Abstract Introduction Fulminant Clostridioides difficile (C. diff) colitis is a relative contraindication to lower endoscopy, as colonic insufflation can precipitate perforation in a distended colon. When computed tomography (CT) demonstrates large-bowel obstruction with a discrete transition point, urgent colonoscopy for decompression and/or stent placement is warranted. We report a case in which fulminant C. diff colitis radiographically mimicked large-bowel obstruction, altering management. Case Presentation A 70-year-old man with chronic lymphocytic leukemia, chronic kidney disease, and recent acute cholecystitis treated with cholecystostomy tube placement and prolonged intravenous antibiotics presented from a nursing facility after being found unresponsive and pulseless. Cardiopulmonary resuscitation achieved return of spontaneous circulation, and he was intubated in the field. In the emergency department, he had no diarrhea, and initial laboratory studies showed a white blood cell (WBC) count of 21,000/µL. CT abdomen and pelvis revealed a large-bowel obstruction with a transition point at the splenic flexure and proximal colonic dilation. Surgery and gastroenterology were consulted, and he was admitted to the intensive care unit on low-dose vasopressors for hypotension. Colonoscopy the following day showed no obstruction but uncovered pseudomembranes and friable mucosa consistent with fulminant C. diff colitis. Stool toxin testing confirmed C. diff, and he was started on oral and rectal vancomycin plus intravenous metronidazole. He rapidly progressed to septic shock from Staphylococcus simulans bacteremia, likely from bacterial translocation, with a lactate of 18.4 and a WBC of 77,000/µL concerning for bowel perforation, requiring maximal vasopressor support. Given severe comorbidities, shock, and multiorgan failure, he was deemed a poor surgical candidate. After goals-of-care discussions, his family elected palliative extubation, and he died shortly thereafter. Discussion This case illustrates a diagnostic dilemma when fulminant C. diff colitis mimics large-bowel obstruction on CT. A discrete transition point typically prompts urgent colonoscopy for decompression and/or stent placement, yet fulminant C. diff is a contraindication to lower endoscopy because of high perforation risk. Fulminant C. diff infection may present with abdominal distention, pain, and obstipation from ileus or toxic megacolon, clinically and radiographically resembling obstruction. In patients with recent broad-spectrum antibiotic exposure, nursing facility residence, and septic shock, C. diff should remain high on the differential even when imaging suggests obstruction. When feasible, stool testing and careful review of CT for colitis features may help distinguish infectious from mechanical etiologies. This case highlights a safety pitfall, urging clinicians to reassess for fulminant C. diff before pursuing lower endoscopy in unstable patients. This abstract is funded by: None
Gallub et al. (Fri,) studied this question.