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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An unusual case of colitis

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An unusual case of colitis

An unusual case of colitis


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


An unusual case of colitis

SHx

  • Married, no children

  • Non-smoker

  • Non drinker


An unusual case of colitis

O/E

  • HR: 116 bpm, regular

  • BP: 120/64 mmHg

  • RR: 20/min

  • T: 36.3 C

  • Sats: 98% RA


An unusual case of colitis

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


An unusual case of colitis

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 colitis

Clostridium perfringens colitis


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


An unusual case of colitis

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.


An unusual case of colitis

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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