BackgroundFor severe, complicated Clostridium difficile infection (CDI), concomitant treatment with IV metronidazole and oral vancomycin is usually prescribed. Sometimes vancomycin per rectum (VPR) is added to increase colonic drug delivery. Our purpose was to examine clinical outcomes of patients with CDI treated with VPR and compare results to a matched control group.MethodsThis was a retrospective case-control study in a setting of tertiary-care ICU on diarrhea patients with a positive toxin test for C. difficile. We identified all ICU patients prescribed VPR from January 2003 to December 2013. The dose of VPR mixed in 100 cc of tap water ranged from 125 to 250 mg Q 6 - 8 hours. All patients had diarrhea and a positive test for C. difficile toxin. Included patients received ≥ 4 doses of VPR. The primary outcome was the combined endpoint of colon surgery or death. We matched VPR cases 1:2 with CDI controls that had identical APACHE II scores.ResultsWe identified 24 CDI patients who received VPR and met inclusion criteria: 11 male, mean age 61.8 ± 15.9 years. All patients received concomitant CDI therapy. Four patients (16.7%) required colectomy, and overall mortality was 45.8%. For the 48 controls, need for surgery was identical (16.7%; P = 1.00). The mortality rate also did not differ (41.7%; P = 0.74). For the combined outcome of surgery or death, the rate was 45.8% for the controls and 50.0% for the VPR group (P = 0.73).ConclusionIn a case-control study, the use of VPR was not demonstrated to reduce the need for colectomy or decrease mortality. Based on our modest sample size and failure to show efficacy, we cannot strongly advocate for the use of VPR.

We report an unusual case of small bowel obstruction caused by an intestinal cast in an 8-year-old female who developed intestinal graft-versus-host disease (GVHD) following two unrelated bone marrow transplants for aplastic anemia, and highlight the pathophysiology, common presentations, and surgical complications of intestinal GVHD from the surgeons' perspective.

INTRODUCTION: Cytomegalovirus (CMV) is a member of the family of herpes virus, which persists for life after a primary infection. It is known to cause colitis in both immunocompromised and immunocompetent hosts. This virus is prevalent in about 50%-80% of the general adult population. CMV enters a latency phase after initial infection. Reactivation can occur anywhere along the gastrointestinal tract. The colonic mucosa is the most common site of reactivation. Clinical, endoscopic, and histological appearance of CMV colitis can mimic inflammatory bowel disease. Given this circumstance is it important to avoid misdiagnosis and mismanagement of CMV colitis given high morbidity associated with it. CASE DESCRIPTION/METHODS: A 59-year-old female with rheumatoid arthritis on chronic steroids and recently prescribed leflunomide presented with a diffuse rash, stomatitis, eosinophilic dominant leukocytosis, and severe diarrhea. A skin biopsy confirmed the diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS). The patient's diarrhea worsened despite negative comprehensive stool panel, clostridium difficile toxin and stool ova/parasites. A CT abdomen revealed diffuse colitis, and as a result the patient underwent flexible sigmoidoscopy showing circumferential colitis with ulcerations (Figure 1). Biopsies taken from the distal colon confirmed Cytomegalovirus (CMV) by viral inclusion bodies seen on hematoxylin-eosin staining (Figure 2). The patient was initiated on IV ganciclovir, however expired after developing septic shock. DISCUSSION: Gastrointestinal (GI) disease caused by CMV is diagnosed on the presence of clinical symptoms, viral inclusion bodies on biopsy, and endoscopically visualized ulcers. The most common sites of CMV related GI involvement is the esophagus and colon. Biopsy with immunohistochemical testing using monoclonal antibodies against CMV is considered the gold standard (Figure 3). Owl's eye inclusion bodies on staining are highly specific for infection with CMV. The gastrointestinal tract is thought to contain latent CMV after a primary infection This case highlights the importance of recognizing the risks of long term medical treatment with immunomodulatory drugs such as leflunomide or corticosteroids, including local reactivation of a latent virus as in our patient.

Most malignant obstructive jaundice arises from primary periampullary tumors and rarely from metastatic cancer of the head and neck. A 60-year-old male was diagnosed with obstructive jaundice due to metastatic squamous cell carcinoma of the tonsil. Only 12 cases of small bowel metastasis from the head and neck have been reported. Most of them originate from laryngeal squamous cell carcinoma, and only one case reported tonsillar cancer metastasizing to the ileum. Our case is the first one, to the best of our knowledge, to illustrate tonsillar cancer with metastasis to the duodenum causing obstructive jaundice.

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