VA Morning Report 6.5.17: Large bowel obstruction and C. diff

Case Summary

72F with a PMH of a prolonged hospital course who developed acute-onset abdominal pain, n/v and obstipation and was found to have a large bowel obstruction attributed to C. diff colitis.


Top Pearls
  1. Don’t forget “things next to the abdomen” that can present as abdominal pain- lower lobe pneumonia, inferior MI, superficial causes (eg zoster), ovaries/uterus
  2. Large bowel obstruction is less common and requires surgery more often than small bowel obstruction. Causes include functional (Ogilvie’s, due to impaired autonomic nervous system) and mechanical obstruction.
  3. Complicated C. diff can cause either total or segmental nonobstructive colonic dilatation, and there is some data to support PR vancoymin in this patient population due to impaired colonic transit.

Bowel obstruction
  • Functional versus mechanical obstruction-
    • Functional- impaired colonic transit due to dysfunctional autonomic nervous system
    • Mechanical- extrinsic, intrinsic, or intraluminal blockage
  • Small bowel obstruction– ~75% of obstructions, more often resolve with medical management
    • Causes (in rough order of incidence)- post-operative adhesions, stricture (IBD, ischemia, XRT), hernias, malignancy, intussusception, volvulus
    • Treatment-
      • Many resolve with decompression from above with NG and supportive care
      • Surgery is indicated if the patient has a closed loop or complete obstruction, perforation, signs of intestinal ischemia and/or is toxic-appearing
  • Large bowel obstruction- ~25% of obstructions, more often require surgical management
    • Functional- Ogilvie’s/pseudo-obstruction (most often in critically ill or post-operative patients), C diff (can be pan-colonic or segmental)
    • Mechanical-
      • Extrinsic to bowel- adhesions, hernias, extraintestinal malignant compression
      • Intrinsic to bowel- colonic malignancy, volvulus (typically sigmoid), inflammation leading to stricture (prior diverticulosis, IBD, ischemic colitis, XRT)
      • Intraluminal- bezoars, feces, foreign bodies including inspissated barium, gallstones (entering the lumen via a cholecystoenteric fistula)
    • Treatment-
      • 75% ultimately require surgery
      • NG if nausea/vomiting and IVF
      • Important to rule out malignancy, stricture with endoscopic evaluation
      • Subsequent treatment depends upon the etiology and location (eg. neostigmine for Ogilvie’s, stenting of a malignant LBO, colectomy in one or multiple stages)

Severe, complicated Clostridium difficile infection
  • This patient had a recent flexible sigmoidoscopy that did not show malignancy or stricture and tested positive for C diff, supporting a diagnosis of severe, complicated C. diff
  • American College of Gastroenterology C. diff severity scoring system and summary of recommended treatments (one of many, all with slightly differing criteria and not validated :)):
Severity criteria     Treatment Comment
Mild-to-moderate– diarrhea plus any additional signs or symptoms not meeting severe or complicated criteria Metronidazole 500mg PO TID x 10 days (or vancomycin 125mg QID x 10 days) Many guidelines suggest starting with PO vancomycin
Severe– albumin <3g/dL plus 1 of the following: WBC >15,000, abd tenderness Vancomycin 125 mg orally four times a day for 10 days
Severe, complicated- ICU admission, hypotension, fever >38.5, ileus or abd distension, mental status changes, WBC >35,000 or <2,000, serum lactate >2.2, end organ failure Vancomycin 500 mg orally four times a day and metronidazole 500 mg IV every 8 h, and vancomycin per rectum (vancomycin 500 mg in 500 ml saline as enema) four times a day Surgical consultation
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