Clostridium Difficile Colitis
Clostridium Difficile Infection
Emergency Physicians frequently encounter patients with Clostridium difficile associated disease (CDAD) and should be aware of the following:
Enzyme immunoassay is the preferred diagnostic assay because the technique is relatively simple. Despite good specificity (up to 99%), EIA is reported to have only moderate and variable sensitivity (60 – 95%).
Metronidazole should be used for initial treatment of non-severe CDAD. The recommended dose is 500 mg tid or 250 mg qid for 10 -14 days.
Relapse is defined by complete abatement of symptoms while on appropriate therapy, followed by subsequent reappearance of symptoms after treatment has been stopped.
- Relapse occurs in 10 – 25% of cases treated with metronidazole or vancomycin. Most relapses occur within 1 -2 weeks after discontinuing antibiotic therapy. Antibiotic resistance does not appear to be a factor in relapse.
- Initial relapse should be treated with metronidazole; subsequent relapses are treated with vancomycin followed by rifaximin
Severe disease – Patients with acute C. difficile infection may develop signs of systemic toxicity warranting admission to an ICU.
- Practice is shifting toward using oral vancomycin (125 mg qid) as initial therapy for severe CDAD.
- Severely ill patients may have markedly delayed passage of oral antibiotics and may benefit from the addition of IV metronidazole because of biliary and intestinal excretion of the drug. In contrast, IV vancomycin has no effect on C. difficile colitis since vancomycin is not excreted into the colon.
- Some severely ill patients with CDAD require emergency colectomy because of toxic megacolon-associated ileus, impending perforation, or refractory septicemia.
IV immunoglobulin contains C. difficile antitoxin and has been used in some patients with relapsing or severe C. difficile colitis. Although there are case reports suggesting IVIG may be a useful addition to antibiotic therapy for refractory CDAD, its use is still controversial.
References: (1) Blossom, DB, McDonald, LC. The challenges posed by reemerging Clostridium difficile infection. Clin Infect Dis 2007; 45:222. (2) Nielsen, ND, et al. Changing epidemiology of Clostridium difficile-associated disease. Infect Dis Clin Pract 2006; 14:296. (3) Salcedo, et al. Intravenous immunoglobulin therapy for severe Clostridium difficile colitis. Gut 1997; 41:366. (4) Fekety, R. Guidelines for the diagnosis and management of Clostridium difficile- associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997; 92:739. (5) Zar, FA, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007; 45:302.
The current CMAJ has an important article about C diff – Patterns of antibiotic use and risk of hospital admission because of Clostridium difficile infection
C diff now enters the differential diagnosis in patients presenting with sporadic diarrhea, even without recent antibiotic exposure.
Of the 836 cases, 442 (52.9%) had no exposure to antibiotics in the 45-day period before the index date, and 382 (45.7%) had no exposure in the 90-day period before the index date. Antibiotic exposure was associated with a rate ratio (RR) of 10.6 (95% confidence interval [CI] 8.912.8). Clindamycin (RR 31.8, 95% CI 17.657.6), cephalosporins (RR 14.9, 95% CI 10.920.3) and gatifloxacin (RR 16.7, 95% CI 8.333.6) were associated with the highest risk. The RR for C. difficile infection associated with antibiotic exposure declined from 15.4 (95% CI 12.219.3) by about 20 days after exposure to 3.2 (95% CI 2.05.0) after 45 days. Use of a proton pump inhibitor was associated with increased risk (RR 1.6, 95% CI 1.32.0), as were concurrent diagnoses of inflammatory bowel disease (RR 4.1, 95% CI 2.66.6), irritable bowel syndrome (RR 3.4, 95% CI 2.35.0) and renal failure (RR 1.7, 95% CI 1.22.2).
