Pseudomembranous Colitis
Endoscopic View of Pseudomembranous Colitis

Video Endoscopic Sequence 1 of 11.

Endoscopic View of Pseudomembranous Colitis

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.

See more links in this atlas: Toxic Dilatation of the Colon and Superimposed pseudomembranous colitis involving the right colon and Ulcerative colitis complicating pseudomembranous colitis of the right colon.

Download the video clips by clicking on the endoscopic images, if you wish to observe in full screen, wait to be downloaded complete then press Alt and Enter for Windows media, Real Player Ctrl and 3. Configure the windows media in repeat is optimal. All endoscopic images shown in this Atlas contain video clips. We recommend seeing the video clips in full screen mode.

 

Pseudomembranous Colitis

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.

 

 

 

 

Pseudomembranous Colitis

Video Endoscopic Sequence 3 of 11.

Endoscopic Image of Pseudomembranous Colitis

Colonoscopy in skilled hands is safe,the risk of perforationis not very great in the early stages of Pseudomembranous colitis with less severe mucosal changes.

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.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 4 of 11.

Image of Typical Pseudomembranes

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.

 

Pseudomembranous Colitis

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.

 

 

 

 

Pseudomembranous Colitis

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.

 

 

 

 

Pseudomembranous Colitis

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.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 8 of 11.

Typical pseudomembranes adherent to the colonic mucosa in antibiotic-associated colitis. The illness occurs after a course of broad-spectrum antibiotics, which permit overgrowth of the bacteria Clostridium difficile.

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.

 

 

Pseudomembranous Colitis

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. CT may be useful for detecting Pseudomembranous colitis in patients with right-sided disease.

 

 

 

 

Pseudomembranous Colitis

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.

 

Pseudomembranous Colitis

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

Video Endoscopic Sequence 1 of 30.

This 78-year-old female, diabetic due to a cat bit in her distal leg, develop a celulitis, her family practice physician prescribed clindamycin therapy, one week after was hospitalized because of watery diarrhea and elevation of the white blood count 25600 103/μL with 98 % of neutrofils. 


 

 

 

 

Pseudomembranous Colitis

Video Endoscopic Sequence 2 of 30.

Rectum

Pseudomembranous colitis is far more common than the sporadic published reports, avoiding a high mortality rate is to establish the diagnosis promptly and give early supportive treatment.

There were volcanic-like eruptions of mucus and pus from distended and partially necrotic glands, this eruption coalescing to form a pseudomembrane on the mucosal surface. The immediately adjacent mucosa was normal.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 3 of 30.

Endoscopic Image of Pseudomembranous Colitis

Symptoms Pseudomembranous colitis is usually associated with watery diarrhea (99%), fever (29%), abdominal pain or cramping (33%) and leukocytosis (61%) [10]. In a study of 48 patients with endoscopic PMC, the above symptoms usually occurred after 4 days of antibiotic treatment , but symptoms can occur up to 6 weeks after antibiotics have been discontinued. Symptoms can occur within a day ortwo of starting antibiotics, suggesting that alteration in the colonic flora can develop rapidly. Cases have even been documented after a single dose of cephalosporin given as preoperative prophylaxis.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 4 of 30.

Creamy white plaques coat the mucosa. This is a typical endoscopic appearance of symptoms Pseudomembranous colitis.

Proctosigmoidoscopy may be completely negative, thus colonoscopy may be needed in some cases.

Gross endoscopic findings usually reveal characteristic raised yellow-tan or green plaques which bleed.

When raised from the mucosa. These plaques range in size from small distinct nodules (2–10 mm) to a confluent layer of pseudomembrane overlying the mucosa. The colonic mucosa may also show erythema, friability and edema.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 5 of 30.

Yellow/white mucosal plaques.

PMC is diagnosed by assessing the patient on three levels: clinical evaluation, stool assays for enteric pathogens and visualization of the colonic mucosa. The first is the medical history and clinical presentation. A history of recent antibiotic use, recent hospitalization, intestinal surgery or residence in a chronic care facility may all predispose to PMC. Symptoms of watery diarrhea, abdominal pain or cramping and fever are typical.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 6 of 30.

Cecum, the appendiceal hole

One must also remember that the anatomical location of pseudomembranes includes virtually all portions of the intestinal tract. When the colon is attacked the more severe lesions occur in the proximal portion-the cecum and ascending colon. In patients with antibiotic-related disease the major impact of the disease is in the colon.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 7 of 30.

Numerous small, raised, yellowish plaques.

Macroscopically there are discrete cream to yellow coloured plaques which vary in size between 2 to 20 mm. These plaques are usually loosely attached to the erythematous bowel wall. The pseudomembranes can be easily removed during endoscopy. The intervening mucosa may show hyperemia, edema and superficial erosion. In advanced cases the pseudomembranes are more confluent and linear ulcers develop.

 

 

 

 

Pseudomembranous Colitis

Video Endoscopic Sequence 8 of 30.

Endoscopic View of Pseudomembranous Colitis

Second look

One week after the specific treatment, a follow up Colonoscopy was performed. Pseudomembranes through all the colon were observed much less and still multiple ulcerated lesions in phase of involution. The watery diarrhea has continued but in smaller quantity.

