El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Endoscopic View of Pseudomembranous Colitis. This 90-year-old male was hospitalized with dysnea, edema   of bilateral pretibial edema, reactive arthritis and tenosynovitis,  malaise and rectal mucoid sanguinolent discharge,  the WBC count of  43.250 103/µL with 99% neutrofils. Approximately 4 weeks earlier, he had started a 10-day course of a third-generation cephalosporin for pneumonia. An abdominal computed tomographic scan  showed diffuse thickening of the colonic wall  with pericolonic inflammation of the transverse and cecum.

 Video Endoscopic Sequence 1 of 11.

 Endoscopic View of Pseudomembranous Colitis

 This 90-year-old male was hospitalized with dysnea, edema
 of bilateral pretibial edema, reactive arthritis and
 tenosynovitis, malaise and rectal mucoid sanguinolent
 discharge,
the WBC count of 43.250 103/μL with 99%
 neutrofils.
Approximately 4 weeks earlier, he had started a
 10-day course of a third-generation cephalosporin for
 pneumonia. An abdominal computed tomographic scan
 showed diffuse thickening of the colonic wall with
 pericolonic inflammation of the transverse and cecum, at
 endoscopy found this images and video clips here
 presented.

 See more links in this atlas: Toxic Dilatation of the Colon
 Superimposed pseudomembranous colitis involving the
 right colon.

 Ulcerative colitis complicating pseudomembranous colitis
 of the right colon.

 Download the video clips by clicking on the endoscopic
 images, if you wish to observe in full screen, wait to be
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 Windows
media, Real Player Ctrl and 3. 
 Configure the windows media in repeat is optimal.
 All endoscopic images shown in this Atlas contain
 video clips.
We recommend seeing the video clips in full
 screen mode.
 
   

Pseudomembranous colitis is a life-threatening complication of broad spectrum antibiotic therapy caused by Clostridium difficile. Untreated, the disease can lead to severe and in many cases fatal complications such as peritonitis due to colonic wall perforation, shock as a consequence of volume depletion, toxic megacolon and massive lower gastrointestinal haemorrhage. Fatal complications mostly occur in elderly people with a high degree of comorbidity.  The risk of developing Clostridium difficile-induced colitis increases with age.

Video Endoscopic Sequence 2 of 11.

 This endoscopic image has a characteristic appearance,
 with yellow adherent plaques 2–10 mm. demonstrating
 multiple yellowish patches ("pseudomembranes") and
 erythematous, friable mucosa.

 Pseudomembranous colitis is a life-threatening
 complication
of broad spectrum antibiotic therapy caused
 by Clostridium difficile. Untreated, the disease can lead to
 severe and in many cases fatal complications such as
 peritonitis due to colonic wall perforation, shock as a
 consequence of volume depletion, toxic megacolon and
 massive lower gastrointestinal haemorrhage. Fatal
 complications mostly occur in elderly people with a high
 degree of comorbidity. The risk of developing Clostridium
 difficile-induced colitis increases with age.

Endoscopic Image of Pseudomembranous Colitis. Any antibiotic can increase the risk of C difficile disease, including metronidazole and vancomycin, which are used in the treatment of CDAD. Disease has been reported following as little as one dose of antibiotic. Although the attributable relative risk has varied among studies, fluoroquinolones, macrolides, clindamycin, beta-lactam/beta-lactamase inhibitors, and all 3 generations of cephalosporins have consistently been shown to pose a significant risk for the development of CDAD.

Video Endoscopic Sequence 3 of 11.

 Endoscopic Image of Pseudomembranous Colitis

 Colonoscopy in skilled hands is safe,the risk of perforation
 is not very great in the early stages of Pseudomembranous
 colitis with less severe mucosal changes.

 Any antibiotic can increase the risk of C difficile disease,
 including metronidazole and vancomycin, which are used in
 the treatment of CDAD. Disease has been reported
 following as little as one dose of antibiotic. Although the
 attributable relative risk has varied among studies.

 Fluoroquinolones, macrolides, clindamycin,
 beta-lactam/beta-lactamase inhibitors, and all
 3 generations of cephalosporins have consistently been
 shown to pose a significant risk for the development of
 CDAD.

