mortality when compared to those affected in younger age-groups. Immunosenescence may be a contributory factor yet the exact immune responses that may protect against CDI are incompletely understood. Increased exposure to antibiotics, frequent and/or prolonged hospital admissions and residing in long-term care facilities provide multiple opportunities for host and pathogen to coincide. This review explores the epidemiology, diagnostic parameters and management of the spectrum of disease in the geriatric population. Deaths attributed to CDI are most common in the elderly population and are a major contributor to gastroenteritis-associated mortality in many countries. The elderly represent an at-risk population from this pathogen and efforts must be directed to preventing infection and optimising treatment in this group.
A 61-year-old male was admitted to our hospital due to right lower abdominal pain and watery diarrhea for 3 d. Beginning 3 wk before he arrived in our hospital, he took 3(rd)-generation cephalosporin (cefixime) for 2 wk due to chronic left ear otitis media. Colonoscopic examination revealed yellowish patches of ulcerations and swelling covered with thick serosanguineous exudate in the cecum and ascending colon. After 7 d of oral metronidazole treatment, his symptoms completely disappeared. We report a case of localized pseudomembranous colitis in the cecum and ascending colon mimicking acute appendicitis associated with cefixime.
Clostridium difficile-associated infection (CDI) can have varying severity from asymptomatic carriage to fulminant colitis. Its incidence and virulence in North America are increasing. The increase in virulence is associated with emergence of the highly toxigenic North American pulsed field gel electrophoresis-1 strain. The major risk factor for CDI is exposure to antibiotics. Another major risk factor is hospitalization. The spectrum of CDI ranges from asymptomatic carriers to fulminant disease. Although asymptomatic carriers require no treatment, fulminant disease carries a substantial mortality regardless of management strategy.
As mentioned in previous chapters, humans live in close association with vast numbers of organisms that are present on the skin, in the mouth, and in the gastrointestinal (GI) tract. Following birth there is a progressive formation of a complex intestinal microflora, which develops into a host-bacterial mutualism in the human intestine. This development is significant to the host initiating its own immune system. Also, initial colonizing intestinal microflora is considered to have a significant effect on the health and well-being of the individual with advancing age. © Springer Science+Business Media, LLC 2009. All rights reserved.
NSAID injury can mimic IBC, can exacerbate IBD, and NSAID use may also be more common in the diarrheal syndrome of collagenous
colitis, though there is no clear role in pathogenesis.
Ileocolonoscopy has a high accuracy in the detection and differentiation of various forms of inflammatory bowel disease.
The main differential still centers around ulcerative colitis and Crohn's disease.
Ileocolonoscopy has also increasingly been used in the evaluation of the value of different therapeutic regimes and in screening for malignancy in patients with longstanding ulcerative colitis.
Clostridium difficile infection (CDI) is the leading infective cause of antibiotic associated diarrhea. The principal objective of this study was to assess the knowledge and awareness of internal medicine (IM) residents regarding the epidemiology, clinical recognition, diagnosis and management of CDI.
A 20-question survey was distributed to 90 IM residents in all three years of their post graduate training in a university-based program. The survey instrument assessed the resident's knowledge of the current epidemiological trend, clinical recognition and presentation, diagnosis and management of CDI.
Forty two out of 90 (48%) residents completed the questionnaire. Only 10/42 (23.8%) of the residents recommended the gold standard investigation for diagnosing CDI. The majority of residents 29/42 (69%) were not aware of the existence of CDI in the outpatient setting and would not test for CDI. Only 50% of the residents were aware of the worse outcome of CDI in inflammatory bowel disease patients and only 12/42 (28.6%) would appropriately risk stratify and treat patients. Almost all of the residents (97.6%) knew about the appropriate time to consult surgery. There was no significant difference in the awareness with respect to the year of training (interns vs. residents), their career choices (primary care vs. fellowship) nor did the knowledge correlate with the United States medical licensing examination (USMLE) scores.
IM residents had suboptimal knowledge of many aspects of the common problem of CDI. Educational efforts should be directed at IM residents, many of whom plan careers as primary care/hospitalists, who will encounter patients with CDI.
Clostridium difficile is a spore-forming, toxin-producing, anaerobic bacterium abundant in soils and water. Frequent and early colonization of the human intestinal flora is common and often asymptomatic. Antimicrobials given commonly disrupt the intestinal microflora and through proliferation in colon and production of toxin A and B it precipitates C. difficile infection (CDI). The enterocytic detachment and bowel inflammation provoke C. difficile-associated diarrhoea (CDAD) sometimes developing into severe pseudomembranous colitis (PMC) and paralytic ileus. Infection is acquired from an endogenous source or from spores in the environment, most easily facilitated during hospital stay. In the elderly, comorbidity, hospitalization and antimicrobial treatment present as major risk factors and the slow recolonization of the normal flora likely responsible for single or multiple recurrences of CDI (25-50%) post therapy. The key procedure for diagnosis is toxin detection from stool specimens and sometimes in combination with culture to increase sensitivity. In mild cases stopping the offending antimicrobial will lead to resolution (25%) but standard therapy still consist of either oral metronidazole or vancomycin. Alternative agents are presently being developed and fidaxomicin, as well as nitrothiazolide are promising. Furthermore, host factors like low antitoxin A levels in serum relates to increased risk of recurrence and small numbers of patients have received immunoglobulin with good results. An immunogenic toxoid vaccine has been developed and human colostrum rich in specific secretory Ig A also support the future use of immunotherapy. Today we experience a tenfold increase of CDI incidence in the western world and both epidemics and therapeutic failure of metronidazole is contributing to morbidity and mortality. The current epidemic of the C. difficile strain NAP1/027 emerging in 2002 in Canada and the USA has now spread to most parts of Europe and virulence factors like high toxin production and sporulation challenge the therapeutic situation and cause great concern among infection control workers. Excessive use of modern fluoroquinolones is thought to play an important role in facilitating this epidemic since NAP1/027 was shown to have acquired moxifloxacin resistance compared to historical strains of the same genotype. Both the current epidemic like this and other local outbreaks from resistant or virulent strains warrant culture to be routinely performed enabling susceptibility testing and typing of the pathogen. Genotyping is most commonly done today by pulse-field gel electrophoresis (PFGE) or PCR ribotyping but multilocus variable-number tandem-repeat analysis (MLVA) seems promising. Epidemiological surveillance using all these tools will help us to better understand the global spread of C. difficile.
Colonoscopic findings among 16 patients with histologically proved antibiotic-associated pseudomembranous colitis (PMC) were analyzed. The characteristic endoscopic changes of PMC with pseudomembranes were observed in only 5 (31%) out of 16 patients by sigmoidoscopy but in 11 (85%) out of 13 patients in whom colonoscopy was also performed. The findings suggest the importance of colonoscopy in the early diagnosis of PMC and indicate that the typical endoscopic changes of PMC are limited to the colon above the rectosigmoid area in most patients with antibiotic-associated colitis. It is emphasized that colonoscopy should be performed at least in clinically suspected PMC cases, in which the early diagnosis of PMC might be missed if sigmoidoscopy alone is performed.