Current status of surgical treatment for fulminant clostridium difficile colitis

Table 1 Major risk factors for the development of Clostridium difficile infection and associated disease

Risk factor	Risk	Proposed mechanism	Notes
Age (> 70 yr[10])	CDI and Severe CDAD	Diminished efficacy of immune response with aging[7]
Medical comorbidities[7]: multiple or those involving major organ systems	CDI and Severe CDAD	Diminished efficacy of immune response	Studies are conflicting with regards to which comorbid illnesses are specifically associated The evidence supporting the association with multiple/prolonged antibiotic use is controversial as this often occurs in patients with recurrent or refractory disease who are already at risk of unfavorable outcomes
Broad spectrum antibiotics Use of 3-4 antibiotics concurrently or prolonged (> 4 wk) use[12]	CDI	Alteration of normal colonic floral barrier to C. difficile colonization
	Severe CDAD
	Suppression of gastric acid production, particularly by proton pump inhibitors[6,7]			CDI	Increased survival of the acid-labile vegetative form of C. difficile while passing through the stomach[6,7]
Immunosuppression[6,13]	CDI and severe CDAD	Disruption of host ability to mount an effective response to both infection and toxemia

C. difficile: Clostridium difficile; CDI: Clostridium difficile infection; CDAD: Clostridium difficile associated disease.

Table 2 Previous studies analyzing surgical management of fulminant Clostridium difficile colitis

Article	Indications for surgical consultation and operative management	Notes
Carchman et al[6]	Indications for Surgical Consultation in Patients with Known or Suspected	Strength/quality of evidence, B-III
Review	CDAD
	Ileus/significant abdominal distension
	Admission to intensive care unit
	Hypotension (+/- vasopressors)
	Mental status changes
	WBC counts ≥ 35 × 109 /μL
	Serum lactate ≥ 2.2 mmol/L
	Any evidence of end-organ failure
	Age ≥ 80 yr with severe CDAD criteria
	Immunosuppression with severe CDAD criteria	Strength/quality of evidence, B-II
	Indications for Operative Management in Patients with CDAD
	Diagnosis of C. difficile colitis as determined by one of the following:
	Positive toxin assay result
	Endoscopic findings (pseudomembranes)
	CT scan findings (pancolitis +/- ascites)
	Plus any one of the following criteria:
	Peritonitis
	Perforation
	Worsening abdominal distension/pain
	Sepsis
	Intubation
	Vasopressor requirement
	Mental status changes
	Unexplained clinical deterioration
	Renal failure
	Lactate level > 5 mmol/L
	WBC count ≥ 50 × 109/μL
	Abdominal compartment syndrome
	Failure to improve with standard therapy within 5 d as determined by resolving symptoms and physical examination, resolving WBC per band count
Osman et al[14]	Summary of the clinical, laboratory, and radiologic features of fulminant C. difficile colitis	Severe, complicated CDAD synonymous with fulminant CDAD is considered to be indication for operative management by these authors.
Original article	Clinical:
	History of diarrhea following antibiotic use
	Systemic toxicity
	Pyrexia ≥ 38 °C
	Tachycardia > 100 beats/min
	Hypotension: BP < 90 mmHg
	Abdominal signs of Peritonitis
	Generalized abdominal pain
	Tenderness
	Abdominal distension
	Rebound tenderness
	Organ failure and requirement for vasopressor therapy
	Laboratory and Radiologic:
	Increasing leukocytosis > 16 × 109 /L
	Lactate > 2.2 mmol/L
	Hypoalbuminemia < 30 g/L
	Radiologic evidence of toxic megacolon (abdominal X-ray or CT)
	Free air under the diaphragm
Butala et al[15]	Prognosticators for development of fulminant colitis	Strength/quality of evidence, B
Review	Age > 65 yr
	Lactate between 2.2-4.9 mmol/L
	WBC count > 16000/μL-surgery within 30 d
	History of Inflammatory bowel disease
	Treatment with intravenous immunoglobulin
	Colitis associated with signs of organ dysfunction
Girotra et al[16]	Summary of red flags for development of fulminant Clostridium difficle colitis
Original article	Age > 70 yr
	Presenting symptoms: Triad of abdominal pain, diarrhea, and distension
	Signs: Tachycardia (heart rate > 100 beats/min), tachypnea (respiratory rate > 20 respirations/min),or hypotension (systolic BP < 90 mmHg)
	Recent C. difficile infection
	Use of antiperistaltic medications (narcotics or anticholinergics)
	White blood cell count > 18000/mm3
	Radiology studies suggestive of megacolon or perforation

C. difficile: Clostridium difficile; CDI: Clostridium difficile infection; CDAD: Clostridium difficile associated disease; WBC: White blood cell.

Table 3 Summary of indications for surgical management

Indicator	Carchman et al[6]	Bignardi et al[9]	Osman et al[14]	Butala et al[15]
Elevated WBC (count ×109)	> 35		> 16	> 16
Serum lactate (mmol/L)	> 2.2 consult		> 2.2	2.2-4.9
	> 5 operate
Peritoneal signs on physical examination including generalized abdominal pain	Present	Present	Present
Abdominal distension	Present	Present	Present
End organ (renal, respiratory) failure/dysfunction	Present		Present	Present
Hypotension (mmHg)	Present	< 90 systolic	< 90 systolic
Tachycardia (bpm)		> 100	> 100
Vasopressor requirement	Yes		Yes
Radiological findings of pancolitis, ascites, megacolon, or perforation	Present		Present
Age (yr)	> 80	> 70		> 65

WBC: White blood cell.