 Clostridium difficile colitis also may follow the use of
 certain cancer chemotherapy drugs
.Pseudomembranous
 colitis has been reported as causing bloody diarrhea after
 chemotherapy.

The frequency of pseudomembranous colitis with potential fatal outcome is underestimated especially in elderly patients.

Video Endoscopic Sequence 4 of 11.

Image of Typical Pseudomembranes

 The frequency of pseudomembranous colitis with potential
 fatal outcome is underestimated especially in elderly
 patients.

 Proton pump inhibitors appear to increase the risk of
 acquiring CDC by reducing the acid concentration in the
 stomach and allowing the organism to pass unharmed into
 the intestine. Patient-to-patient transmission increases the
 risk of acquiring CDC. Patients with an infected roommate
 are more likely to get CDC than patients without an
 infected roommate. Transmission of infection by hospital
 personnel contaminated with C. difficile is
 possible but preventable by using disposable gloves and
 washing hands thoroughly after examining patients.

 

Clostridium difficile-associated pseudomembranous colitis is an increasingly common nosocomial infection that usually responds to oral antibiotics. Two antibacterials have been shown to be effective in the treatment of pseudomembranous colitis: oral or parenteral metronidazole (250mg 4 times daily for 7 to 10 days) and oral vancomycin (from 125mg 3 times daily to 500mg 4 times daily in severe cases). Vancomycin is well tolerated compared with metronidazole but its cost is higher.

Video Endoscopic Sequence 5 of 11.

 Clostridium difficile-associated pseudomembranous colitis
 is an increasingly common nosocomial infection that usually
 responds to oral antibiotics. Two antibacterials have been
 shown to be effective in the treatment of
 pseudomembranous colitis: oral or parenteral
 metronidazole (250mg 4 times daily for 7 to 10 days) and
 oral vancomycin (from 125mg 3 times daily to 500mg 4
 times daily in severe cases). Vancomycin is well tolerated
 compared with metronidazole but its cost is higher.

As soon as pseudomembranous colitis is suspected, the implicated antibacterial should be withdrawn, symptomatic treatment of diarrhea started and specific antibacterial therapy initiated. The diagnosis can be confirmed by the isolation of C. difficile or its toxins in stool.

Video Endoscopic Sequence 6 of 11.

 As soon as pseudomembranous colitis is suspected, the
 implicated antibacterial should be withdrawn, symptomatic
 treatment of diarrhea started and specific antibacterial
 therapy initiated. The diagnosis can be confirmed by the
 isolation of C. difficile or its toxins in stool.

 Infection with C. difficile is associated with a spectrum of
 clinical scenarios, which include an asymptomatic carrier
 state, simple antibiotic-associated diarrhea,
 pseudomembranous colitis, and fulminant colitis. The
 virulence of the bacteria combined with the immune status
 of the patient likely accounts for this variability
. The
 majority of patients have a mild form of the disorder. New
 risk factors for CDC in the community such as gastric acid
 -suppressive agents are being identified as well as
 epidemiological factors leading to spread of the spores in
 the hospital setting. Other risk factors have been identified
 such as renal failure, chronic obstructive pulmonary
 disease, intensive care units, preoperative bowel
 preparations, advanced age, and altered intestinal motility.
 Elderly patients tend to develop infection through
 nosocomial spread.17 Up to 20 per cent of infected
 individuals develop symptomatic relapse.

The presence of pseudomembranes is virtually diagnostic of pseudomembranous colitis. In general, colonoscopy is superior to sigmoidoscopy because in 10% of patients, pseudomembranous colitis is rectosigmoid-sparing. The findings with colonoscopy vary from diffuse, patchy colitis in mild cases to the characteristic raised, adherent, yellow plaques seen in pseudomembranous colitis. Other endoscopic findings include erythema, edema, friability, and erosions.

Video Endoscopic Sequence 7 of 11.

 The presence of pseudomembranes is virtually diagnostic
 of pseudomembranous colitis. In general, colonoscopy is
 superior to sigmoidoscopy because in 10% of patients,
 pseudomembranous colitis is rectosigmoid-sparing. The
 findings with colonoscopy vary from diffuse, patchy colitis
 in mild cases to the characteristic raised, adherent, yellow
 plaques seen in pseudomembranous colitis. Other
 endoscopic findings include erythema, edema, friability,
 and erosions.

