Dr Vu Kwan Staff Specialist Department of Gastroenterology Westmead Hospital

 72 year old male  Background: Ischaemic heart disease  NSTEMI 2009  Coronary stent  Echocardiogram: EF 25% Atrial fibrillation  Warfarin Chronic kidney disease  Baseline creatinine ~180

 Per rectum bleeding Admitted for observation Discharged for outpatient colonoscopy  Recurrent bleeding Admitted for inpatient colonoscopy  Colonoscopy: Multiple large colonic polyps Endoscopic mucosal resection performed Histology  Multiple tubular adenomas  Invasive malignancy not excluded

 Represented 3 days post-procedure with recurrent rectal bleeding  ED assessment: “Post-polypectomy bleeding” “Possible peptic ulcer bleeding”  Commenced on high dose proton-pump inhibitor infusion  Observed for several days  bleeding cessation  Discharged home

 Represented 2 days later with bloody diarrhoea  Up to 10 episodes per day  Initially assumed to be ongoing post- polypectomy bleeding  No stool tests performed

Pseudomembranous colitis

 No history of recent antibiotics  Only history: Elderly male Multiple co-morbidities Repeated hospitalisations Only new medication = PPI

 Commenced on oral metronidazole  Ongoing fluid balance problems  Dehydration due to diarrhoea  Worsening renal function  Fluid therapy resulting in pulmonary oedema  Prolonged HDU admission with other medical complications  Eventual resolution of diarrhoea & discharge 3 weeks later

 One of the most common healthcare- associated infections  Spectrum of disease ranging from asymptomatic carriage to fulminant colitis  Commonly a result of antibiotic therapy due to alteration of normal gut flora

 Can occur without antibiotic use, importantly via nosocomial transmission  Mortality rates of up to ~25% reported, particularly in elderly 1 1. Crogan et al, Geriatr Nurs 2007

Asymptomatic carriageC.difficile diarrhoeaC.difficile colitisPseudomembranous colitisFulminant colitis

 Approximately 20% of hospitalised patients are C. difficile carriers  Significant reservoir for disease transmission  Contribution of host’s immune response is unclear

 Watery diarrhoea >3 times per day >2 days duration  More severe cases Up to 15 motions per day Lower abdominal pain and cramping Low grade fever Leucocytosis  Onset may be during antibiotic therapy or 5-10 days after treatment Can present up to 10 weeks after antibiotic cessation

 More significant illness than diarrhoea alone  Constitutional symptoms, fever, abdominal pain + watery diarrhoea  Colonoscopy: Non-specific diffuse or patchy erythematous colitis

 The classic manifestation of full-blown C.difficile colitis  Symptoms similar to, but often more severe than, colitis due to other causes  Unwell, WCC, hypoalbuminaemia  Colonoscopy: Classical raised white/yellow plaques

 Severe manifestation affecting ~3%  Account for the most serious complications:  Perforation  Prolonged ileus  Toxic megacolon  Death  Clinical features of fever, leucocytosis, abdominal distension

1 Small bowel 2 Bacteraemia 3 Reactive arthritis 4 Others

 Particularly described in small bowel subjected to recent surgery Inflammatory bowel disease post ileal-anal anastomosis  Pseudomembrane formation  May act as a reservoir for recurrent colonic infection?

 Uncommon  Associated with high mortality rate 1  May be more common in patients with underlying gastrointestinal diseases 2 1.Daruwala et al, Clin Med Case Reports Libby et al, Int J Infect Dis 2009

 Polyarticular arthritis Knee and wrist in 50% of cases  Onset average 11 days after diarrhoea 1  Prolonged illness : average 68 days to resolve 2 1.Birnbaum et al, Clin Rheumatol Jacobs et al, Medicine (Baltimore) 2001

 Cellultis  Necrotising fasciitis  Osteomyelitis  Prosthesis infection  Intra-abdominal abscess  Empyema  etc

 General risk factors 1. Long duration antibiotics 2. Multiple antibiotics 3. Nature of faecal flora 4. Production of requisite cytotoxins 5. Presence of host risk factors  Specific risk factors 1. Immunosuppressive drugs 2. Gastric acid suppression 3. Cancer chemotherapy with antibiotic properties

 Advanced age  Nasogastric tube  Severe underlying illness  Prolonged hospitalisation  Enema therapy  GI stimulants  Stool softeners

 Chronic, relapsing inflammatory disorders of the bowel of unknown aetiology  Ulcerative colitis  Crohn’s disease  Enteric infections account for ~10% of ‘relapses’ C.difficile in about half May mimic a relapse, OR trigger a true relapse

 Crucial that C.difficile is considered in the differential diagnosis of every ‘flare’  Otherwise inappropriate escalation of immunosuppression may result in severe infection  High index of suspicion required as classical pseudomembranes don’t form in IBD  Treatment is to REDUCE their usual immunosuppressive drugs

 Gastric acid inhibits germination of ingested C.dificile spores  Therefore, medications lowering gastric acid could increase risk of C.difficile infection Clinical data are conflicting

 Abdominal xray  CT scan  Colonoscopy

 Important in patients who are unwell with C.difficile infection  Findings: Ileus Toxic megacolon Perforation

 Diagnosis can often be made on CT alone  Several characteristic findings: Gross bowel wall thickening Luminal narrowing Characteristic signs:  “Accordion sign”  “Target sign”

 Pathognomonic appearance of pseudomembranes Raised, white/yellow plaques  Up to 1/3 right-sided only, so full colonoscopy better than sigmoidoscopy  Biopsies reveal spectrum of mucosal inflammation and necrosis

 Beware colonoscopy in unwell patients with ileus or megacolon Risk of perforation  If clinical picture and stool tests are suggestive, minimal role for colonoscopy

 Health-care associated infection of great clinical significance  Spectrum of disease ranging from asymptomatic infection to fuliminant colitis and death  Imaging investigations are complimentary to clinical index of suspicion

 Approximately 15-20% of patients with CDAD relapse following successful treatment One relapse predicts further relapses!  Sudden recurrence of diarrhoea within ~1 week of treatment cessation