eMedicine Specialties > General Surgery > Colorectal

Pseudomembranous Colitis, Surgical Treatment: Treatment

Author: Said Fadi Yassin, MD, Assistant Professor of Surgery, Department of Cardiothoracic Surgery, University of New Mexico School of Medicine
Contributor Information and Disclosures

Updated: Apr 7, 2009

Treatment

Medical Therapy

In mild or moderate cases, supportive therapy alone is sufficient. This includes discontinuing or changing the offending antibiotics, avoiding narcotics and antidiarrheal agents, maintaining fluid and electrolyte intake, and enteric isolation. Most patients, 75% of symptomatic patients and 25% of patients with colitis, will experience complete recovery within 10 days. In fulminant or intractable cases, hospitalization for IV hydration will be necessary.

Oral treatment with antimicrobial agents effective against C difficile is the preferred treatment. No reliable parenteral treatment for pseudomembranous colitis exists. In elderly patients and in severely ill patients, empirical antibiotic treatment should be started when the diagnosis is suspected. In severe cases, in cases where supportive therapy fails, and in cases where the offending antibiotic cannot be discontinued, a short course (7-10 d) of specific antibiotic therapy should be administered along with the supportive therapy, and the offending antibiotic should be changed to another appropriate agent when possible. Recurrent diseases respond well to re-treatment with vancomycin.

In cases with multiple recurrences, a few suggested therapeutic regimens exist. A long course of oral antibiotic (4-6 wk) may be administered, followed by gradual tapering, or pulsing, of vancomycin (125 mg qid for 1 wk, 125 mg bid for 1 wk, 125 mg qd for 1 wk, or 125 mg qod for 1 wk; followed by 125 mg q72h for 2 wk). Another suggested regimen is administering 5-7 days of intermittent antibiotic treatment periods alternating with periods off antibiotics. Treatment with a combination of vancomycin and rifampin was reported to be successful in some cases.

Vancomycin

It is the most reliable treatment of the disease (response rate in adult men is 90-100%). The risk of developing resistant bacterial strains should be considered. Because oral vancomycin is absorbed poorly, the high stool concentration that is required for the treatment of C difficile can be achieved without systemic side effects. The recommended dose is 125 mg every 6 hours for 7-14 days for adults and 500 mg/1.73 m2 every 6 hours for infants. It can be used as therapeutic trial in infants to establish the diagnosis.

Vancomycin 500 mg qid is the treatment of choice for staphylococcal enterocolitis, typhlitis, and severely ill patients with C difficile colitis. In patients who do not improve promptly, reassessment is warranted to make sure that no other diagnosis has been missed. If the diagnosis remains the same, vancomycin should be switched to metronidazole. When parenteral therapy is the only possible treatment due to paralytic ileus, using both vancomycin and metronidazole intravenously, supplemented by vancomycin 500 mg qid via nasogastric tube or by enema, is recommended.

Metronidazole

It is inexpensive, effective treatment for pseudomembranous colitis. It is the preferred first line of treatment, with a response rate of 86-92% when used orally in adult men. It is equal to vancomycin in relapse rate with higher side effect profile. An oral dose of 250 mg qid for 7-10 days is recommended. It is not recommended for children or for women during pregnancy.

Bacitracin

Recommended oral dose is 500-1000 mg qid for 7-19 days. As alternative therapy for symptomatic relief, it is less effective than vancomycin in clearing C difficile from stool.

Teicoplanin

It is a new antibiotic with a recommended oral dose of 100 mg bid. It compares favorably with vancomycin, with a longer half-life that allows less frequent dosage.

Cholestyramine

It contains anion exchange binding resins, which exert their beneficial effect in pseudomembranous colitis by binding C difficile toxins and eliminating these toxins from the colonic lumen. It is used in patients with mild disease and in relapses. The response rate is variable and low in general. The recommended oral dose is 4 g qid. Obstipation is the most common adverse effect. It should not be used simultaneously with vancomycin.