 Histologically the condition is characterized by
 pseudomembranes which represent exudate of necrotic
 cells from the denuded mucosa. The diagnosis is typically
 made with stool assay for the C.difficile toxin or by stool
 culture.

 Typical pseudomembranes adherent to the colonic mucosa in antibiotic-associated colitis. The illness occurs after a course of broad-spectrum antibiotics, which permit overgrowth of the bacteria Clostridium difficile. C. difficile multiplies within the gut when other bowel flora are suppressed by antibiotic treatment. It produces two toxins: toxin A is an enterotoxin and cytotoxin that binds to cell surface receptors and disrupts cytoplasmic microfilaments, while toxin B is cytotoxic and enters the damaged mucosa and produces further cell damage. Both toxins stimulate leucocyte migration and inflammatory mediator production contributing to mucosal inflammation.

Video Endoscopic Sequence 8 of 11.

 Typical pseudomembranes adherent to the colonic mucosa
 in antibiotic-associated colitis. The illness occurs after a
 course of broad-spectrum antibiotics, which permit
 overgrowth of the bacteria Clostridium difficile.

 C. difficile multiplies within the gut when other bowel flora
 are suppressed by antibiotic treatment. It produces two
 toxins: toxin A is an
enterotoxin and cytotoxin that binds to
 cell surface receptors and disrupts cytoplasmic
 microfilaments,
while toxin B is cytotoxic and enters the
 damaged mucosa and produces further cell damage. Both
 toxins stimulate leucocyte migration and inflammatory
 mediator production contributing to mucosal inflammation.

 Pubmed: Clostridium difficile colitis in the critically ill.

 

Diagnosis of pseudomembranous  colitis by computed tomography , In patients with pseudomembranous colitis, the colonic wall has a characteristic appearance on computed tomographic scans of the abdomen: it is diffusely thickened and the ascending or descending colon viewed on end has a donut-like appearance. It is important to recognize the possible association of such findings with pseudomembranous colitis in order to make an accurate diagnosis in patients experiencing an acute abdominal catastrophe.

Video Endoscopic Sequence 9 of 11.

Computed Tomography

 The computed Tomography of the patient, the colonic wall
 it is diffusely thickened and the ascending or descending
 colon viewed thickened. CT may be useful for detecting
 Pseudomembranous colitis in patients with right-sided
 disease.

Diagnosis of pseudomembranous  colitis by computed tomography , In patients with pseudomembranous colitis, the colonic wall has a characteristic appearance on computed tomographic scans of the abdomen: it is diffusely thickened and the ascending or descending colon viewed on end has a donut-like appearance. It is important to recognize the possible association of such findings with pseudomembranous colitis in order to make an accurate diagnosis in patients experiencing an acute abdominal catastrophe.

Video Endoscopic Sequence 10 of 11.

Diagnosis of pseudomembranous colitis by computed tomography

 In patients with pseudomembranous colitis, the colonic wall
 has a characteristic appearance on computed tomographic
 scans of the abdomen: it is diffusely thickened and the
 ascending or descending colon viewed on end has a
 donut -like appearance. It is important to recognize the
 possible association of such findings with
 pseudomembranous colitis in order to make an accurate
 diagnosis in patients experiencing an acute abdominal
 catastrophe.

CT findings include marked low attenuation wall thickening, which can be circumferential or eccentric. In one series the average wall thickness was 14.7mm, significantly greater than wall thickening seen in other inflammatory conditions.(1) Haustral folds are thickened and can appear as broad transverse bands, referred to as "accordion pattern.(1) The colon wall may enhance secondary to the hyperemia. Classically PMC is a pancolitis although there are reports of PMC sparing the rectum (2) Ascites can occasionally be present.

Video Endoscopic Sequence 11 of 11.

 CT findings include marked low attenuation wall thickening,
 which can be circumferential or eccentric. In one series the
 average wall thickness was 14.7mm, significantly greater
 than wall thickening seen in other inflammatory conditions.
 Haustral folds are thickened and can appear as broad
 transverse bands, referred to as "accordion pattern. The
 colon wall may enhance secondary to the hyperemia.
 Classically PMC is a pancolitis although there are reports
 of PMC sparing the rectum. Ascites can occasionally be
 present.

