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Management of pseudomembranous colitis
L L Morris1, M R Villalba, J L Glover
1Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan 48073.
Abstract:
Controversy exists as to the appropriate management of fulminant C. difficile-associated pseudomembranous colitis (PMC). We reviewed our most recent 5-year experience with 191 patients with PMC. Nine patients had an initial presentation of a surgical abdomen with clinical signs of peritonitis, elevated white blood cell count, and eight had received antibiotics prior to presentation. Two patients were placed on no cardiopulmonary resuscitation status at admission to the surgical intensive care unit; both died within 24 hours. The remaining seven patients had exploratory laparotomies. The four who had total abdominal colectomies with ileostomies recovered promptly. Two of the other three had no resection because there was edema of the colon, but no other gross pathological changes. The third had only a segmental colon resection. All three deteriorated postoperatively, and two were dead within 48 hours. The remaining patient was returned to the operating room 48 hours after the first procedure, and an abdominal colectomy and ileostomy was performed. She never recovered, however, and died 12 days later. We conclude that although most patients with PMC can be treated effectively medically, total abdominal colectomy with ileostomy is indicated when signs of peritonitis occur, even if the only finding at laparotomy is edema of the colon.
Insights
Fulminant Clostridioides difficile-associated pseudomembranous colitis (PMC) requires prompt surgical intervention. Total abdominal colectomy with ileostomy is indicated for patients presenting with peritonitis, even with only colonic edema, for improved outcomes.
Area of Science:
- Gastroenterology
- Surgical Critical Care
- Infectious Diseases
Background:
- Management of fulminant Clostridioides difficile-associated pseudomembranous colitis (PMC) remains controversial.
- Antibiotic use is a common precursor to C. difficile infection.
Purpose of the Study:
- To evaluate the outcomes of surgical management for patients with fulminant PMC.
- To determine the indications for surgical intervention in PMC cases presenting with peritonitis.
Main Methods:
- Retrospective review of 191 patients with PMC over a 5-year period.
- Analysis of outcomes for patients undergoing exploratory laparotomy and colectomy.
- Comparison of outcomes based on surgical approach and intraoperative findings.
Main Results:
- Nine patients presented with signs of peritonitis; eight had prior antibiotic exposure.
- Seven patients underwent exploratory laparotomy.
- Total abdominal colectomy with ileostomy led to prompt recovery in four patients, while less extensive surgery or no resection resulted in deterioration and death in three of the remaining three patients.
Conclusions:
- While medical management is effective for most PMC cases, surgical intervention is crucial for fulminant disease with peritonitis.
- Total abdominal colectomy with ileostomy is the recommended surgical approach for PMC patients exhibiting peritonitis, even with minimal intraoperative findings like colonic edema.