Monday, October 12, 2009

Clostridial Difficile Colitis


Since becoming an Attending Surgeon, I've performed 17 subtotal colectomies (went back and counted) on patients with fulminant c diff colitis over the past three years. As a resident, I don't recall ever doing or even hearing of a patient getting a colectomy for severe c diff. But it's a growing trend. This is a disease entity that didn't exist 15 years ago. Antibiotic induced alteration of colonic bacterial flora allows for overgrowth of this normally non-pathogenic bug. The spectrum of severity is broad, with rare cases (1-5%) progressing to the severe variety of fulminant colitis. What we're finding is that earlier surgical intervention in these severe cases represents the patient's best chance at survival.

There's a good review of fulminant c diff colitis in the May 2009 Archives issue from Harvard. Fulminant colitis is defined by the presence of systemic toxicity. Some salient points:
*In-hospital mortality was 35%
*Three key indicators of mortality were WBC >35k/bandemia, age >70, cardiopulmonary failure/need for pressors/vent
*Earlier surgery was associated with improved survival

The most interesting point was that patient outcomes correlated with which service (surgical vs medicine) that the patient was admitted to. Patients on a surgical service were 3 times more likely to survive fulminant colitis than those patients cared for by the medicine service. They were operated on more frequently and more expeditiously (as one would assume).

So the question is: If fulminant c diff colitis is a surgical disease, shouldn't all patients immediately be transferred to a surgical service once signs of systemic toxicity set in? If the patient is "sick" (renal failure, hypotensive, septic, etc) and has peritonitis on exam, I proceed directly to the OR. Some of these patients I fear are lingering on the medical service with a diagnosis of "infectious colitis" for far too long. Not all c diff is a surgical problem, just like not all cases of acute pancreatitis need to be followed by a surgeon. But it's important to properly stratify these patients and get the surgeon involved sooner rather than later...

7 comments:

radinc said...

c diff is a terrible problem, and one that we're responsible for creating through our own indiscriminate antibiotic use.

there's great data out of europe and other countries to show that probiotics work to prevent c diff, decrease severity, and increase cure rates.

with data like this everyone who gets an antibiotic should get a probiotic too. it should be like ldl and lipitor. too bad there is little financial incentive to promoting these cheap supplements.

it's the same with fish oil, some good studies (in the nejm no less) show it *doubles* stent patency at three months.

I'm not sure what my point is, just to say that there are some big problems that have simple, cheap interventions that have good benefit, and it's frustrating that they're not used.

later,
radinc

HudsonMD said...

Jeff,
I appreciate your aggressiveness with these patients and it appears that the surgical literature supports early surgical intervention. Unfortunetly i have a very hard time convincing some of the surgeons of this fact. It can be very frustrating. There are times i wish i could "cut"!

Frank Drackman said...

Is that a Mr. Menckle's Diverticulum? Or an Appendix that doesn't know its place?
And looks like either Free-Air or Pneumatos-is Whatever-is right next to it...
CUT!!!!!!!!!!!
Easy for me to say, I'm not a Surgeon.
But anything that gets patients away from those Quack-Flea-Witchdoctors has gotta be a good thing.
They'll bleed someone down to a Hemoglobin of "1" with all their friggin tests, thought Phlebotomy went out of style centuries ago.
And I think C dificile's God's way of tellin you you took to many Z-packs...

Frank

Frank

Hua Kul said...

Hello Dr. Parks. I have a question regarding your post. (I went to the PubMed link but could only read the abstract since I don’t have a subscription.) By systemic toxicity do you mean bacteria and/or toxins in the bloodstream or a general immune system response (which I’ve seen referred to as a “cytokine storm”)? If it is the immune system response which is inflaming the colon and other organs, Dr. David Moskowitz in St. Louis (www.genomed.com) uses a therapy of high dose lipophilic ACE inhibitors to suppress this reaction in cases of various viral infections, such as SARS and West Nile Virus. I have been wondering for awhile if this would be effective against C. diff. colitis of the severity you have described.

Anonymous said...

Buckeye, you are entitled to your interpretation of history as I am to mine; my version is that c.diff colitis has probably been around even before the introduction of macrolides and the other great new antibiotics at our disposal. I still recall the flurry of lawsuits in the 70's that alleged Lincocin was the specific causative agent of the colitis and should be banned from the market.
So it is really not as recent a phenomenon as we often think, but one that we getting better at recognizing and treating earlier. And surgeons, who eventually have to deal with the worst cases are leading the way. Great post, keep up the good work. I really admire and envy your writing skills.

Anonymous said...

Hi. While I agree with your approach, I have concerns about your interpretation of the recent study. There may be reasons why a patient is on the medical vs. surgical service. Such a bias could explain the differences in outcomes just as readily as any difference in interventions between the 2 cohorts. You really need an RCT to answer the question, "does early surgical intervention improve outcome?" This will of course never be done given practicalities.

dianna myers said...

HI I AM SO GLAD TO FIND THIS OHIO SURGEON. THAT THINKS SOME EARLIER SURGICAL INTERVENTION IS GOOD. WE LIVE IN GA. MY HUSBAND HAD THE WEIGHT LOSS SURGERYOVER 2 YEARS AGO AND GOT C DIFF DURING THAT TIME. HE WAS IN SURGER 13 HOURS INSTEAD OF 4. HE HAS SINCE OCT. HAD C DIFF COLITIS MANDY TIMES AND IN HOSPITAL WAS IN IN OCT. ALMOST THE WHOLE MONTH. ON FLAGYL NOW STABLE BUT ONLY GAINED 2 LBS. FROM THE 40 HE LOSS WHEN HE HAD THE SICK SPELLS. HE IS FROM COLUMBUS,OH. HE IS GOING TO WEAN OFF FLAGYL INEND OF MAY WHEN WE COME TO OHIO THIS SUMMER WE WOULD LIKE TO VISIT THIS DR. THANK YOU DANNY AND DIANNA MYERS /DDZIGZAG@BELLSOUTH.NET