DMcG: 68 year old man B/G: bilateral hip replacement, psoriasis 23/08/07: Transferred from Letterkenny General Hospital

triple vessel disease with complete LAD occlusion 24/08/07: CABG x 3 uncomplicated extubated day 1 post op

Day 3 nausea and vomiting, pyrexial Day 4 loose stools lower sternal wound infection noted > flucloxacillin IV commenced Day 5 ongoing vomiting and diarrhoea, pyrexia 38.9

Day 6 abdominal distension, bowel sounds present, tachycardic 110 > NPO > IV fluids and wide bore NG > CXR and PFA > general surgical consult

General surgery initial assessment: > central abdominal pain, diarrhoea > pyrexial, tachycardic > abdomen mildly distended, mildly tender lower abdomen, no guarding or rigidity, bowel sounds.

PFA dilated large bowel WCC 18 Na 133 CRP 180 Imp: ?systemic sepsis syndrome ?infective diarrhoea Advised: antibiotics, micro consult, urgent CT abdomen/pelvis, stool for CMS

Day 6 norovirus positive Day 7 morning Clostridium difficile positive > flucloxacillin stopped CT abdomen thick-walled caecum, ascending colon and descending colon, dilated transverse colon consistent with pseudomembranous colitis

Day 7 : deterioration tachypnoeic, desaturating, hypotensive, oliguric S/B anaesthetist immediately Brought to theatre at 18.30 for total colectomy and end ileostomy formation

> grossly dilated, distended colon resected > rectal stump protected with 2-layer closure > abdominal cavity washed out with saline > terminal ileostomy fashioned in RIF > Robinson drain inserted > Transferred to ICU Commenced on IV tazocin & metronidazole as per microbiology

ICU day 1 post op: - anuric requiring CVVHD - daily proctoscopy to decompress rectal stump - requiring inotropic support, intubated and ventilated

Day 3 post op: - making urine - NG feeding commenced 10ml/hr - stoma functioning - stopped inotropes - WCC raised - 20

Day 9 extubated, off dialysis Day 13 transferred to cardiothoracic HDU Uneventful course Day 26 transferred back to Letterkenny

Discussion
Clostridium difficile Diagnosis and management of toxic megacolon Medical and surgical treatment options and outcomes

Discussion

C difficile is a spore-forming, gram-positive bacillus first described in 1935 as part of the normal colonic flora of healthy infants. Asymptomatic carriage in 3-5% of healthy adults Leading cause of nosocomial enteric infection Affects up to 20% of hospitalised patients1/3 will become symptomatic

Pathogenesis
Antibiotic therapy Disruption of colonic mucosa C Diff exposure and colonization Release of toxin A (enterotoxin) and toxin B (cytotoxin) Mucosal injury and inflammation

Risk Factors

Advanced age Antibiotic therapy Immunosuppressive therapy Multiple and severe underlying diseases Placement of a nasogastric tube Recent surgical procedure Admission to intensive care unit Prolonged hospital stay Residing in a nursing home Sharing a hospital room with a C. diff-infected patient Use of antacids

Clinical variants of C. diff infection

Asymptomatic carriage Antibiotic associated diarrhoea without colitis Antibiotic associated colitis without pseudomembrane formation Pseudomembranous colitis Fulminant colitis

Causes of Toxic Megacolon

Inflammatory bowel disease -Ulcerative colitis -Crohns disease

Infectious colitis Bacterial -Pseudomembranous colitis (Clostridium difficile) Parasitic -Amoebiasis

46% 2%

31% 3%

Colitis due to special medical therapy -Cytotoxic chemotherapy -Beta mimetics

Ischaemia

3% 4% 11%

Distribution of aetiology
Aetiology
IBD Other Time period 1984-94 n (%) 21 (30) 10 (14)

1995-2004 n (%)
12(17) 27(39)