JAMA Review (Jama 2009;301(9):954)
vanco 125 mg qid for 2 weeks
125 bid for 1 week
125 qd for 1 week
125 qod for 8 days
125 q 3 days for 15 days
Acquired Megacolon-constipation leads to decreased bowel tone
most common in sigmoid
Diverticulitis-perf is complication, obstruction. CT. Use cefoxitin or Amp/Gent/Flagyl. L sided appie
can form mesenteric phlegmon or abscess
Simple phlegmonous diverticulitis: treat conservatively. Allow patient oral fluids, pain control, and broad spectrum antibiotics. Cipro and flagyl or 2nd gen cephalosporin
Diverticulitis in Young Patients Diverticular disease is generally considered to be a disease of the elderly, but the incidence below age 40 is increasing. Studies conducted in the 1960s reported the incidence of diverticulosis to be lower than 5% in those under the age of 40; more recent studies suggest an incidence of 12Â30% in this age group (1,2). Diverticulitis results from a microperforation of a diverticulum, which is usually quickly walled off by pericolic fat (causing only subclinical inflammation), but is sometimes poorly contained (resulting in free perforation and generalized peritonitis). The majority of affected patients complain of left lower quadrant pain of several days duration. Younger patients with diverticulitis are more likely to be male and obese (1,3). They often have atypical presentations – up to 25% present with right lower quadrant pain. Not surprisingly, the condition is often misdiagnosed. An abdominal CT scan can accurately establish the diagnosis, allows the clinician to avoid discharging the patient with “nonspecific abdominal pain”, and avoids delaying appropriate treatment. References: (1) Cole CD, et al. Case Series: Diverticulitis in the Young J of Emerg Med 2007;Articles in Press, published online 31 May 2007. (2) Biondo S, et al. Acute colonic diverticulitis in patients under 50 years of age Br J Surg 2002;89:1137Â1141. (3) Marinella MA, et al. Acute diverticulitis in patients 40 years of age and younger Am J Emerg Med 2000;18:140Â142. (EMEDHome)
From Michelle Lin:
Diverticulitis: Outpatient Treatment
Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of EM. 2011 in press.
BOTTOM LINE: Uncomplicated diverticulitis might be treated as outpatient if:
· Can tolerate POs
· No significant comorbidities
· Able to obtain antibiotics
· Have adequate pain control
· Access to followup and social support
Mizuki A, et al. Aliment Pharmacol Ther. 2005;21:889-97.
Prospective observ. study of outpatient abx treatment for diverticulitis in Japan
Diverticulitis diagnosis: Based on exam, blood tests, and ultrasound (no CT)
Inclusion criteria: Age < 80 years, diverticulitis
Exclusion criteria: Severe diverticulitis on ultrasound, uncontrolled DM, heart failure, renal dz, end-stage cancer, antibiotics within past 24 hrs.
Study group: n=70 during 1997-2002 period
Method: Day 4 and Day 7 followup
Result: 68 of 70 (97%) were successfully treated as outpatient
Ridgway PF, et al. Colorectal Dis. 2009;11:941-6.
Randomized controlled trial of IV vs PO antibiotics (cipro/metronidazole combo) for diverticulitis in Ireland. All patients admitted to hospital.
Diverticulitis diagnosis: Purely based on clinical exam (no imaging test).
Inclusion criteria: Left iliac fossa pain and LLQ abdominal tenderness
Exclusion criteria: Generalized abdominal tenderness or evidence of perforation
Study group: n=79 (41 with PO abx, 38 with IV abx)
Result: No difference in tenderness and days-to-resolution between groups.
Alonso S, et al. Colorectal Dis. 2009.
Cohort study with outpatient treatment using PO antibiotics (amox/clavulanic + metronidazole combo). All patients admitted to hospital.
Inclusion criteria: Diverticulitis diagnosis by clinical exam, labs, and CT imaging
Exclusion criteria: Unable to tolerate POs, comorbidities (DM, renal insufficiency, heart failure, COPD, no family support)
Study group: n=70
Methods: Follow-up 4-7 days after initial ED visit.
Result: 68 (97%) were successfully treated as outpatient. 2 (3%) failed outpatient tx because for increased abdominal pain (1) and vomiting (1).
