El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
This 90-year-old male was hospitalized with dysnea, edema of bilateral pretibial edema, reactive arthritis and tenosynovitis, malaise and rectal mucoid sanguinolent discharge, the WBC count of 43.250 103/µL with 99% neutrofils. Approximately 4 weeks earlier, he had started a 10-day course of a third-generation cephalosporin for pneumonia. An abdominal computed tomographic scan showed diffuse thickening of the colonic wall with pericolonic inflammation of the transverse and cecum.

 Video Endoscopic Sequence 1 of 11.

 This 90-year-old male was hospitalized with dysnea, edema
 of bilateral pretibial edema, reactive arthritis and
 tenosynovitis, malaise and rectal mucoid sanguinolent
 discharge, the WBC count of 43.250 103/μL with 99%
 neutrofils. Approximately 4 weeks earlier, he had started a
 10-day course of a third-generation cephalosporin for
 pneumonia. An abdominal computed tomographic scan
 showed diffuse thickening of the colonic wall with
 pericolonic inflammation of the transverse and cecum, at
 endoscopy found this images and video clips here
 presented.

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Pseudomembranous colitis is a life-threatening complication of broad spectrum antibiotic therapy caused by Clostridium difficile. Untreated, the disease can lead to severe and in many cases fatal complications such as peritonitis due to colonic wall perforation, shock as a consequence of volume depletion, toxic megacolon and massive lower gastrointestinal haemorrhage. Fatal complications mostly occur in elderly people with a high degree of comorbidity. The risk of developing Clostridium difficile-induced colitis increases with age.

Video Endoscopic Sequence 2 of 11.

 This endoscopic image has a characteristic appearance,
 with yellow adherent plaques 2–10 mm. demonstrating
 multiple yellowish patches ("pseudomembranes") and
 erythematous, friable mucosa.

 Pseudomembranous colitis is a life-threatening
 complication of broad spectrum antibiotic therapy caused
 by Clostridium difficile. Untreated, the disease can lead to
 severe and in many cases fatal complications such as
 peritonitis due to colonic wall perforation, shock as a
 consequence of volume depletion, toxic megacolon and
 massive lower gastrointestinal haemorrhage. Fatal
 complications mostly occur in elderly people with a high
 degree of comorbidity. The risk of developing Clostridium
 difficile-induced colitis increases with age.
Any antibiotic can increase the risk of C difficile disease, including metronidazole and vancomycin, which are used in the treatment of CDAD. Disease has been reported following as little as one dose of antibiotic. Although the attributable relative risk has varied among studies, fluoroquinolones, macrolides, clindamycin, beta-lactam/beta-lactamase inhibitors, and all 3 generations of cephalosporins have consistently been shown to pose a significant risk for the development of CDAD.

Video Endoscopic Sequence 3 of 11.

 Any antibiotic can increase the risk of C difficile disease,
 including metronidazole and vancomycin, which are used in
 the treatment of CDAD. Disease has been reported
 following as little as one dose of antibiotic. Although the
 attributable relative risk has varied among studies.

 fluoroquinolones, macrolides, clindamycin,
 beta-lactam/beta-lactamase inhibitors, and all
 3 generations of cephalosporins have consistently been
 shown to pose a significant risk for the development of
 CDAD.

 Clostridium difficile colitis also may follow the use of
 certain cancer chemotherapy drugs.Pseudomembranous
 colitis has been reported as causing bloody diarrhea after
 chemotherapy.
The frequency of pseudomembranous colitis with potential fatal outcome is underestimated especially in elderly patients.

Video Endoscopic Sequence 4 of 11.

 The frequency of pseudomembranous colitis with potential
 fatal outcome is underestimated especially in elderly
 patients.

 Proton pump inhibitors appear to increase the risk of
 acquiring CDC by reducing the acid concentration in the
 stomach and allowing the organism to pass unharmed into
 the intestine. Patient-to-patient transmission increases the
 risk of acquiring CDC. Patients with an infected roommate
 are more likely to get CDC than patients without an
 infected roommate. Transmission of infection by hospital
 personnel contaminated with C. difficile is
 possible but preventable by using disposable gloves and
 washing hands thoroughly after examining patients.

