Abstract
A 20 year old female with a history of Ulcerative colitis status post total colectomy and end ileostomy was admitted to the intensive care unit with septic shock. She had initially been diagnosed with fulminant ulcerative pancolitis three months prior, and after failing to respond to dual therapy with high dose infliximab and azathioprine, she underwent total colectomy and end ileostomy as the first part of a staged ileal pouch-anal anastomosis procedure.
Upon presentation to the emergency department, she endorsed fevers, chills, abdominal pain, and decreased stomal output. Diagnostic workup was notable for polymerase chain reaction (PCR) positive for Clostridium difficile toxin A and toxin B. She began treatment with oral vancomycin and IV flagyl, but remained critically ill with persistent fevers, vasopressor requirement and imaging showing 4.1 cm dilation of her distal ileum. As such the decision was made to attempt decompression via placement of a rectal tube into her ileostomy, after which her ostomy output improved from <20cc/day to 7L in the ensuing 48 hours. During this time she defervesced, was taken off of vasopressors, and was able to be discharged from the hospital one week later.
Infectious agents are the most common cause of diarrhea worldwide. Amongst implicated culprits, C. difficile is both the most common nosocomial infection and the most common cause of death due to gastrointestinal infections. Mechanisms of infectious diarrhea include formation of various toxins as well as cellular adherence and invasion (1). In the case of C. difficile, the gram positive anaerobe produces both an enterotoxin (toxin A) and a cytotoxin (toxin B).
In patients found to have C. difficile infections (CDI), the vast majority are affected by colitis. There is a small prevalence of extracolonic CDI, including extraintestinal in a small subgroup (0.17%)(2). According to literature, extracolonic CDI carries a 20% mortality rate. Out of those cases of extracolonic CDI, the majority (4/7 in a small case series), had a history of a previous colonic surgery (3). It has been postulated that the reason for increased prevalence amongst patients with previous colonic surgery is the adaptation of ileal flora to resemble fecal flora following ileostomy (3).
Although not considered to be standard of care, colonic decompression has been described for patients with toxic megacolon refractory to medical therapy. In a seven patient series which looked at decompressive colonoscopy with intracolonic perfusion of vancomycin in patients with toxic megacolon, 57% had complete resolution (5). In a patient who has undergone ileostomy and who had a significant amount of dilation on her imaging, we felt that her clinical scenario was analogous to megacolon, and that an escalation in therapy was warranted.
Image 1. CT Abdomen showing diffuse ileal dilation
Toxic megacolon due to Salmonella acute infectious colitis requiring total colectomy following loop ileostomy closure