Intravenous Immunoglobulin (IVIG)

 It is known that individuals with high antitoxin IgG titers are more likely to recover quickly or be asymptomatic carriers, while patients with low titers are reported to have more severe, more prolonged, or recurrent disease. Because more than 50% of the population has detectable serum IgG antibodies to C difficile toxins A and B, pooled normal IVIG has toxin-neutralizing activity. Thus, IVIG (400 mg/kg) may be a worthwhile intervention in fulminant or refractory disease.7,9,10

Antidiarrheal agents

Antiperistaltic drugs should be avoided. They may provide temporary symptomatic relief, but they may protract the disease by prolonging the mucosal exposure to the bacterial toxins, resulting in more severe colonic damage. Postoperative narcotics may play a similar role. Lomotil is especially dangerous in infants.

Restoration of normal flora

In patients with multiple relapses, attempts have been made to recolonize the colon by introducing organisms to suppress C difficile. Some of the results were encouraging. Oral Lactobacillus GG has been used. Enema with feces from healthy person, though it carries the risk of disease transmission, also has been used. Oral nonpathogenic yeast, such as Saccharomyces boulardii, also has been used effectively in treatment of multiple relapses.

Steroids

Corticosteroid therapy was reported to be safe and effective in the treatment of severe cases but is not widely recommended.

Surgical Therapy

Two thirds of patients with toxic megacolon require surgical intervention.6

  • Diverting ileostomy or resection of diseased bowel (subtotal colectomy)
    • This was necessary treatment before antibiotic therapy was available.
    • This treatment currently is used only as a life-saving measure, such as in cases of perforated cecum or toxic megacolon.11  
  • Colostomy or ileostomy
    • This approach is used rarely for direct instillation of antibiotic into the colon lumen in patients with paralytic ileus.
    • Pseudomembranous colitis could be the cause of early dysfunction of the colostomy.
    • Ileal involvement in the disease has been reported as a complication of ileostomy.
  • Early subtotal colectomy - This is advocated by some surgeons in fulminant toxic cases that do not respond after a week of intensive medical therapy, because the risk of perforation increases after 7 days of ineffective medical therapy. Research groups have been trying to identify objective parameters that can be used to determine which patients are most likely to benefit from surgery.

Follow-up

  • Many patients remain asymptomatic carriers of C difficile, and most of them never relapse.
  • Ten percent to 20% of all treated patients will have a relapse regardless of the therapeutic agent used. This could be due either to germination of spores or reinfection. Response to retreatment with vancomycin usually is favorable.
  • In patients with multiple symptomatic relapses, vancomycin pulsing is recommended (125 mg qid for 1 wk, 125 mg bid for 1 wk, 125 mg qd for 1 wk, or 125 mg qod for 1 wk; followed by 125 mg q72h for 2 wk).

Complications

  • Hypovolemic shock, dehydration, and electrolytes depletion may occur.
  • Hypoproteinemia as a result of protein-losing enteropathy may occur in patients with prolonged diarrhea.
  • Cecal perforation, toxic megacolon,6 hemorrhage, and sepsis also can occur.

More on Pseudomembranous Colitis, Surgical Treatment

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Follow-up: Pseudomembranous Colitis, Surgical Treatment
Multimedia: Pseudomembranous Colitis, Surgical Treatment
References
Further Reading
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Keywords

pseudomembranous colitis , colitis, Clostridium, Clostridium difficile, C difficile, Clostridium difficile colitis, toxic megacolon, antibiotic side effects, antibiotic diarrhea, antibiotics diarrhea, C difficile colitis, antibiotic colitis, antibiotic-associated colitis

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Contributor Information and Disclosures

Author

Said Fadi Yassin, MD, Assistant Professor of Surgery, Department of Cardiothoracic Surgery, University of New Mexico School of Medicine
Said Fadi Yassin, MD is a member of the following medical societies: Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Amy L Friedman, MD, Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse
Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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