History and Physical Examination
Symptoms of pseudomembranous colitis may not begin until a few weeks after discontinuance of the antibiotic. They may range from loose stool in the mildest cases to toxic megacolon (fever, nausea, vomiting, and ileus) [8] and colonic perforation (rigid abdomen and rebound tenderness) in the most severe cases.
Symptoms include the following:
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Profuse, watery or mucoid, green, foul-smelling, liquid stool may contain small amounts of blood
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Cramping abdominal pain may occur
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The patient's temperature may reach 103-105°F (39.4-40.6ºC)
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Extraintestinal manifestations of oligoarthritis and iridocyclitis are extremely rare
One day to 6 weeks may elapse between the start of antibiotic therapy and the beginning of the clinical symptoms. In most cases, however, symptoms begin 3-9 days after the antibiotics are started.
In some cases (5-19%), the disease is localized to the cecum and the proximal colon. These patients may present with acute abdomen and localized rebound tenderness in the right lower quadrant but no diarrhea. With such a clinical presentation, considering this diagnosis and confirming it with stool studies (stool cytology results might be negative for C difficile toxins) and computed tomography (CT) may help avoid unnecessary surgery.
C difficile colitis should be suspected in infants and children with Hirschsprung disease when it is complicated by enterocolitis. These cases call for special attention because they often are associated with high risk.
Refractory C difficile colitis can be defined as disease that does not respond to vancomycin or metronidazole. Fulminant C difficile colitis can be defined as disease that progresses rapidly to cause systemic manifestation, including hypotension, renal failure, and anasarca. In practice, these two forms often overlap; their management is challenging, and their incidence is rising.
With these conditions, abdominal distention and tenderness may be present, and diarrhea may be absent or minimal as a consequence of ileus, which may obscure the diagnosis. Subtotal colectomy can be lifesaving, but the optimal timing is difficult to establish. Early surgical consultation when fulminant or refractory disease is suspected is highly recomended. [9]
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, [8] hemorrhage, and sepsis also can occur.
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Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
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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, which range from 2-10 mm in diameter and are scattered over the colorectal mucosa. Courtesy of Gregory Ginsberg, MD, University of Pennsylvania.
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Gross pathology specimen from a case of pseudomembranous colitis revealing characteristic yellowish plaques.
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Gross pathology specimen from a case of pseudomembranous colitis, again demonstrating characteristic yellowish plaques.
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Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
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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).
