Objectives: To examine the course of patients who have died or required colectomy for Clostridium difficile colitis (CDC) in a large University Health System as a means to define the clinical syndrome, patient risk factors and morbidity and mortality from fulminant disease. Summary Background Data: CDC is a poorly recognized cause of mortality. Patients with CDC may develop a sudden systemic inflammatory syndrome that is unresponsive to standard medical therapy. No large series has examined this group of patients.
Methods: Sixty-seven patients were examined with a histologically and clinically confirmed diagnosis of fulminant CDC (FCDC). A retrospective review identified 46 patients with FCDC diagnosed after colectomy and another 21 patients whose cause of death through autopsy was determined to be FCDC over a period beginning 1989 through 2000.
Results: In the group undergoing colectomy, the overall mortality of operative intervention was 59%. 74% of patients undergoing colectomy had undergone a previous operative procedure within the previous month-79% of these were cardiothoracic procedures. 24% percent had a previously documented history of CDC. 35% of patients required colectomy within one week of the onset of symptoms. Pre-operative vasopressors requirements predicted mortality after colectomy (69%vs 14%*). Immunocompetent patients were more likely to die after colectomy compared to immunosuppressed patients (65% vs 47%*). Patients with FCDC who died without operative intervention when compared with those who had undergone colectomy were more likely to be immunosuppressed (62% vs 33%*), less likely to have undergone a recent surgical procedure (74% vs 24%*), more likely to be admitted to medical services (48% vs 24%*), and less likely to have a correct pre-event diagnosis of CDC (90% vs 62%*). CT was the most sensitive method of diagnosis (100%). Perforation was found in only one patient. Absolute leukocytosis did not predict survival. (*: p<0.05).
Conclusions: FCDC has a very high mortality rate once the requirement for vasopressors has been initiated. Patients with immunosuppression, a history of CDC, and those who have undergone recent cardiovascular procedures seem at highest risk. Patients who have documented or presumptive CDC with a rapidly rising WBC and systemic symptoms despite medical therapy should undergo urgent total abdominal colectomy and end ileostomy before vasopressor requirements. CT scan reliably and quickly diagnosed FCDC in all patients.
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