Etzioni DA, et al. Dis Colon Rectum. 2010;53:861-865.
Retrospective study of outpatient diverticulitis patients
Diverticulitis diagnosis by clinical exam, labs, and CT
Inclusion criteria: Outpatient diverticulitis patients
Exclusion criteria: Prior dx of diverticulitis, colorectal cancer, inflammatory bowel dz
Study group: n=693 outpatient diverticulitis patients
Result: 554 (94%) were successfully treated as outpatient.
Predictors of treatment failure:
· Female: OR = 3.08 [1.31-7.28]
· Free fluid on CT: OR = 3.19 [1.45-7.05]
· WBC, perforation, abscess, phlegmon were not predictive (OR crossed 1.0)
Large Bowel Obstruction
carcinoma, diverticulitis, volvulus (sigmoid from chronic constipation, try decompression. Cecal from congenital lack of fixation)
1 day for ascending colon
3 days for descending
much longer if complications arise
neostigmine dosing 0.5-1 mg over 4 hours QD
70-90% of adults will have a cause discovered unlike peds in whom most cases are idiopathic
66% will have neoplasms found as the cause
Sx are usually present for a month prior to presentation, presents with N/V, change in bowel habits, melena, weight loss.
Peutz-Jeghers, an autosomal dominant disease causing GI polyps is also a possible cause. (JEM 3/2003)
Case 2: A 84-year-old female presents with a one-week history of abdominal pain and distention. She was seen by her PMD for the same 2 days ago with a reportedly benign exam and was diagnosed with constipation, and given instructions to take milk of magnesia. She returned to her PMD today with increased pain and distention and was sent to the ED for further evaluation. The patient is unable to describe the pain but localized it to the lower abdomen. She has been eating normally without nausea and has had no BM for 1 week. Her daughter requests that she be given pain medicine immediately for the pain. PMH: Hypothyroidism, Hip fracture, DVT, and Alzheimer’s. Meds: Synthroid, KCl, Indapamide, Aricept, ASA.
Physical Exam: Thin black female in mild to moderate pain. Vitals include HR 120, BP 84/55, RR 20, T 36.7°C, O2 Sat 96% on RA. HEENT: nl, Chest: Tachy RRR, Lungs clear, Abdomen: distended with diffuse tenderness and rebound. Neuro: baseline dementia, otherwise normal. Stool: heme negative
· Mesenteric ischemia
· Perforated viscus
· Small bowel obstruction
What elements of the physical are missing? What tests will help you? Can this patient be given pain medicine?
Use of pain medicine for patients with abdominal pain
· The common practice of withholding pain medicine from patients with abdominal pain for fear of altering the exam and clouding the diagnosis is not supported in the literature.
· All available studies (Attard, LoVecchio, Mahadevan, Pace, Vermeulen, Zoltie) on this topic show that pain medicine, indeed, relieves suffering versus placebo without altering diagnostic abilities of clinicians.
· Many studies show that the use of pain medicine even aids the clinician in making the correct diagnosis.
· Study to prove no adverse effects from pain medicine would require 1,500 patients and has yet to be done. (Lee)
· In many cases, it is reasonable to negotiate with the surgical consult that may not be familiar with or agree with the literature support for analgesics in abdominal pain. For example: if the consult will be delayed more that 15 or 20 minutes, then a short acting narcotic, such as fentanyl, will be given prior to consult exam.
Case 2: Additional information
EKG: Sinus tachycardia, no old EKG
UA: RBC 4, WBC 13
Lytes: normal except Cr 2.2
CBC: Hct 40.5 WBC 25 Platelets 310
Another case of urosepsis and constipation in the elderly?
Is there a role for plain abdominal radiographs in this patient?
KUB shown below:
Case 2: ED course
The patient becomes more tachypnic and her oxygen saturation falls to the low 80’s.
What is the next step?
Our patient was intubated, given antibiotics, and taken to the operating room. She became hypotensive and required dopamine intraoperatively. In surgery, 63 cm of necrotic sigmoid colon was resected leaving the patient with a colostomy and a rectal Hartmann pouch.
