Dr Vu Kwan

Staff Specialist

Department of Gastroenterology

Westmead Hospital

�72 year old male

�Background:• Ischaemic heart disease

� NSTEMI 2009

� Coronary stent

� Echocardiogram: EF 25%

• Atrial fibrillation� Warfarin

• Chronic kidney disease� Baseline creatinine ~180

� Per rectum bleeding• Admitted for observation

• Discharged for outpatient colonoscopy

� Recurrent bleeding• Admitted for inpatient colonoscopy

� Colonoscopy:• Multiple large colonic polyps• Endoscopic mucosal resection performed

• Histology � Multiple tubular adenomas

� Invasive malignancy not excluded

� Represented 3 days post-procedure with recurrent rectal bleeding

� ED assessment:• “Post-polypectomy bleeding”

• “Possible peptic ulcer bleeding”

� Commenced on high dose proton-pump inhibitor infusion

� Observed for several days � bleeding cessation

� Discharged home

�Represented 2 days later with bloody

diarrhoea

�Up to 10 episodes per day

� Initially assumed to be ongoing post-

polypectomy bleeding

�No stool tests performed

Pseudomembranous colitis

�No history of recent antibiotics

�Only history:

• Elderly male

• Multiple co-morbidities

• Repeated hospitalisations

• Only new medication = PPI

�Commenced on oral metronidazole

�Ongoing fluid balance problems� Dehydration due to diarrhoea

� Worsening renal function

� Fluid therapy resulting in pulmonary oedema

� Prolonged HDU admission with other medical complications

�Eventual resolution of diarrhoea & discharge 3 weeks later

�One of the most common healthcare-

associated infections

�Spectrum of disease ranging from

asymptomatic carriage to fulminant

colitis

�Commonly a result of antibiotic therapy

due to alteration of normal gut flora

�Can occur without antibiotic use,

importantly via nosocomial transmission

�Mortality rates of up to ~25% reported,

particularly in elderly1

1. Crogan et al, Geriatr Nurs 2007

�Approximately 20% of hospitalised

patients are C. difficile carriers

�Significant reservoir for disease

transmission

�Contribution of host’s immune response

is unclear

� Watery diarrhoea• >3 times per day

• >2 days duration

� More severe cases• Up to 15 motions per day

• Lower abdominal pain and cramping• Low grade fever

• Leucocytosis

� Onset may be during antibiotic therapy or 5-10 days after treatment• Can present up to 10 weeks after antibiotic cessation

�More significant illness than diarrhoea

alone

�Constitutional symptoms, fever,

abdominal pain + watery diarrhoea

�Colonoscopy:

• Non-specific diffuse or patchy erythematous

colitis

�The classic manifestation of full-blown C.difficile colitis

�Symptoms similar to, but often more severe than, colitis due to other causes

�Unwell, WCC, hypoalbuminaemia

�Colonoscopy:• Classical raised white/yellow plaques

�Severe manifestation affecting ~3%

�Account for the most serious complications:� Perforation

� Prolonged ileus

� Toxic megacolon

� Death

�Clinical features of fever, leucocytosis,

abdominal distension

1 Small bowel

2 Bacteraemia

3 Reactive arthritis

4 Others

�Particularly described in small bowel

subjected to recent surgery

• Inflammatory bowel disease post ileal-anal

anastomosis

�Pseudomembrane formation

�May act as a reservoir for recurrent

colonic infection?

�Uncommon

�Associated with high mortality rate1

�May be more common in patients with

underlying gastrointestinal diseases2

1. Daruwala et al, Clin Med Case Reports 2009

2. Libby et al, Int J Infect Dis 2009

�Polyarticular arthritis

• Knee and wrist in 50% of cases

�Onset average 11 days after diarrhoea1

�Prolonged illness : average 68 days to

resolve2

1. Birnbaum et al, Clin Rheumatol 2008

2. Jacobs et al, Medicine (Baltimore) 2001

�Cellultis

�Necrotising fasciitis

�Osteomyelitis

�Prosthesis infection

� Intra-abdominal abscess

�Empyema

�etc

�General risk factors1. Long duration antibiotics

2. Multiple antibiotics

3. Nature of faecal flora

4. Production of requisite cytotoxins

5. Presence of host risk factors

�Specific risk factors1. Immunosuppressive drugs

2. Gastric acid suppression

3. Cancer chemotherapy with antibiotic properties

�Advanced age

�Nasogastric tube

�Severe underlying illness

�Prolonged hospitalisation

�Enema therapy

�GI stimulants

�Stool softeners

�Chronic, relapsing inflammatory disorders of the bowel of unknown aetiology

� Ulcerative colitis

� Crohn’s disease

�Enteric infections account for ~10% of ‘relapses’• C.difficile in about half

• May mimic a relapse, OR trigger a true relapse

�Crucial that C.difficile is considered in the differential diagnosis of every ‘flare’

�Otherwise inappropriate escalation of immunosuppression may result in severe infection

�High index of suspicion required as classical pseudomembranes don’t form in IBD

�Treatment is to REDUCE their usual immunosuppressive drugs

�Gastric acid inhibits germination of

ingested C.dificile spores

�Therefore, medications lowering gastric

acid could increase risk of C.difficile

infection

• Clinical data are conflicting