This 78-year-old female, diabetic due to a cat bit in her distal leg develop a celulitis, her family practice physician prescribed clindamycin therapy,  one week after was hospitalized because of watery diarrhea and elevation of the white blood count 25600 103/µL with 98 % of neutrofils.

 Video Endoscopic Sequence 1 of 30.

 This 78-year-old female, diabetic due to a cat bit in her
 distal leg develop a celulitis, her family practice physician
 prescribed clindamycin therapy, one week after was
 hospitalized because of watery diarrhea and elevation of
 the white blood count 25600 103/μL with 98 % of
 neutrofils. 

Pseudomembranous colitis is far more common than the sporadic published reports, avoiding a high mortality rate is to establish the diagnosis promptly and give early supportive treatment.   There were volcanic-like eruptions of mucus and pus from distended and partially necrotic glands, this eruption coalescing to form a pseudomembrane on the mucosal surface. The immediately adjacent mucosa was normal.

 Video Endoscopic Sequence 2 of 30.

Rectum

 Pseudomembranous colitis is far more common than the
 sporadic published reports, avoiding a high mortality rate is
 to establish the diagnosis promptly and give early
 supportive treatment.

 There were volcanic-like eruptions of mucus and pus from
 distended and partially necrotic glands, this eruption
 coalescing to form a pseudomembrane on the mucosal
 surface. The immediately adjacent mucosa was normal.

Endoscopic Image of Pseudomembranous Colitis. Symptoms Pseudomembranous colitis  is usually associated with watery diarrhea (99%), fever (29%), abdominal pain or cramping (33%) and leukocytosis (61%) [10]. In a study of 48 patients with endoscopic PMC, the above symptoms usually occurred after 4 days of antibiotic treatment , but symptoms can occur up to 6 weeks after antibiotics have been discontinued. Symptoms can occur within a day or two of starting antibiotics, suggesting that alteration in the colonic flora can develop rapidly. Cases have even been documented after a single dose of cephalosporin given as preoperative prophylaxis

 Video Endoscopic Sequence 3 of 30.

 Endoscopic Image of Pseudomembranous Colitis

 Symptoms Pseudomembranous colitis is usually associated
 with watery diarrhea (99%), fever (29%), abdominal pain
 or cramping (33%) and leukocytosis (61%) [10]. In a study
 of 48 patients with endoscopic PMC, the above symptoms
 usually occurred after 4 days of antibiotic treatment , but
 symptoms can occur up to 6 weeks after antibiotics have
 been discontinued. Symptoms can occur within a day or two
 of starting antibiotics, suggesting that alteration in the
 colonic flora can develop rapidly. Cases have even been
 documented after a single dose of cephalosporin given as
 preoperative prophylaxis.

 

Creamy white plaques coat the mucosa. This is a typical  endoscopic appearance of symptoms Pseudomembranous  colitis.      Proctosigmoidoscopy may be completely negative, thus colonoscopy may be needed in some cases.

 Video Endoscopic Sequence 4 of 30.

 Creamy white plaques coat the mucosa. This is a typical
 endoscopic appearance of symptoms Pseudomembranous
 colitis.

 Proctosigmoidoscopy may be completely negative, thus
 colonoscopy may be needed in some cases.

 Gross endoscopic findings usually reveal characteristic
 raised yellow-tan or green plaques which bleed.

 When raised from the mucosa. These plaques range in size
 from small distinct nodules (2–10 mm) to a confluent layer
 of pseudomembrane overlying the mucosa. The colonic
 mucosa may also show erythema, friability and edema.

PMC is diagnosed by assessing the patient on three levels: clinical evaluation, stool assays for enteric pathogens and visualization of the colonic mucosa. The first is the medical history and clinical presentation. A history of recent antibiotic use, recent hospitalization, intestinal surgery or residence in a chronic care facility may all predispose to PMC. Symptoms of watery diarrhea, abdominal pain or cramping and fever are typical.

 Video Endoscopic Sequence 5 of 30.

 Yellow/white mucosal plaques.