· Rotation of bowel segment around its mesenteric axis leading to luminal obstruction, vascular insufficiency, and eventual bowel necrosis.
· Causes 5-6% of all large bowel obstructions (3rd leading cause after cancer and diverticulitis).
· Occurs most often in inactive elderly with debilitating diseases.
· Also occurs in patients with severe psychiatric or neurologic diseases.
· Often due to severe, chronic constipation.
· Early symptoms intermittent cramping, lower abdominal pain, and distention.
· Later symptoms nausea, vomiting, dehydration, obstipation (vomiting and obstipation often not present as in this case).
· May have a history of similar episodes that resolved spontaneously.
· Physical exam moderate abdominal tenderness, but may not be impressive.
· Fever, marked tenderness, and peritonitis are late findings and suggest bowel ischemia.
· Mortality 20% overall, 53% when bowel is gangrenous.
· One of the few diagnoses made on plane films (at least 80% of the time)
1) Severely dilated single loop of colon in left abdomen
2) Both ends in pelvis and bowel pointing superiorly (“bent innertube sign”)
· Water soluble or barium enema confirms the diagnosis
1) “Bird’s beak” deformity at the point of twists
2) Cut-off of contrast flow into proximal colon
· Surgery for gangrenous bowel or failed reduction.
· For stable patients the volvulus can usually be reduced with sigmoidoscopy and rectal tube insertion. (Successful 85%-95% of the time).
· The rectal tube stents the bowel and prevents reoccurrence of the volvulus over the short term.
· Recurrence rate is 90% if reduction is not followed by colopexy.
Remarkably our patient was extubated and weaned off of dopamine the day after surgery. She was discharged to home 6 days after surgery and continues to be a devoted patient of her primary care physician.
1) Beware of the diagnosis of constipation in elderly patients with abdominal pain.
2) Sigmoid volvulus may present with out significant symptoms of obstruction.
3) Add volvulus to your list of reasons to obtain abdominal radiographs in the patients with abdominal pain.
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Common in the elderly from constipation or chronic inactivity
both ends of the loop of distended bowel will point towards the pelvis.
need rectal tube decompression
any age, but commonly in young people
Inflammatory Bowel Disease (IBD)
arthritis, erythema nodusum, pyoderma gangrenosum, ascending cholangitis, uveitis
Ulcerative Colitis: A recurrent inflammatory process involving the mucosa and submucosa of the colon and rectum Epidemiology- prevalence ranges from 37.5-229 per 100,000 persons -males > females -in men incidence peaks in the 30s -more common in urban areas -found almost exclusively in industrialized nations Pathophysiology-50% begin in colon and stay there -30% pass the colon -20% pancolitis with no skip areas as seen with Crohns disease -Crypt abscesses leads to inflammatory cell migration with loss of colonic structure and subsequent inability to absorb water and sodium all associated with protein loss -Submucosal vessel repair occurs with resultant inflammation rate greater than repair (blood and pus), the mucosa hypertrophies and then you get reversible strictures with spasm -Finally the colon becomes foreshortened, rigid, straight and subsequently lacks the haustral markings -In severe cases, the typical mucosal appearance consists of thick inflammatory exudates composed of blood, pus, and mucus covering irregular, shallow ulcers Clinical presentation: Initially can present with a wide spectrum of severity with only a small percentage presenting with the classical symptoms of: -fever, crampy abdominal pain, tenesmus, urgency -frequent, painful passage of stools with blood, pus, and mucus -Majority of patients present with cyclical diarrheal/fever/tensesmus/crampy abdominal pain/anorexia/weight loss, which is often insidious in onset -diarrhea may not be bloody -Can also present with acute exacerbations of known disease -Characterized by relapses and acute exacerbations with complete resolution in between attacks -Recurrences often associated with emotional