Management of Clostridium difficile Colitis in the Setting of Ogilvie’s Syndrome

Mohammed Alkhero; Megha Shalavadi; Midhat Lakhani; Indraneel Chakrabarty

Management of Clostridium difficile Colitis in the Setting of Ogilvie’s Syndrome

Mohammed Alkhero^1*, Megha Shalavadi¹, Midhat Lakhani¹, Indraneel Chakrabarty²

¹Internal Medicine Resident, UHS SOCAL MEC/ Internal Medicine Residency Program, USA

²Department of Gastroenterology, UHS SOCAL MEC Internal Medicine Residency Program, USA

*Corresponding author: Mohammed Alkhero, Internal Medicine Resident, UHS SOCAL MEC/ Internal Medicine Residency Program, USA

Received Date: 02 April, 2020; Accepted Date: 20 April, 2020; Published Date: 24 April, 2020

Citation: Alkhero M, Shalavadi M, Lakhani M, Chakrabarty I (2020) Management of Clostridium difficile Colitis in the Setting of Ogilvie’s Syndrome. J Dig Dis Hepatol 5: 170. DOI: 10.29011/2574-3511.100070

Abstract

Acute Colonic Pseudo-Obstruction (ACPO), Ogilvie’s syndrome, refers to marked dilation of the colon in the absence of mechanical obstruction. ACPO is associated with significant morbidity and mortality, requiring urgent gastroenterological evaluation. Since it is a diagnosis of exclusion, mechanical obstruction, other causes of toxic mega colon such as Clostridium Difficile Infection (CDI), and ischemia and perforation must be eliminated from the differential diagnosis. Increasing age, caecal diameter, delay in decompression, and status of the bowel significantly influences mortality. We describe a case of C. difficile colitis in the setting of recurrent colonic pseudo-obstruction.

Keywords

Ogilvie’s syndrome; Clostridium difficile colitis; Fecal microbiota transplant

Case Presentation

A 77 year old male came into the hospital with one week of frequent watery bowel movements and abdominal distention that were sudden in onset. The patient denied abdominal pain, nausea, vomiting, hematochezia or mucous in stools and fever. He had no recent history of antibiotics or proton pump inhibitor use. Physical examination showed only left lower quadrant tenderness. Labs revealed a normal leukocyte count and hypokalemia. Urinalysis showed presence of nitrites, leukocyte esterase and more than 50 WBC’s. The patient was started on intravenous ertapenem for complicated UTI. C. difficile toxin B was detected by PCR the next day and intravenous metronidazole and oral vancomycin were started. Ertapenem was discontinued after seven days to prevent facilitating C. difficile growth. His clinical condition fluctuated over the next two weeks with variable abdominal distention. Abdominal X-ray continued to show colonic dilatation. CT with contrast demonstrated a maximum colonic diameter of 12.5 cm. A colonoscopy was performed with successful decompression. Histopathology showed benign colonic mucosa without evidence of inflammation. After the colonoscopy the patient’s distention resolved but he continued to have foul-smelling diarrhea up to three times/day. Five more days of antibiotics after a total of eight days IV metronidazole and 13 days of PO Vancomycin were given to eradicate the CDI. Despite this, he developed tense abdominal distension and the decision for Fecal Microbiota Transplantation (FMT) was made. Antibiotics were held for 48 hours before the procedure. Fecal microbiota was transplanted via colonoscopy. The patient improved, and three days later the patient was having 1-2 semi-solid bowel movements/day. He was discharged back to his care facility in a stable condition.

Discussion and Conclusion

Up to 95 percent of affected patients with ACPO have predisposing conditions, such as trauma, surgery, or infection [1]. CDI is a public health problem which caused approximately 29,000 deaths in the United States in 2011, and up to $4.8 billion in acute inpatient care costs [2,3]. FMT is strongly recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments [4]. Our patient’s case suggests that when CDI is complicated by other contributing conditions, like Ogilvie’s, FMT can be of benefit on initial presentation. This could result in reductions in the costs of antibiotics, associated resources, and length of stay; as well as fewer complications and improved survival.