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An unusual case of colitis

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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  1. An unusual case of colitis

  2. 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

  3. 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

  4. Past Medical/Surgical Hx PMHx/PSHx: Cholecystectomy Meds: Nil Allergies: NKDA FHx: Nil

  5. SHx • Married, no children • Non-smoker • Non drinker

  6. O/E • HR: 116 bpm, regular • BP: 120/64 mmHg • RR: 20/min • T: 36.3 C • Sats: 98% RA

  7. 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

  8. 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

  9. Radiology • CXR showed prominent bowel loop beneath left hemidiaphragm • PFA – grossly distended loops of bowel

  10. Ddx • Colitis (infective vs inflammatory) • Gastroenteritis

  11. 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

  12. CT abdomen • Oedematous, fluid filled right colon • Free fluid in abdomen and loculated collection in pouch of Douglas • Bilateral ovarian cysts • Bilateral pleural effusions

  13. Flexi sigmoidoscopy • Normal mucosa • No distal colitis • Full colonoscopy not performed due to risk of perforation

  14. 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

  15. 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

  16. 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.

  17. 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

  18. 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

  19. Introduction Aetiology of colitis: 1. Inflammatory - Ulcerative colitis - Crohn’s disease - Indeterminate colitis 2. Ischaemic

  20. Introduction 3. Infective: -Enterotoxigenic E. coli -Shigella -Salmonella -Campylobacter -C. difficile -Yersinia enterocolitica 4. Radiation

  21. Clostridium perfringens colitis

  22. 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

  23. 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.

  24. 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

  25. 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.

  26. Medical students Remember the aetiology of colitis Differential diagnosis of lower abdominal pain & distension Treatment for C. perfringens colitis

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