 PMC is diagnosed by assessing the patient on three levels:
 clinical evaluation, stool assays for enteric pathogens and
 visualization of the colonic mucosa. The first is the medical
 history and clinical presentation. A history of recent
 antibiotic use, recent hospitalization, intestinal surgery or
 residence in a chronic care facility may all predispose to
 PMC. Symptoms of watery diarrhea, abdominal pain or
 cramping and fever are typical
.

Cecum, the appendiceal hole.   One must also remember that the anatomical location of pseudomembranes includes virtually all portions of the intestinal tract. When the colon is attacked the more severe lesions occur in the proximal portion-the caecum and ascending colon. In patients with antibiotic-related disease the major impact of the disease is in the colon.

 Video Endoscopic Sequence 6 of 30.

Cecum, the appendiceal hole

 One must also remember that the anatomical location of
 pseudomembranes includes virtually all portions of the
 intestinal tract. When the colon is attacked the more
 severe lesions occur in the proximal portion-the cecum and
 ascending colon. In patients with antibiotic-related disease
 the major impact of the disease is in the colon.

Macroscopically there are discrete cream to yellow coloured plaques which vary in size between 2 to 20 mm. These plaques are usually loosely attached to the erythematous bowel wall. The pseudomembranes can be easily removed during endoscopy. The intervening mucosa may show hyperemia, edema and superficial erosion. In advanced cases the pseudomembranes are more confluent and linear ulcers develop.

 Video Endoscopic Sequence 7 of 30.

 Numerous small, raised, yellowish plaques.

 Macroscopically there are discrete cream to yellow
 coloured plaques which vary in size between 2 to 20 mm.
 These plaques are usually loosely attached to the
 erythematous bowel wall. The pseudomembranes can be
 easily removed during endoscopy. The intervening mucosa
 may show hyperemia, edema and superficial erosion. In
 advanced cases the pseudomembranes are more confluent
 and linear ulcers develop.

Endoscopic View of Pseudomembranous Colitis . One week after the specific treatment, a follow up. Endoscopy was performed. pseudomembranes through all the colon are observed much less and still multiple ulcerated lesions in phase of involution. the watery diarrhea has continued but in smaller quantity.

 Video Endoscopic Sequence 8 of 30.

Endoscopic View of Pseudomembranous Colitis

Second look

 One week after the specific treatment, a follow up
 Colonoscopy was performed. Pseudomembranes through
 all the colon were observed much less and still multiple
 ulcerated lesions in phase of involution. The watery
 diarrhea has continued but in smaller quantity.

 Pseudomembranous colitis may affect all age groups,
 although a lower incidence has been noted in children.

 

Close up of one lesion, magnifying colonoscopy.

 Video Endoscopic Sequence 9 of 30.

Second look

Close up of one lesion, magnifying colonoscopy

(One week after the specific treatment second endoscopy)

Clostridium difficile colitis complicated by leukemoid reactions.

 Video Endoscopic Sequence 10 of 30.

Clostridium difficile colitis complicated by leukemoid reactions

 Patients with C difficile colitis and a leukocyte count
 greater than 35 x 10(9)/L have a poor prognosis with a
 much higher mortality rate than patients who have C
 difficile colitis without a leukemoid reaction.

 Development of pseudomembranes in the gastrointestinal
 tract during acute inflammatory or vascular diseases has
 been confined to the small and/or large bowel, with rare
 occurrences in the esophagus. Pseudomembranous
 enterocolitis is a serious, often fatal disease that usually
 follows antimicrobial therapy and Clostridium difficile
 infection. Other reported risk factors include cancer,
 ischemic colitis, leukemia, severe infection, and neonatal
 necrotizing enterocolitis.

One week after the specific treatment,

 Video Endoscopic Sequence 11 of 30.

One week after the specific treatment

 Fulminant colitis develops in approximately 1% to 3% of
 patients. Serious complications include
 dehydration, electrolyte imbalance, hypotension,
 hypoalbuminemia with anasarca, and toxic megacolon.
 Colonic perforation is a rare but devastating complication.

 

ColitisssPseudoMembranousx12

 Video Endoscopic Sequence 12 of 30.

 Therapy for PMC includes discontinuation of implicated
 antimicrobial agents, administration of antimicrobial agents
 directed against C. difficile, and supportive measures.
 Diarrhea will resolve without specific antimicrobial therapy
 in 15% to 25% of patients. Supportive measures include
 intravenous (IV) fluids to correct dehydration and
 electrolyte imbalance. Nutritional support may be required
 to correct hypoalbuminemia. Antiperistaltic agents should
 be avoided because they may delay clearance of toxins
 from the colon, leading to increased colonic injury, ileus,
 and toxic dilation.

