Minieviews
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastrointest Surg. Jun 27, 2013; 5(6): 167-172
Published online Jun 27, 2013. doi: 10.4240/wjgs.v5.i6.167
Current status of surgical treatment for fulminant clostridium difficile colitis
Andrew J Klobuka, Alexey Markelov
Andrew J Klobuka, Alexey Markelov, Department of Surgery, Easton Hospital, Drexel University College of Medicine, Easton, PA 18042, United States
Author contributions: Klobuka AJ and Markelov A contributed equally to this work
Correspondence to: Alexey Markelov, MD, Department of Surgery, Easton Hospital, Drexel University College of Medicine, 250 S 25th Street, Easton, PA 18042, United States. dr.markelov@gmail.com
Telephone: +1-516-6696821 Fax: +1-610-2504851
Received: December 10, 2012
Revised: April 18, 2013
Accepted: May 22, 2013
Published online: June 27, 2013
Processing time: 195 Days and 15.6 Hours
Abstract

Mortality rates attributable to fulminant Clostridium difficile (C. difficile) colitis remain high and are reported to be 38%-80%. Historically, the threshold for surgical intervention has been judged empirically because level I evidence to guide decision making is lacking. Studies of the surgical management of C. difficile infection have been limited by small sample size and the lack of a standard definition of fulminancy. Multiple small and medium-sized series have examined the surgical management of C. difficile. However, because of a lack of prospective, randomized studies, it has been difficult to identify the optimal point for surgical intervention in patients with severe fulminant C. difficile colitis. Our goal was to analyze the existing body of literature in an attempt to define host constellations, which would predict the development of the more aggressive form of this disease and hence justify an early or earlier surgical intervention. A Pubmed search was conducted using the keywords “fulminant”, “clostridium difficile”, “surgery”, and “colitis”. Reviews and meta-analyses proposing indications for surgical consultation or operative management in patients with C. difficile colitis were included. After analyzing current literature, we identified a number of parameters that are associated with unfavorable outcomes. The parameters include age greater than 65 years old, peritoneal signs on physical examination, abdominal distension, signs of end-organ failure, hypotension less than 90 mmHg systolic blood pressure, tachycardia greater than 100 bpm, vasopressor requirement, elevated WBC count of greater than at least

16 × 109/μL, serum lactate of greater than 2.2 mmol/L, and lastly, radiologic findings suggestive of pancolitis, ascites, megacolon, or colonic perforation. Even though fairly strong evidence exists in contemporary literature, we recommend use of these identified parameters with caution in clinical practice when it comes to the actual decision to treat certain patients more aggressively. The identified risk factors should be used to lower surgeons’ threshold for operative treatment early in the course of the disease.

Keywords: Fulminant Clostridium difficile; Colitis; Toxic megacolon; Total colectomy; Surgical management

Core tip: Studies of the surgical management of Clostridium difficile infection have been limited by small sample size and the lack of a standard definition of fulminancy. Our goal was to analyze the existing body of literature in an attempt to define host constellations which would predict the development of the more aggressive form of this disease and hence justify an early or earlier surgical intervention. We identified a number of parameters that are associated with unfavorable outcomes. The identified risk factors should be used to lower surgeons’ threshold for operative treatment early in the course of the disease.