Clostridium Difficile Colitis Workup

  • Author: Faten N Aberra, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: May 18, 2012
 

Laboratory Studies

Electrolytes

Dehydration and electrolyte imbalance may accompany severe disease.

Albumin

Hypoalbuminemia and anasarca may accompany severe disease.

CBC count

Leukocytosis may be present.

Stool examination

Stool may be hemoccult positive in severe colitis, but grossly bloody stools are unusual.

Fecal leukocytes are present in about half of the cases.

Stool assays for C difficile from the most sensitive to the least sensitive

  • Stool culture is the most sensitive (sensitivity 90-100% and specificity 84-100%) but results are slow and may lead to delay in diagnosis if used alone.
  • Glutamate dehydrogenase enzyme immunoassay (EIA) is very sensitive (sensitivity 85-100% and specificity 87-98%). This test detects the presence of glutamate dehydrogenase produced by C difficile. Positive test results need to be rerun by another assay to verify.
  • Real-time PCR may be used to detect C difficile gene toxin. In a study of 132 patients who had tested positive for C difficile using the glutamate dehydrogenase EIA and PCR for toxin B genes, 32% had a negative EIA result for toxin A and B. No significant difference was noted in the disease severity of illness of patients with C difficile based on presence or absence of toxin.[6]
  • The stool cytotoxin test has sensitivity of 70-100% and specificity of 90-100%. Diarrheal stool is filtered and then added to cultured fibroblasts. A positive test result is the demonstration of a cytopathic effect that is neutralized by specific antiserum. This test result is reported only as positive or negative, it is expensive, and it requires an overnight incubation and a tissue culture facility.
  • Enzyme immunoassay for detecting toxins A and B is used in most labs. The sensitivity is moderate (79-80%) and specificity is excellent (98%). Repeat testing is needed if an initial test is negative. EIA for toxin A is available but used less frequently with the availability of EIA for toxin A and B.
  • Glutamate dehydrogenase can also be detected by latex agglutination technique. Sensitivity of this test is poor, 48-59%, and the specificity is 95-96%.
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Procedures

Endoscopy

Endoscopy may demonstrate the presence of raised, yellowish-white, 2- to 10-mm plaques overlying an erythematous and edematous mucosa. These plaques are termed pseudomembranes.

Pseudomembranes are observed in 14-25% of patients with mild disease and 87% of patients with fulminant disease.

Most patients have disease throughout the colon. However, sigmoidoscopy alone may not reveal any abnormality if the disease is confined to the right colon. Typical pseudomembranes are beyond the limit of the flexible sigmoidoscopy in 10% of patients. Therefore, colonoscopy is more useful.

Endoscopic examination findings may be normal in patients with mild disease or may demonstrate nonspecific colitis in moderate cases. Endoscopy is the least sensitive for diagnosing C difficile as compared to stool assays.

Sigmoidoscopy and colonoscopy in patients with fulminant colitis may be contraindicated because of the risk of perforation. Limited proctoscopy, with minimal air insufflation, may be a useful diagnostic tool.

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Histologic Findings

Biopsy of pseudomembranous plaques reveals an inflammatory exudate composed of mucinous fibrinous material containing polymorphonuclear cells.

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Contributor Information and Disclosures
Author

Faten N Aberra, MD  Assistant Professor, Department of Medicine, Division of Gastroenterology, University of Pennsylvania School of Medicine

Faten N Aberra, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, Crohns and Colitis Foundation of America, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Craig A Gronczewski, MD  Clinical Assistant Professor, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey; Consulting Staff, Princeton Medical Center; Consulting Staff, Robert Wood Johnson University Hospital

Craig A Gronczewski, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Jonathan P Katz, MD  Assistant Professor of Medicine, Department of Medicine, University of Pennsylvania School of Medicine

Jonathan P Katz, MD is a member of the following medical societies: American Gastroenterological Association and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Waqar A Qureshi, MD  Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center

Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

BS Anand, MD  Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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Endoscopic visualization of pseudomembranous colitis, a characteristic manifestation of full-blown Clostridium difficile colitis. Classic pseudomembranes are visible as raised yellow plaques ranging from 2-10 mm in diameter and scattered over the colorectal mucosa. Courtesy of Gregory Ginsberg, MD, University of Pennsylvania.
Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Gross pathology specimen from a case of pseudomembranous colitis revealing characteristic yellowish plaques.
Gross pathology specimen from a case of pseudomembranous colitis, again demonstrating characteristic yellowish plaques.
Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
Barium enema demonstrating typical serrated appearance of the barium column (resulting from trapped barium between the edematous mucosal folds and the plaquelike membranes of pseudomembranous colitis).
Axial CT scan of pseudomembranous colitis.
CT scan of pseudomembranous colitis.
Ultrasound image of pseudomembranous colitis.
 
 
 
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