Pseudomembranous colitis: a surgical disease?

Abstract

Background: Pseudomembranous colitis (PMC) is an increasingly common nosocomial infection caused by Clostridium difficile and its toxins. The disease is usually successfully treated with oral vancomycin. The toxic form of PMC, which requires surgical intervention, is uncommon and often carries a high mortality rate. The indications and recommended surgical procedure and the results of current surgical treatment remain unclear.

Methods: All charts of adults undergoing surgical intervention for PMC during the last 6 years were retrospectively reviewed. During the last 6 years an estimated 37,000 C. difficile toxin assays have been performed with 3300 positive results.

Results: Thirteen adults (0.39%) underwent surgical intervention for PMC. Surgical intervention was performed for systemic toxic effects in all patients, with physical signs of peritonitis in six patients and worsening computed tomographic scans with ongoing illness despite appropriate medical therapy in five. The overall mortality rate in the series was 38%; in those undergoing left hemicolectomy (n = 4) the mortality rate was 100% versus a mortality rate of 14% for those undergoing subtotal colectomy (n = 9).

Conclusions: Despite the effectiveness of oral vancomycin therapy, surgical therapy is occasionally although rarely indicated for the treatment of toxic PMC. Surgical intervention should be considered when the patient has signs of organ failure, a worsening CT scan, or signs of peritonitis. At laparotomy the external appearance of the colon is often deceptively normal and should not influence the surgical procedure of choice, subtotal colectomy. These severely ill patients can be treated with an acceptable morbidity and mortality rate.