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Abdomen » Gastrointestinal
Pseudomembranous Colitis
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Presentation
This 23 year old male with a past medical history of relapsed malignant mediastinal germ cell tumor and aspiration pneumonia presented with two episodes of syncope and abdominal pain. An abdominal ultrasound was performed.
 
 
 
Caption: Grayscale transverse image of the right colon
Description: Grayscale transverse image of the right colon demonstrates diffuse concentric bowel wall thickening measuring up to 16 mm thickness in the ascending colon. The shaggy appearance of bowel wall with mucosal irregularity is concerning for mucosal thickening
 
 
 
Caption: Grayscale transverse image of the left colon
Description: Grayscale transverse image of the left colon demonstrates nodular concentric bowel wall thickening involving the entire descending colon. There is pericolonic mesenteric edema reflecting surrounding inflammatory change.
 
 
 
Caption: Grayscale longitudinal image of the left colon
Description: Grayscale longitudinal image of the left colon demonstrates marked concentric bowel wall thickening with surrounding simple free fluid.
 
 
 
Caption: Grayscale transverse image of the sigmoid colon
Description: Grayscale transverse image of the sigmoid colon demonstrates nodular concentric bowel wall thickening with pericolonic mesenteric edema reflecting surrounding fat stranding.
 
 
 
Caption: Color Doppler coronal image of the hepatic flexure
Description: Color Doppler coronal image of the hepatic flexure demonstrates diffuse concentric bowel wall thickening without any hyperemia and pericolonic edema.
 
 
Caption: Left colon video clip
Description: 
 
 
Caption: Right colon video clip
Description: 
 
Differential Diagnosis
Colitis due to Shigella, Salmonella, Campylobacter
Drug toxicity
Bowel ischemia
 
Final Diagnosis Pseudomembranous Colitis (C. Diff +)
 
Discussion
Pseudomembranous colitis (PMC), an inflammatory colitis largely caused by Clostridium difficile, is the most common cause of infectious health care-associated diarrhea.  Its incidence has increased markedly in recent years, with immunocompromised and antibiotic-exposed patients being at high risk. Mortality from PMC is up to 3.5% in those infected.

C. difficile’s toxin A and toxin B work in concert to cause bowel cell death and pseudomembrane formation, leading to extensive diarrhea, fever, and cramping abdominal pain.  Bowel loops can become dilated and complications such as toxic megacolon, mesenteric edema, and bowel perforation can develop.

Delay in diagnosis is significantly associated with higher mortality rate from PMC.  The gold standard for diagnosis of PMC is C. difficile cytotoxin assay, though enzyme immunoassay for toxin A and B as well as PCR have a more rapid turnaround time.  

Ultrasound can provide the first signs of C. difficile pseudomembranous colitis. Sonographic signs include pancolitis (typically concentric nodular thickening ranging between 5 to 20 mm thickness), mural irregularity, pericolonic increased echogenicity due to mesenteric edema, and simple ascites. Lack of hyperemia on color Doppler sonography may be helpful.

Treatment begins with stopping concurrent antibiotic therapy if possible, and initiating metronidazole or vancomycin to treat the PMC.

 
Case References
Bope ET, Kellerman RD. The Infectious Diseases. Conn’s Current Therapy 2017:479-635.

Kawamoto S, Horton K, Fishman E. Pseudomembranous Colitis: Spectrum of Imaging Findings with Pathologic Correlation. RSNA RadioGraphics 1999; 19(4). DOI: http://dx.doi.org/10.1148/radiographics.19.4.g99jl07887

Jobe BA et al. Clostridium Difficile colitis: an increasing hospital-acquired illness. The American Journal of Sourgery 1995 May; 169(5): 480-483. DOI: https://doi.org/10.1016/S0002-9610(99)80199-8

 
Follow Up The patient unfortunately did not recover from this episode of aspiration pneumonia due to esophageal fistula formation and succumbed to illness.
 
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