stress, infections or other acute illnesses, pregnancy, use of cathartics and antibiotics, or withdrawal of therapeutic medications -Extracolonic manifestations in up to 25% of cases to include: Musculoskeletal: -rheumatologic disorders including peripheral/axial arthropathy -up to 5-20% of cases of UC -metabolic bone disorders including osteoporosis and osteopenia -23-59% of patients Dermatologic: -Erythema nodosum in 10-20% of cases Osis and It is of the Gut: An Update Kurtis Holt, MD ACEP Scientific Assembly October 2002 -Pyoderma gangrenosum in 1-10% of cases -Sweets syndrome (acute febrile neutrophilic dermatosis) -apthous ulcers -pyoderma vegetans -Epidermolysis bullosa acquisita Mild- 60% of cases -limited to rectum in 80% of cases with <4 stools per day with or without blood -no fevers, tachycardia, or anemia and a normal ESR Moderate-25% of cases -disease extends into the ascending colon with > 4 large stools per day -mild fever and tachycardia Severe disease- 15% of patients -disease limited to left colon in only 10% of cases with >6 bloody stools per day -fever, tachycardia, anemia, and dehydration are hallmarks -associated laboratory abnormalities include hypoalbuminemia, elevated ESR and relapses/recurrences are frequently associated with extraintestinal manifestations Pediatrics- often have significantly more extensive disease with the same symptoms as adults but differ in that the extraintestinal manifestations may be dominant -often associated with growth failure, arthropathy, and liver disease Diagnosis: Once thought to be the diagnostic method of choice, Barium enemas are no longer recommended to make the initial diagnosis or in the cases of acute relapses -predispose to toxic megacolon -diagnosis of UC should be considered in anyone who presents with bloody diarrhea and the right clinical scenerio -quickly becoming the procedure of choice for bloody stools, ENDOSCOPY a long with intestinal biopsy, is the most accurate method for diagnoses -also rules out/in other potentially dangerous diagnosis ED diagnosis- clinical grounds, more importantly? -rule out other life threatening diseases/lesions Other radiologic studies AAS- rule out obstruction/toxic megacolon CT scan- rule out other life threatening entities Complications: Toxic Megacolon- occurs in up to 5% of cases -dilated colon >5-6 cm with loss of haustral markings on AAS -septic, apathetic, lethargic, pain/distension/tenderness ->10 bowel movements per day -predisposing factors -discontinuing medications -barium enema -colonoscopy -cessation of smoking Osis and It is of the Gut: An Update Kurtis Holt, MD ACEP Scientific Assembly October 2002 -motility-affecting drugs
ED Treatment: Mild to Moderate disease -outpatient management with prednisone 40mg/day -topical steroids with steroid enemas -sulfasalazine at 500mg po QID -mesalamine 5-ASA (newer more expensive) available -increase fiber in diet and AVOID anti-diarrheals -close follow up with primary care, especially if started on new meds Severe disease- ADMISSION -IV fluids and correction of electrolyte abnormalities -hydrocortisone 100mg IV or methylprednisolone 20mg IV -referral to general surgery for evaluation for possible colectomy
Crohns Disease- a chronic inflammatory bowel condition affecting any part of the GI tract -also referred to as terminal ileitis, regional enteritis, granulomatous ileocolitis Epidemiology- 30-60 persons per 100,000 in the US -incidence doubling every 10 years -onset generally between the ages of 15 and 40 with both sexes involved equally -8 times more likely in the Jewish population Pathophysiology- TRANSMURAL inflammation -may involve adjacent lymph nodes -20% have colonic involvement alone and of those patients with small bowel disease 30% will develop coexisting colon involvement -50% both colon and ileum -more likely to affect other organ systems Distinguishing factors -involves all layers of the bowel (into serosa) -not continuous i.e. skip areas -rectal involvement is not common -but anal and rectal fistulas/abscesses are -characteristic small bowel involvement -grossly bloody stools much less common Clinical Presentation- patients will have one of three patterns of disease -inflammatory disease -strictures -fistulas -similar to UC but more variable and usually worse with 80% of the cases having -abdominal pain and cramps -fever, anorexia, and diarrhea -weight loss Osis and It is of the Gut: An Update Kurtis Holt, MD ACEP Scientific Assembly October 2002 Extraintestinal manifestations Hydronephrosis secondary to involvement of the right ureter