 Antimicrobial options include oral metronidazole or
 vancomycin for 10 days. Antibiotic treatment should be
 oral, since C. difficile is restricted to the lumen of the
 colon. If IV treatment is necessary because the patient
 cannot tolerate oral medication or a feeding tube, only
 metronidazole is effective. Vancomycin should not be given
 intravenously because effective colonic luminal
 concentrations cannot be attained by this route.

ColitisssPseudoMembranousx13

 Video Endoscopic Sequence 13 of 30.

In this image and video clip, an infusion of yogurt applied through of the working channel of the colonoscope as observed here.

(There have also been anecdotal reports of success with yogurt enemas.)

 Yogurt contain pro-biotic microorganisms – such as
 Lactobacillus casei, Lactobacillus acidophilus and
 Bifidobac terium longum.

 Restoration of Human Bowel Flora (Human Probiotics
 Infusion).

 The treatment uses bowel flora (feces) homogenized in
 sterile saline, often filtered, and the slurry containing the
 total living protective bacteria is infused into the bowel of
 the patient. This can be done through a colonoscope under
 sedation, via enema, or through a naso-jejunal tube to take
 care of the small bowel reservoir of CD.

ColitisssPseudoMembranousx14

 Video Endoscopic Sequence 14 of 30.

(One week after the specific treatment second endoscopy)

 Probiotics are live microorganisms consisting of
 non-pathogenic yeast and bacteria that are believed to
 restore the microbial balance of the gastrointestinal tract
 altered by infection with Clostridium difficile (C. difficile).

 Enemas with human stool have been suggested as a means
 of reconstituting normal flora, but this approach lacks
 aesthetic appeal and carries the risk of transmitting
 infection.

Colonic ulcer with exudate and mucus retention.

 Video Endoscopic Sequence 15 of 30.

Colonic ulcer with exudate and mucus retention.

 

Digital print pattern of the colonic glands with mucus and exudate.

 Video Endoscopic Sequence 16 of 30.

Digital print pattern of the colonic glands with mucus and exudate.

Colonic ulcer with purulent exudate.

 Video Endoscopic Sequence 17 of 30.

Colonic ulcer with purulent exudate.

Twenty days  after the specific treatment was initiated, a second follow up endoscopy was performed, this endoscopy was carry out in ambulatory basis..

 Video Endoscopic Sequence 18 of 30.

 (Third Colonoscopy)

 Twenty days after the specific treatment was initiated, a
 second follow up colonoscopy was performed, this
 endoscopy was carry out in ambulatory basis.

There are some pseudomembranes and small ulcer are observed in this image.

 Video Endoscopic Sequence 19 of 30.

 (Third look)

There are some pseudomembranes and small ulcer are observed in this image.

A close up with magnyfing colonoscope.

 Video Endoscopic Sequence 20 of 30.

 (Third Colonoscopy)

A close up with magnyfing colonoscope

Practically most of the Pseudomembranes have been disappeared observing most of the lesion are in phase of remission.

 Video Endoscopic Sequence 21 of 30.

 Practically most of the Pseudomembranes have been
 disappeared observing most of the lesion are in phase of
 remission.

 Toxic megacolon is well-established as an unusual
 presentation of C. difficile colitis. These patients are less
 likely to present with typical symptoms such as diarrhea or
 typical risk factors like recent administration of antibiotics,
 so diagnosis can be a challenge. A patient presenting with
 toxic megacolon without a history of inflammatory bowel
 disease should be assumed to have C. difficile colitis until
 proven otherwise, and medical or surgical therapy
 administered accordingly.

 Video Endoscopic Sequence 22 of 30.

 (Third Colonoscopy)

Again a follow up endoscopy

Smaller plaques, but already confluent.

 Video Endoscopic Sequence 23 of 30.

 (Third Colonoscopy)

Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy.    Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.

 Video Endoscopic Sequence 24 of 30.

