Pseudomembranous Colitis Surgery Workup

  • Author: Said Fadi Yassin, MD; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Sep 15, 2011
 

Laboratory Studies

  • Complete blood count (CBC) - A CBC will reveal leukocytosis, with the white blood cell (WBC) count varying from 10,000-50,000/mL.
  • Blood chemistry - Hypoalbuminemia is common.
  • Fecal leukocytes - Positive tests for fecal leukocytes (3-5 leukocytes per high-power field [HPF]) excludes benign diarrhea; however, a negative result does not exclude colitis.
  • Stool culture - Culture of C difficile is relatively demanding, with low predictive value due to the large number of asymptomatic carriers. Many laboratories do not perform this test.
  • Stool assay for C difficile toxins (mostly toxin B)
    • This test requires 2 days. It is considered positive when cultured cells undergo cytopathic changes when exposed to stool, and the result then is confirmed by neutralizing these toxins with specific antitoxins.
    • This is the criterion standard test (sensitivity is 95% in patients with antibiotic-induced diarrhea, and sensitivity increases with the severity of the colitis); however, results are negative in 5-10% of patients with endoscopic evidence of pseudomembranous colitis.
  • Enzyme-linked immunoabsorbent assay (ELISA) for toxin A - This test is less expensive than stool assay for C difficile toxins and is completed in 2.5 hours; however, sensitivity (75-85%) is lower.
  • Latex agglutination test - This test has poor sensitivity and specificity.
  • Polymerase chain reaction (PCR) - The PCR test is expensive and highly sensitive; it is currently used only as a research tool in laboratories for detecting C difficile toxin genes in fecal specimens.[8]
  • Glutamate dehydrogenase - The enzyme glutamate dehydrogenase is expressed at high levels by all strains of C difficile and is referred to as the common antigen.[8] ELISA screening tests that detect this enzyme have been shown to be highly sensitive, simple, and cost-effective. Although none of these screening tests specifically identify toxigenic strains, since the enzyme is produced by toxigenic and nontoxigenic strains, they have negative predictive values of roughly 99%, which supports their value for ruling specimens negative for C difficile.[8]
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Imaging Studies

  • Plain abdominal radiography
    • This may show mucosal edema and abnormal haustral pattern. The latter is shown in the image below. Frontal abdominal radiograph in a patient with proFrontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
    • Ileus pattern was described in 28% of the patients.
    • It is useful to rule out toxic megacolon or perforation.
  • Air contrast barium enema study
    • It can outline the mucosal abnormalities further; however, these are late and nonspecific findings.
    • This procedure is not recommended, because it carries the risk of perforation and may precipitate toxic megacolon.
  • CT scanning - This modality may show distension and diffuse and focal thickening of the wall of the colon, along with pericolonic inflammation.
  • Nuclear study - Indium-labeled leukocyte scan will show nonspecific inflammation of the colonic mucosa.
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Other Tests

  • Therapeutic trial
    • Pseudomembranous colitis is uncommon in infants and young children. They commonly harbor C difficile and its toxins in their stool, which makes it difficult to diagnose the disease in this age group.
    • A therapeutic trial with vancomycin may be the only way to confirm the clinical significance of the positive toxins in the stool.
  • Rigid proctosigmoidoscopy
    • This test is diagnostic in 77% of patients.
    • Endoscopic visualization of the pseudomembranes characteristic of the disease is the most rapid and definitive diagnostic method.
    • When the pseudomembranes are manipulated, ulcerated mucosa is uncovered.
    • In early stages of the disease, lesions may be confused with Crohn disease, Behçet disease, and viral colitis.
  • Flexible sigmoidoscopy - This procedure is diagnostic in 91% of the patients.
  • Colonoscopy
    • This procedure may be required in 10% of the cases where the disease is localized to the cecum or transverse colon with rectal sparing.
    • It is a hazardous procedure in patients with toxic megacolon.
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Contributor Information and Disclosures
Author

Said Fadi Yassin, MD  Associate 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.

Specialty Editor Board

H Scott Bjerke, MD, FACS  Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

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.

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

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.

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 Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, 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 Consulting; ARdelyx Ownership interest Board membership

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Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Endoscopic visualization of pseudomembranous colitis, a characteristic manifestation of full-blown Clostridium difficile colitis. Classic pseudomembranes are visible as raised yellow plaques, which range from 2-10 mm in diameter and are scattered over the colorectal mucosa. Courtesy of Gregory Ginsberg, MD, University of Pennsylvania.
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).
 
 
 
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