A 50-year-old woman comes to the emergency department due to abdominal pain. For 3 days, she had lower abdominal cramping and frequent watery diarrhea, but over the past 24 hours, the pain has progressively worsened; she has also had a fever. The patient has no chronic medical conditions but recently finished a course of ciprofloxacin for pyelonephritis. Temperature is 38.9 C (102 F), blood pressure is 110/68 mm Hg, and pulse is 118/min. Abdominal examination shows lower abdominal tenderness without guarding or rigidity. Abdominal CT scan reveals colonic wall edema without perforation. The patient is admitted to the hospital and treated with intravenous fluids and oral vancomycin. Stool toxin assay is positive for Clostridioides (formerly Clostridium) difficile. Two days later, the diarrhea has decreased, but the abdominal pain is worsening. Examination shows an absence of bowel sounds; the abdomen is distended and diffusely tender to both palpation and release of palpation pressure. Abdominal x-ray reveals dilation of the transverse and descending colon to 10 cm. Serum lactate is 6 mmol/L (normal: <2). Which of the following is the best next step in management?
This patient with Clostridioides (formerly Clostridium) difficile infection (CDI) has worsening abdominal pain, signs of peritonitis, and severe colonic dilation (ie, toxic megacolon) despite appropriate medical management. The best next step is laparotomy to evaluate for colonic necrosis or perforation and to treat (eg, resect, lavage) the diseased colon.
CDI occurs most commonly in patients with recent antibiotic use (eg, ciprofloxacin) and has a wide spectrum of severity, from nonsevere disease (eg, abdominal cramping, watery diarrhea, fever) to life-threatening, fulminant colitis with toxic megacolon. This patient initially had nonsevere disease and received appropriate treatment with oral vancomycin. However, the CDI progressed, and, now, multiple clinical indicators warrant surgical evaluation:
Signs of peritonitis: Diffuse abdominal tenderness, rebound tenderness (ie, tenderness with release of palpation pressure)
Colonic dilation: Megacolon (ie, colonic diameter >6 cm) on abdominal x-ray, with associated loss of smooth muscular tone (eg, decreased diarrhea)
Increased serum lactate: Possible marker of colonic ischemia
Peritonitis often indicates bowel perforation and is a definitive indication for surgical exploration, which is performed via laparotomy (or laparoscopy in some institutions). Findings of necrosis, perforation, or abdominal compartment syndrome warrant colonic resection (ie, total abdominal colectomy). A diverting loop ileostomy with colonic lavage (eg, polyethylene glycol intraoperatively, vancomycin postoperatively) may be considered for patients without these findings.
(Choices A and E) Management of acute colonic pseudoobstruction (ie, obstructive symptoms/signs without a mechanical cause) may include colonoscopic decompression or administration of neostigmine, an acetylcholinesterase inhibitor that increases gastrointestinal motility. However, these interventions are not typically used with severe infection/inflammation (eg, fulminant CDI) due to the high risk of colonic perforation; they are inappropriate in a patient with clinical peritonitis.
(Choice B) Fecal microbiota transplantation, which can help restore a healthy gut microbiome, is generally used for recurrent CDI. Although it shows promise in some studies as part of the management of severe CDI, it does not replace surgical intervention for patients with peritonitis and suspected colonic ischemia (eg, increased serum lactate).
(Choice C) Intravenous corticosteroids are commonly used for flares of ulcerative colitis or Crohn disease but are not used in management of toxic megacolon due to CDI.
Educational objective:
Surgical evaluation is warranted for patients with Clostridioides (formerly Clostridium) difficile infection that progresses despite appropriate medical management, especially when abdominal symptoms worsen or when megacolon or increased serum lactate is present. Peritonitis is a definitive indication for surgical exploration (eg, laparotomy).