Clostridium difficile infection (CDI) is a frequent cause of
 morbidity and mortality among elderly hospitalized
 patients. A small but increasing number of patients have
 developed fulminant CDI, and a significant number of
 these patients require emergency colectomy.

 Both the incidence and severity of CDI are increasing.
 Fulminant CDI is underappreciated as a life-threatening
 disease because of a lack of awareness of its severity and
 its nonspecific clinical syndrome. Early diagnosis and
 treatment are essential for a good outcome, and early
 surgical intervention should be used in patients who are
 unresponsive to medical therapy. The surgical procedure
 of choice is a total abdominal colectomy with end ileostomy,
 although the mortality rate remains high.

                                   Medline

In spite of twenty days of treatment and improvement of the symptoms there are some ulcerated lesions in phase of remission.

 Video Endoscopic Sequence 25 of 30.

 In spite of twenty days of treatment and improvement of
 the symptoms there are some ulcerated lesions in phase of
 remission.

ColitisssPseudoMembranousx26

 Video Endoscopic Sequence 26 of 30.

There are still some raised reddened lesions with scanty Pseudomembranes.

ColitisssPseudoMembranousx27

 Video Endoscopic Sequence 27 of 30.

Confusing Terminology

  • Antibiotic-associated diarrhea
    • C. difficile is only one cause
  • Clostridium difficile-associated diarrhea
    • diarrhea + positive stool test
  • Clostridium difficile colitis
    • underlying pathologic process
  • Pseudomembranous colitis
    - endoscopic demonstration of exudative lesions
  • Toxic megacolon
    -radiologic and surgical diagnosis
ColitisssPseudoMembranousx28

 Video Endoscopic Sequence 28 of 30.

Unproven therapies

  • Tapering course of standard antimicrobials
  • Yeast (Saccharomyces boulardii) with AB
  • Cholestyramine
  • Lactobacillus acidophilus
  • Nontoxigenic C. difficile (oral)
  • Bacterial enemas
  • Rectal infusion of normal feces

 Video Endoscopic Sequence 29 of 30.

 (Third Colonoscopy)

ColitisssPseudoMembranousx30

 Video Endoscopic Sequence 30 of 30.

 (Third Look)

 Pseudomembranous colitis was first described in 1893
 when a patient with severe diarrhea was found to have
 "diphtheritic colitis" at autopsy. The condition was
 attributed to mucosal ischemia or viral infection until 1977,
 when it was reported that stool specimens from affected
 patients contained a toxin that produced cytopathic
 changes in tissue-culture cells. Within a year of that report,
 C. difficile, a spore-forming, gram-positive, anaerobic
 bacillus, was identified as the source of the cytotoxin.

 

Pseudomembranous Colitis.  A 43 year-old woman, Suffering of deformed rheumatoid arthritis, who underwent a cholecystectomy. Broad-spectrum antibiotics were administered, and one week after she was released from the hospital, she developed severe diarrhea and sepsis. The patient was hospitalized, and a colonoscopy was performed.

Pseudomembranous Colitis.

 A 43 year-old woman, Suffering of deformed rheumatoid
 arthritis, underwent a cholecystectomy.
 Broad-spectrum antibiotics were administered,
and one
 week after she was released from the hospital, she
 developed severe diarrhea and sepsis. The patient was
 hospitalized, and a colonoscopy was performed showing this
 image and video clip.

 

Endoscopic View of Pseudomembranous Colitis . Typical pseudomembranes adherent to the colonic mucosa in antibiotic-associated colitis.  The illness occurs after a course of broad-spectrum antibiotics, which permitted an overgrowth of the bacteria Clostridium difficile. Discrete, rounded collections of adherent, white to yellow exudate can coalesce into large swatches. Lesions are most common in the rectum but can affect the entire colon and appendix.

Endoscopic View of Pseudomembranous Colitis

 A 26 year-old man, who was under course of antibiotic
 therapy underwent a watery diarrhea and sepsis.

 Typical pseudomembranes adherent to the colonic
 mucosa in antibiotic-associated colitis.
 The illness occurs after a course of broad-spectrum
 antibiotics, which permitted an overgrowth of the bacteria
 Clostridium difficile.
 Discrete, rounded collections of adherent, white to yellow
 exudate can coalesce into large swatches.
 Lesions are most common in the rectum but can affect the
 entire colon and appendix.