Clostridioides difficile masked as a large bowel obstruction

Author(s):
Michael Amaturo, DO; Garnet Vanterpool; Melissa McIntosh

Background:

Clostridioides difficile is an anaerobic, spore-forming, Gram-positive bacilli that releases potent exotoxins that targets the colonic epithelial cells. It’s one of the most common causes of nosocomial infections of the Gl tract in the United States.

Of those infected with Clostridioides difficile, fulminant C. difficile colitis will occur in 3-8%.  Fulminant C. diff is characterized by severe diffuse or lower quadrant abdominal pain, abdominal distension, hypotension, lactic acidosis, and up-trending leukocytosis. Possible complications include ileus, colonic perforation, and toxic megacolon.

Hypothesis:

Patients who acquire clostridiodes difficile have a possibility of developing large bowel obstruction.

Methods:

66 year old female with a history of diabetes mellitus, hyperlipidemia, hypertension, ESRD on hemodialysis, obstructive sleep apnea on CPAP, colonoscopy in 2020. Patient presented to the emergency department complaining of rectal bleeding, abdominal pain, and no bowel movement or flatulence for 6 days. Her vitals were stable and she was afebrile. On physical examination, diffuse abdominal tenderness was elicited on palpation with abdominal distension and guarding. Of note, WBCs were elevated at 11.7, and RBCs, Hgb, Hct all decreased at 2.77, 7.6, and 24.3 respectively.

Results:

Abdominal x-ray showed a distended large bowel and CT of the abdomen and pelvis revealed distended right and transverse colon with narrowing of distal descending and sigmoid colon. Patient was admitted to medicine and general surgery was consulted for suspected large bowel obstruction. A colonoscopy was performed and during the procedure, areas of patchy necrosis were seen with pseudomembranes which were highly suspicious for fulminant C. difficile. Given the nature of necrotic bowel seen on colonoscopy, an exploratory laparotomy and subtotal colectomy with end ileostomy were performed.

Conclusions:

Patient was transferred to the SICU for post-op management with a course of antibiotics for pseudomembranous colitis. Fulminant C. difficile is a rare occurrence of clostridioides difficile and is seen in very few patients. Risk factors include recent antibiotic use, old age >65 years, and recent hospital stay. Given the nature of this patient’s presentation, large bowel obstruction was identified. However, the culprit for this patient’s LBO was fulminant C. difficile. In most cases, C. difficile complication includes ileus, colonic perforation, and toxic megacolon. So this instance of large bowel obstruction is a rare occurrence.