Toxic megacolon associatedClostridium difficilecolitis

Abstract

Toxic megacolon is a severe complication of Clostridium difficile (C. difficile ) colitis. As the prevalence of C. difficile colitis increases and treatments become more refractory, clinicians will encounter more patients with C. difficile associated toxic megacolon in the future. Here, we review a case of toxic megacolon secondary to C. difficile colitis and review the current literature on diag nosis and management. We identify both clinical and radiologic criteria for diagnosis and discuss both medical and surgical options for management. Ultimately, we recommend using the Jalen criteria in conjunction with daily abdominal radiographs to help establish the dia gnosis of toxic megacolon and to make appropriate treat ment recommendations. Aggressive medical manage ment using supportive measures and antibiotics should remain the mainstay of treatment. Surgical intervention should be considered if the patient does not clinically improve within 23 d of initial treatment.

Point-Counterpoint: What Is the Optimal Approach for Detection of Clostridium difficile Infection?

“…As Dubberke and Burnham have noted, one must "treat the patient, not the test" (44). Some patients with positive toxin assays have asymptomatic colonization (37,38), and some patients with negative toxin assays have CDIs (10,11,13,15,16,(40)(41)(42)(43). More than half of patients with symptomatic CDIs would be missed by reliance on a toxin immunoassay (11,15,16,42,43), an unacceptably high proportion of false-negative results.…”

“…Production of toxin is essential but not sufficient for disease, and even patients with high fecal toxin levels may be asymptomatic (37,38), particularly if they have toxin-neutralizing antibodies (39). With regard to sensitivity, it is equally important to recognize that toxin assays can be negative in patients with symptomatic (and even life-threatening) CDIs (10,13,40,41). The insensitivity of toxin assays has been demonstrated even for cases of pseudomembranous colitis and was a major consideration leading to the development of more-sensitive NAATs.…”

Clostridium Difficile Infection from a Surgical Perspective

“…The early use of CT scan can be helpful in determining if patients have fulminant colitis. 56 Radiological characteristics of colitis may be incidentally found on CT scans ordered for other purposes. While they are suggestive of CDI, the diagnosis of CDI should not solely rely on the imaging as it has a false negative rate in the range of 0-22 %.…”

Toxic megacolon associated with Clostridium difficile infection recurrence: a case report complicated by multiple bacterial infections and successfully treated with oral fidaxomicin

“…Tra queste, il megacolon tossico si verifica in una percentuale compresa tra 0,4% e 3% dei casi. Pare che esso derivi dalle alterazioni infiammatorie che interessano il viscere a tutto spessore spingendosi sino alla lamina propria con conseguente alterata motilità e dilatazione [7][8][9]. Il grado di dilatazione necessario affinché si possa porre diagnosi di megacolon risulta ancora controverso, ma si attesta intorno a valori > 6 cm.…”