 
Clostridium difficile-associated pseudomembranous colitis is an increasingly common nosocomial infection that usually responds to oral antibiotics. Two antibacterials have been shown to be effective in the treatment of pseudomembranous colitis: oral or parenteral metronidazole (250mg 4 times daily for 7 to 10 days) and oral vancomycin (from 125mg 3 times daily to 500mg 4 times daily in severe cases). Vancomycin is well tolerated compared with metronidazole but its cost is higher.

Video Endoscopic Sequence 5 of 11.

 Clostridium difficile-associated pseudomembranous colitis
 is an increasingly common nosocomial infection that usually
 responds to oral antibiotics. Two antibacterials have been
 shown to be effective in the treatment of
 pseudomembranous colitis: oral or parenteral
 metronidazole (250mg 4 times daily for 7 to 10 days) and
 oral vancomycin (from 125mg 3 times daily to 500mg 4
 times daily in severe cases). Vancomycin is well tolerated
 compared with metronidazole but its cost is higher.
As soon as pseudomembranous colitis is suspected, the implicated antibacterial should be withdrawn, symptomatic treatment of diarrhea started and specific antibacterial therapy initiated. The diagnosis can be confirmed by the isolation of C. difficile or its toxins in stool.

Video Endoscopic Sequence 6 of 11.

 As soon as pseudomembranous colitis is suspected, the
 implicated antibacterial should be withdrawn, symptomatic
 treatment of diarrhea started and specific antibacterial
 therapy initiated. The diagnosis can be confirmed by the
 isolation of C. difficile or its toxins in stool.

 Infection with C. difficile is associated with a spectrum of
 clinical scenarios, which include an asymptomatic carrier
 state, simple antibiotic-associated diarrhea,
 pseudomembranous colitis, and fulminant colitis. The
 virulence of the bacteria combined with the immune status
 of the patient likely accounts for this variability. The
 majority of patients have a mild form of the disorder. New
 risk factors for CDC in the community such as gastric acid
 -suppressive agents are being identified as well as
 epidemiological factors leading to spread of the spores in
 the hospital setting. Other risk factors have been identified
 such as renal failure, chronic obstructive pulmonary
 disease, intensive care units, preoperative bowel
 preparations, advanced age, and altered intestinal motility.
 Elderly patients tend to develop infection through
 nosocomial spread.17 Up to 20 per cent of infected
 individuals develop symptomatic relapse.
The presence of pseudomembranes is virtually diagnostic of pseudomembranous colitis. In general, colonoscopy is superior to sigmoidoscopy because in 10% of patients, pseudomembranous colitis is rectosigmoid-sparing. The findings with colonoscopy vary from diffuse, patchy colitis in mild cases to the characteristic raised, adherent, yellow plaques seen in pseudomembranous colitis. Other endoscopic findings include erythema, edema, friability, and erosions.

Video Endoscopic Sequence 7 of 11.

 The presence of pseudomembranes is virtually diagnostic
 of pseudomembranous colitis. In general, colonoscopy is
 superior to sigmoidoscopy because in 10% of patients,
 pseudomembranous colitis is rectosigmoid-sparing. The
 findings with colonoscopy vary from diffuse, patchy colitis
 in mild cases to the characteristic raised, adherent, yellow
 plaques seen in pseudomembranous colitis. Other
 endoscopic findings include erythema, edema, friability,
 and erosions.

 Histologically the condition is characterized by
 pseudomembranes which represent exudate of necrotic
 cells from the denuded mucosa. The diagnosis is typically
 made with stool assay for the C.difficile toxin or by stool
 culture.
C. difficile multiplies within the gut when other bowel flora are suppressed by antibiotic treatment. It produces two toxins: toxin A is an enterotoxin and cytotoxin that binds to cell surface receptors and disrupts cytoplasmic microfilaments, while toxin B is cytotoxic and enters the damaged mucosa and produces further cell damage. Both toxins stimulate leucocyte migration and inflammatory mediator production contributing to mucosal inflammation.

Video Endoscopic Sequence 8 of 11.