Nephrolithiasis secondary to increased oxalate absorption in the damaged small bowel Hepatobiliary- 50% of patients with IBD -gallstones found in 13-34% -hepatic steatosis most common -5% of patients found to have primary sclerosing cholangitis (PSC) -75% of patients with PSC found to have UC -uncommon -pericholangitis, chronic hepatitis, cholangiocarcinoma -rare -pancreatitis, haptic amyloidosis, granulomatis hepatitis Arthritis-20% -ankylosing spondylitis -peripheral arthritis of knees, ankles, wris ts and fingers Vascular-6% -thromboembolic, vasculitis, arteritis -mortality rate 25% making it the 3rd leading cause of death Dermataologic-15% -more common in women -erythema nodosum, pyoderma gangrenosum, -occular complications such as episcleritis and uveitis Diagnosis: Can be difficult as many of these patients will present with the extraintestinal manifestations discussed Clues- presence or history of anorectal problems (fistulas/abscesses) Radiologic imaging similar to US with CT mainly used to rule out other entities or rule out abscess secondary to the disease Diagnosis most likely confirmed by sigmoidoscopy with rectal biopsy CT f indings UC vs Crohns -wall thickness >2cm in Crohns, <1.5 in UC -small bowel uninvolved in UC -perirectal and perisacral fat presence in UC -mesenteric stranding with Crohns -rectum uninvolved in Crohns ED Treatment: Very similar to UC with the only difference being the addition of Metronidazole which has been found to be helpful, otherwise in both UC and Crohns routine administration of antibiotics is not recommended unless a suppurative complication (abscess) has been found Enteric coated fish oil has been shown to reduce the frequency of relapses Disposition: similar to UC. Newly diagnosed cases of UC and Crohns are generally admitted to facilitate an expeditious work-up and medical management in coordination with the patients primary care physicianFlagyl
Reduction in blood flow to the IMA and SMA colonic collaterals
splenic flexure in 75% of cases.
Most are transient. Lower abd pain, 24 hrs of bloody diarrhea. Abdominal pain can precede bloody diarrhea.
young female joggers on OCPs also get ischemic colitis
leads to stricture or bleeding
Primary Epiploic Appendagitis
Torsion of epiploic appendage. Tend to be younger than diverticulitis pts (35 vs. 55), pain was rapid onset, constant, localized to LLQ. Usually presents s rebound c normal labs. Diverticulitis is usually much more diffuse and has rebound.
Irritable Bowel Syndrome (IBS)
Presence for at least 12 weeks during past year of abdominal pain/discomfort with 2 of 3:
- Relieved by defecation
- Onset associated with a change in the frequency of defecation
- Change in the form of the stool
Alarm Symptoms: GI bleeding, anorexia or weight loss, fever, persistent diarrhea resulting in dehydration, nocturnal symptoms, severe constipation or fecal impaction, Family history of GI cancer, IBD, or celiac sprue, onset after 45 years old.
Work-up for primary care initial diagnosis: CBC, ESR, Lytes, TFTs. Eventual flex sig.
Low dose antidepressants such as desipramine (50-150 mg) or amitriptyline (25 to 100 mg) have been found to be effective in eliminating the abdominal pain of IBS. SSRIs may also work, but experience is limited.
Volume 53, Issue 06 March 21, 2006
NEW APPROACHES TO IRRITABLE BOWEL SYNDROME
Richard A. Weisiger, MD, PhD, Professor, Department of Medicine, and
Director, Gastrointestinal Faculty Practice, University of California,
San Francisco, School of Medicine
Irritable bowel syndrome (IBS):
group of functional bowel
disorders; predominant features include abdominal pain or discomfort
associated with defecation or change in bowel habit
and disordered defecation (constipation, diarrhea, or combination);