Cinical Outcome of Surgery for Fulminant Clostridium Difficile Colitis

The clinical presentation of C difficile infection ranges from asymptomatic carriage, colitis with or without pseudomembranes and fulminant colitis. Although not common, fulminant C difficile colitis can result in bowel perforation and peritonitis and mortality of up to 80% has been reported. We retrospectively analyzed the outcome of 13 patients who underwent surgery for fulminant C difficile colitis in the period 1996–2002 in our Unit. The indications for surgery were systemic toxicity and peritonitis (n=9) and radiologic and clinical evidence of progressive toxic colonic dilatation (n=4). C difficile infection as the cause of colitis was diagnosed pre-operatively in only 6 patients (46.2%), five of whom underwent a subtotal colectomy and one right hemicolectomy. Overall mortality in our series was 38%. Subtotal colectomy was associated with a mortality rate (MR) of 12.5% (n=8) while the MR for left hemicolectomy was 100% (n=4). One patient underwent a right hemicolectomy survived after prolonged hospital stay. Hemicolectomy was undertaken on the basis of deceptively normal external appearance of the rest of the colon intraoperatively. All patients received appropriate treatment at time of diagnosis of C difficile.

Conclusion: Early or pre-operative microbiological diagnosis of C difficile infection can be difficult in fulminant cases. Early diagnosis may be improved by sending at least three stool specimens and possibly by sigmoidoscopic and histologic examinations. In patients with fulminant colitis who develop signs of toxicity or peritonitis, a pre-operative diagnosis of C difficile infection may aid the surgeon in opting for subtotal colectomy as the surgery of choice.