C. Ausch*, R. D. Madoff, M. Gnant, H. R. Rosen*, J. Garcia -Aguilar, N. Ho lbling*, F. Herbst, V.Buxhofer*, B. Holzer*, D. A. Rothenberger and R. Schiessel* Aetiology and surgical management of toxicmegacolon. Colorecatal disease (8) 195-201. June 2005

Diagnosis of Toxic Megacolon

1. Evidence of dilatation: Clinical: Visible abdominal distension, abdominal tenderness, diarrhoea, bloody diarrhoea, constipation, obstipation, bowel sounds. Radiological: segmental or total colonic distension >6cm, small bowel and gastric distension.
2. Evidence of toxicity: 3 of -Pyrexia >38.6 -Tachycardia >120bpm -Leucocytosis >10.5 x109 -Anaemia 1 of -Dehydration -Cognitive changes -Electrolyte disturbance -Hypotension

3. Subsequent pathological confirmation of dilatation and transmural extension of the inflammatory process
Jalan KN, Sircus W, Card WI, Falconer CW, Bruce CB, Crean GP, McManus JP, Small WP, Smith AN. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. 1969 Jul;57(1):6882.

Management

General IV fluids Correct e- abnormalities Complete bowel rest Discontinue anticholenergics and narcotics Stool CMS Blood cultures (bacteraemia in up to 25%) Decompression Rectal tube NG tube Repositioning manoeuvres Endoscopy: with extreme caution as risk of perforation Radiology Frequent assessment with plain films CT

Treatment: Medical

Conservative: Stop causative antibiotic Trial of medical therapy Oral metronidazole +/- oral vancomycin IV metronidazole Bacitracin, teicoplanin Toxin binding agents eg. Cholestyramine Probiotics IV immunoglobulin Faecal reconsistution

Treatment: Surgical
Save the patient, not the colon

Surgery required in up to 80% of cases in some studies Reserved for the most severe cases Absolute indications include: free perforation; massive haemorrhage; increasing transfusion requirement; worsening signs of toxicity; progression of colonic dilatation. Most surgical studies recommend colectomy if there is persistent colonic distension after 48-72hrs. Early intervention is associated with lower morbidity and mortality Surgery of choice is subtotal colectomy with end ileostomy and Hartmann closure of the rectum or sigmoid mucous fistula.

Outcomes: Morbidity

C. Ausch*, R. D. Madoff, M. Gnant, H. R. Rosen*, J. Garcia -Aguilar, N. Ho lbling*, F. Herbst, V.Buxhofer*, B. Holzer*, D. A. Rothenberger and R. Schiessel* Aetiology and surgical management of toxicmegacolon. Colorecatal disease (8) 195-201. June 2005

Outcomes: Mortality

C. Ausch*, R. D. Madoff, M. Gnant, H. R. Rosen*, J. Garcia -Aguilar, N. Ho lbling*, F. Herbst, V.Buxhofer*, B. Holzer*, D. A. Rothenberger and R. Schiessel* Aetiology and surgical management of toxicmegacolon. Colorecatal disease (8) 195 -201. June 2005

Outcomes

Perforation is a major factor in and mortality: 8.7% if no perforation, 51% with perforation1 Overall mortality has improved some recent studies showing no mortality compared with >50% in 19692 Difficult to show objective difference between outcome of TM due to IBD and other aetiologies due to significant changes in aetiology and recent developments in ICU medicine

1 Binderow SR, Wexner SD. Current surgical therapy for mucosal ulcerative colitis. Dis Col Rectum 1994; 37: 610 24 2. Jalan KN, Sircus W, Card WI, Falconer CW, Bruce CB, Crean GP, McManus JP, Small WP, Smith AN. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. 1969 Jul;57(1):6882.

Conclusions

Toxic megacolon complicating pseudomembranous colitis carries a high morbidity and mortality rate Early surgical intervention when conservative and medical treatment have failed is associated with better outcomes and quality of life