Necrotizing Clostridium difficile Enteritis Complicating Fulminant Colitis

Background: Clostridium difficile infections result from an imbalance in normal bacterial flora, allowing C. difficile bacteria overgrowth. Whereas such bacterial overgrowth is typically confined to the colon, there have been reports of an increasing prevalence of C. difficile infections involving the small bowel, with the majority of patients presenting with a history of partial or total colectomy. We present two rare cases of necrotizing C. difficile enteritis complicating fulminant C. difficile colitis. Case Presentations: A 74-year-old male presented with a two-week history of watery diarrhea and escalating abdominal pain without recent antibiotic use. Work-up was significant for leukocytosis, bandemia, lactic acidosis, and elevated creatinine. Initial diagnosis of C. difficile was treated with intravenous fluoroquinolone and metronidazole. He deteriorated and a total colectomy with small bowel resection was performed. Final pathology revealed pseudomembranous colitis with focal mucosal ischemia and pseudomembranous necrotizing enteritis. Post-operatively the patient's condition fluctuated, requiring re-initiation of antibiotics and vasopressor therapy; he ultimately recovered. A 72-year-old female presented with severe abdominal pain and septic shock two weeks after total abdominal colectomy with end ileostomy for severe C. difficile colitis. An exploratory laparotomy appeared normal, without an identifiable pathology source. Post-operatively she required vasopressor support and mechanical ventilation. She received intravenous metronidazole and vancomycin enemas. Clostridium difficile assays confirmed the diagnosis of relapsed pseudomembranous enteritis. Antibiotic therapy continued without further incident. Conclusion: Clostridium difficile enteritis presents a unique challenge because of its difficulty in diagnosis, a fact underscored by the high morbidity and mortality of small bowel of C. difficile infections. Clostridium difficile enteritis should be suspected in patients not improving after recent colectomy for C. difficile colitis. Continuation of antibiotics and total colectomy should be considered in patients with un-explained acute intra-abdominal pathology or persistent sepsis after colectomy for fulminant C. difficile colitis.