Intensive Care Med (2003) 29:1030 DOI 10.1007/s00134-003-1754-7
CORRESPONDENCE
Giles Dobson Caroline Hickey John Trinder
Clostridium difficile colitis causing toxic megacolon, severe sepsis and multiple organ dysfunction syndrome Received: 11 September 2002 Accepted: 6 March 2003 Published online: 7 May 2003 © Springer-Verlag 2003
Sir: The occurrence of toxic megacolon, severe sepsis and multiple organ dysfunction syndrome (MODS) secondary to Clostridium difficile infection is rare and associated with high mortality. We report a patient who survived following definitive surgical management. A 69-year-old man with pneumonia was admitted to ICU for ventilation. Cefotaxime and clarithromycin were commenced empirically. Subsequently the patient developed diarrhoea and cefotaxime was discontinued. Stool samples tested positive for C. difficile toxin and enteral metronidazole was commenced. Despite treatment the patient developed pyrexia and leucocytosis (62×109/l), and vasopressor support was required. Abdominal computed tomography (Fig. 1) demonstrated dilatation and oedema of the transverse colon and inflammation of the pericolonic fat. A subsequent laparotomy revealed massive distension of the transverse colon and subtotal colectomy was performed. Postoperatively there was marked clinical improvement but the patient developed renal failure, requiring dialysis. Toxic megacolon is a life-threatening complication of colitis characterised by acute dilatation of all or part of the colon to a diameter greater than 6 cm accompanied by systemic toxicity [1]. The progression of C. difficile associated toxic megacolon to MODS may follow breakdown of gut barrier function. Subsequent translocation of C. difficile toxin into the portal venous system may result in cytokine production by hepatic macrophages [2]. When toxic megacolon complicates C. difficile pseudomembranous colitis, surgery is required in 65–71% of cases [3]. Indications for operative intervention have been previously reported as including colonic perforation, toxic megacolon, peritonitis, fulminant colitis refractory to medical treatment and the development of organ failure. Morris et al. [3] reported 23 surgi-
Fig. 1 Preoperative computed tomography of the abdomen. There is dilatation of the transverse colon, bowel wall oedema and inflammation of the pericolonic fat
cally managed cases. Colectomy was performed in 73% of the cohort with a 24% mortality. The remaining 27% received a diversional procedure with a 66% mortality. Lipsett et al. [4] reported 13 cases with an overall mortality of 38%. Mortality was 100% in those who had a left hemicolectomy vs. a 14% mortality in those who underwent subtotal colectomy. Reports of severe sepsis and septic shock secondary to C. difficile infection are rare. Chatila et al. [3] reported four patients that did not develop MODS who survived. Lowenkron et al. [5] reported three patients, two of whom had surgical intervention for fulminant C. difficile colitis. All of the patients described died of MODS. In conclusion, this case report highlights the potential for C. difficile infection to cause toxic megacolon, severe sepsis and MODS. We have demonstrated, in contrast to the majority of reported cases, that survival is possible in this clinical setting. When C. difficile infection is diagnosed, there is no room for complacency and a high index of suspicion is required in order to observe for potential complications. If the patient does not respond to optimal medical treatment and/or is developing organ dysfunction, early surgical intervention is mandatory. The literature suggests that the operative procedure of choice is a subtotal colectomy. A more conservative surgical approach is associated with prohibitive mortality.
References 1. Cone JB, Wetzel W (1982) Toxic megacolon secondary to pseudomembranous colitis. Dis Colon Rectum 25:478–482 2. Chatila W, Manthous CA (1995) Clostridium difficile causing sepsis and an acute abdomen in critically ill patients. Crit Care Med 23:1146–1150 3. Morris JB, Zollinger RM, Stellato TA (1990) Role of surgery in antibioticinduced pseudomembranous enterocolitis. Am J Surg 160:535–538 4. Lipsett PA, Samantaray DK, Tam ML, Bartlett JG, Lillemoe KD (1994) Pseudomembranous colitis: a surgical disease? Surgery 116:491–496 5. Lowenkron SE, Waxner J, Khullar P, Ilowite JS, Niederman MS, Fein AM (1996) Clostridium difficile infection as a cause of severe sepsis. Intensive Care Med 22:990–994 G. Dobson (✉) Specialist Registrar in Anaesthesia, Department of Clinical Anaesthesia, The Royal Group of Hospitals, Grosvenor Road, Belfast BT12 68A, Northern Ireland e-mail:
[email protected] Tel.: +44-02890-240503 Fax: +44-02890-325725 G. Dobson · C. Hickey · J. Trinder Department of Anaesthesia and Intensive Care, Ulster Hospital, Dundonald, BT16 1RH Belfast, Northern Ireland