 C. difficile multiplies within the gut when other bowel flora
 are suppressed by antibiotic treatment. It produces two
 toxins: toxin A is an enterotoxin and cytotoxin that binds to
 cell surface receptors and disrupts cytoplasmic
 microfilaments, while toxin B is cytotoxic and enters the
 damaged mucosa and produces further cell damage. Both
 toxins stimulate leucocyte migration and inflammatory
 mediator production contributing to mucosal inflammation.

 Pubmed: Clostridium difficile colitis in the critically ill.

 
Diagnosis of pseudomembranous colitis by computed tomography , In patients with pseudomembranous colitis, the colonic wall has a characteristic appearance on computed tomographic scans of the abdomen: it is diffusely thickened and the ascending or descending colon viewed on end has a donut-like appearance. It is important to recognize the possible association of such findings with pseudomembranous colitis in order to make an accurate diagnosis in patients experiencing an acute abdominal catastrophe.

Video Endoscopic Sequence 9 of 11.

Computed Tomography

 The computed Tomography of the patient, the colonic wall
 it is diffusely thickened and the ascending or descending
 colon viewed thickened.

Diagnosis of pseudomembranous colitis by computed tomography , In patients with pseudomembranous colitis, the colonic wall has a characteristic appearance on computed tomographic scans of the abdomen: it is diffusely thickened and the ascending or descending colon viewed on end has a donut-like appearance. It is important to recognize the possible association of such findings with pseudomembranous colitis in order to make an accurate diagnosis in patients experiencing an acute abdominal catastrophe.

Video Endoscopic Sequence 10 of 11.

Diagnosis of pseudomembranous colitis by computed tomography

 In patients with pseudomembranous colitis, the colonic wall
 has a characteristic appearance on computed tomographic
 scans of the abdomen: it is diffusely thickened and the
 ascending or descending colon viewed on end has a
 donut -like appearance. It is important to recognize the
 possible association of such findings with
 pseudomembranous colitis in order to make an accurate
 diagnosis in patients experiencing an acute abdominal
 catastrophe.

CT findings include marked low attenuation wall thickening, which can be circumferential or eccentric. In one series the average wall thickness was 14.7mm, significantly greater than wall thickening seen in other inflammatory conditions.(1) Haustral folds are thickened and can appear as broad transverse bands, referred to as "accordion pattern.(1) The colon wall may enhance secondary to the hyperemia. Classically PMC is a pancolitis although there are reports of PMC sparing the rectum (2) Ascites can occasionally be present.

Video Endoscopic Sequence 11 of 11.

 CT findings include marked low attenuation wall thickening,
 which can be circumferential or eccentric. In one series the
 average wall thickness was 14.7mm, significantly greater
 than wall thickening seen in other inflammatory conditions.
 Haustral folds are thickened and can appear as broad
 transverse bands, referred to as "accordion pattern. The
 colon wall may enhance secondary to the hyperemia.
 Classically PMC is a pancolitis although there are reports
 of PMC sparing the rectum. Ascites can occasionally be
 present.

Pseudomembranous Colitis. A 43 year-old woman, who underwent a cholecystectomy. Broad-spectrum antibiotics were administered, and one week after she was released from the hospital, she developed severe diarrhea and sepsis. The patient was hospitalized, and a colonoscopy was performed.

Pseudomembranous Colitis.

 A 43 year-old woman, who underwent a cholecystectomy.
 Broad-spectrum antibiotics were administered, and one
 week after she was released from the hospital, she
 developed severe diarrhea and sepsis. The patient was
 hospitalized, and a colonoscopy was performed.

 
Pseudomembranous Colitis. Typical pseudomembranes adherent to the colonic mucosa in antibiotic-associated colitis. The illness occurs after a course of broad-spectrum antibiotics, which permitted an overgrowth of the bacteria Clostridium difficile. Discrete, rounded collections of adherent, white to yellow exudate can coalesce into large swatches. Lesions are most common in the rectum but can affect the entire colon and appendix.

Pseudomembranous Colitis.

 Typical pseudomembranes adherent to the colonic
 mucosa in antibiotic-associated colitis.
 The illness occurs after a course of broad-spectrum
 antibiotics, which permitted an overgrowth of the bacteria
 Clostridium difficile.
 Discrete, rounded collections of adherent, white to yellow
 exudate can coalesce into large swatches.
 Lesions are most common in the rectum but can affect the
 entire colon and appendix.