Clostridium difficile Enteritis and Bowel Ischemia After Recent Total Abdominal Colectomy: A Fatal Case of Extra-Colonic Pseudomembranous Disease

Pseudomembranous enteritis is a rare, often aggressive form of C. difficile infection affecting the small bowel. Colonization often manifests in patients with surgically absent colons, where intestinal metaplasia to colonic-type mucosa provides a more favorable environment for bacterial overgrowth. Common risk factors such as antibiotic overuse, advanced age, and pre-existing inflammatory bowel disease provide the impetus for a more fulminant disease course. We present a case of fatal pseudomembranous enteritis complicated by volvulus and bowel ischemia in a patient 4 months after total colectomy. An 84-year-old male who recently completed a 3-week course of Cefuroxime for pneumonia presented from a care facility with severe diarrhea and evidence of septic shock. He was diagnosed with fulminant pseudomembranous colitis caused by C. difficile infection ultimately requiring a total colectomy after bowel perforation was discovered. He was resuscitated and discharged only to readmit 4 days later with increased ostomy output and clinical signs of dehydration. Repeat C. difficile testing by immunoassay was negative and he was discharged with Loperimide and Octreotide therapy. Four months later he presented to the hospital in septic shock with concern for pneumonia. CT scan of the abdomen revealed a closed loop bowel obstruction. He was taken for surgical lysis of adhesions, where volvulus and bowel ischemia was discovered and resected. Flexible sigmoidoscopy of the rectal stump showed no evidence of infection. Microscopic examination of the resected segment demonstrated diffuse pseudomembranous inflammation with areas of focal necrosis. Pathology confirmed C. difficile infection of the small bowel. He was transitioned to comfort care and died two days later from peritonitis and multi-organ failure. Total abdominal colectomy remains a life-saving means of source control for fulminant C. difficle infection. While severe disease is common in the colon, extension of pseudomembranous inflammation to the small bowel is rarely seen. Gut peristalsis and the action of the ileocecal valve are thought to contribute some mechanical defense against retrograde infection, however this function is altered after colectomy and ileostomy formation. Colonization of the ileum after surgery is likely under-reported, and it is imperative that clinicians consider C. difficle in the differential diagnosis of patients presenting with high ostomy output and clinical signs of sepsis.