an unusual case of colitis
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An unusual case of colitis. DM, 55yo. Previously well woman was referred by GP for lower abdominal pain and vomiting Noticed increasing flatus 5/7 prior Loose BM x 3/7 relieved by immodium Crampy abdominal pain ++ Multiple episodes of N+V. History. Nil anorexia/weight loss

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dm 55yo
DM, 55yo
  • Previously well woman was referred by GP for lower abdominal pain and vomiting
  • Noticed increasing flatus 5/7 prior
  • Loose BM x 3/7 relieved by immodium
  • Crampy abdominal pain ++
  • Multiple episodes of N+V
history
History
  • Nil anorexia/weight loss
  • No recent exposure to C.difficile or gastroenteritis
  • No recent travel
  • Last antibiotic use was 6/12 ago – flucloxacillin & amoxicillin for paronychia
past medical surgical hx
Past Medical/Surgical Hx

PMHx/PSHx: Cholecystectomy

Meds: Nil

Allergies: NKDA

FHx: Nil

slide5
SHx
  • Married, no children
  • Non-smoker
  • Non drinker
slide6
O/E
  • HR: 116 bpm, regular
  • BP: 120/64 mmHg
  • RR: 20/min
  • T: 36.3 C
  • Sats: 98% RA
slide7
O/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 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

Blood investigations
radiology
Radiology
  • CXR showed prominent bowel loop beneath left hemidiaphragm
  • PFA – grossly distended loops of bowel
slide10
Ddx
  • Colitis (infective vs inflammatory)
  • Gastroenteritis
initial management
Initial management
  • Aggressive fluid resuscitation
  • NGT
  • Close monitoring of fluid balance
  • IV hydrocortisone, IV ciprofloxacin, IV metronidazole and oral vancomycin
  • Urgent CT abdomen done on 17/6/9
ct abdomen
CT abdomen
  • Oedematous, fluid filled right colon
  • Free fluid in abdomen and loculated collection in pouch of Douglas
  • Bilateral ovarian cysts
  • Bilateral pleural effusions
flexi sigmoidoscopy
Flexi sigmoidoscopy
  • Normal mucosa
  • No distal colitis
  • Full colonoscopy not performed due to risk of perforation
course in hospital
Course 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 Injury
  • Transferred to ICU
microbiology and id
Microbiology and ID
  • C. diff toxin negative
  • ?infective vs inflammatory process
  • Decision: treat until C. diff can be r/o
  • IV metronidazole, PO vancomycin for C.difficile
  • IV piperacillin/tazobactam in case of abdominal sepsis
microbiology and id1
Microbiology 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 hospital1
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
discharge
Discharge
  • Patient 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
introduction
Introduction

Aetiology of colitis:

1. Inflammatory

- Ulcerative colitis

- Crohn’s disease

- Indeterminate colitis

2. Ischaemic

introduction1
Introduction

3. Infective:

-Enterotoxigenic E. coli

-Shigella

-Salmonella

-Campylobacter

-C. difficile

-Yersinia enterocolitica

4. Radiation

clostridium perfringens colitis1
Clostridium 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

slide25

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.

slide26

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 students
Medical students

Remember the aetiology of colitis

Differential diagnosis of lower abdominal pain & distension

Treatment for C. perfringens colitis

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