Pseudomembranous colitis may affect all age groups, although a lower incidence has been noted in children.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 9 of 30.

Second look

Close up of one lesion, magnifying colonoscopy

(One week after the specific treatment second endoscopy)

 

Pseudomembranous Colitis

Video Endoscopic Sequence 10 of 30.

Clostridium difficile colitis complicated by leukemoid reactions.

Patients with C difficile colitis and a leukocyte count greater than 35 x 10(9)/L have a poor prognosis with a much higher mortality rate than patients who have C difficile colitis without a leukemoid reaction.

Development of pseudomembranes in the gastrointestinal tract during acute inflammatory or vascular diseases has been confined to the small and/or large bowel, with rare occurrences in the esophagus. Pseudomembranous enterocolitis is a serious, often fatal disease that usually follows antimicrobial therapy and Clostridium difficile infection. Other reported risk factors include cancer, ischemic colitis, leukemia, severe infection, and neonatal necrotizing enterocolitis.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 11 of 30.

One week after the specific treatment

Fulminant colitis develops in approximately 1% to 3% of patients. Serious complications include dehydration, electrolyte imbalance, hypotension, hypoalbuminemia with anasarca, and toxic megacolon. Colonic perforation is a rare but devastating complication.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 12 of 30.

Therapy for PMC includes discontinuation of implicated antimicrobial agents, administration of antimicrobial agents directed against C. difficile, and supportive measures. Diarrhea will resolve without specific antimicrobial therapy in 15% to 25% of patients. Supportive measures include intravenous (IV) fluids to correct dehydration and electrolyte imbalance. Nutritional support may be required to correct hypoalbuminemia. Antiperistaltic agents should be avoided because they may delay clearance of toxins from the colon, leading to increased colonic injury, ileus, and toxic dilation.

Antimicrobial options include oral metronidazole or vancomycin for 10 days. Antibiotic treatment should be oral, since C. difficile is restricted to the lumen of the colon. If IV treatment is necessary because the patient cannot tolerate oral medication or a feeding tube, only metronidazole is effective. Vancomycin should not be given intravenously because effective colonic luminal concentrations cannot be attained by this route.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 13 of 30.

In this image and video clip, an infusion of yogurt is applied through of the working channel of the colonoscope as observed here.

(There have also been anecdotal reports of success with yogurt enemas.)

Yogurt contain pro-biotic microorganisms – such asLactobacillus casei, Lactobacillus acidophilus and Bifidobac terium longum.

Restoration of Human Bowel Flora (Human Probiotics Infusion).

The treatment uses bowel flora (feces) homogenized in sterile saline, often filtered, and the slurry containing the total living protective bacteria is infused into the bowel of the patient. This can be done through a colonoscope under sedation, via enema, or through a naso-jejunal tube to take care of the small bowel reservoir of CD.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 14 of 30.

(One week after the specific treatment second endoscopy)

Probiotics are live microorganisms consisting of non-pathogenic yeast and bacteria that are believed to restore the microbial balance of the gastrointestinal tract altered by infection with Clostridium difficile (C. difficile).

Enemas with human stool have been suggested as a means of reconstituting normal flora, but this approach lacks aesthetic appeal and carries the risk of transmitting infection.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 15 of 30.

Colonic ulcer with exudate and mucus retention.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 16 of 30.

Digital print pattern of the colonic glands with mucus and exudate.

Pseudomembranous Colitis

Video Endoscopic Sequence 17 of 30.

Colonic ulcer with purulent exudate.

Pseudomembranous Colitis

Video Endoscopic Sequence 18 of 30.

(Third Colonoscopy)

Twenty days after the specific treatment was initiated, a second follow up colonoscopy was performed, this endoscopy was carry out in ambulatory basis.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 19 of 30.

(Third look)

There are some pseudomembranes and small ulcer are observed in this image.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 20 of 30.

(Third Colonoscopy)

A close up with magnyfing colonoscope.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 21 of 30.

Practically most of the Pseudomembranes have been disappeared observing most of the lesion are in phase of remission.

Toxic megacolon is well-established as an unusual presentation of C. difficile colitis. These patients are less likely to present with typical symptoms such as diarrhea or typical risk factors like recent administration of antibiotics, so diagnosis can be a challenge. A patient presenting with toxic megacolon without a history of inflammatory bowel disease should be assumed to have C. difficile colitis until proven otherwise, and medical or surgical therapy administered accordingly.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 22 of 30.

(Third Colonoscopy)

Again a follow up endoscopy

Smaller plaques, but already confluent.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 23 of 30.

(Third Colonoscopy)

 

Pseudomembranous Colitis

Video Endoscopic Sequence 24 of 30.

Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy.

Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with endileostomy, although the mortality rate remains high.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 25 of 30.

In spite of twenty days of treatment and improvement of the symptoms there are some ulcerated lesions in phase of remission.


Pseudomembranous Colitis

Video Endoscopic Sequence 26 of 30.

There are still some raised reddened lesions with scanty Pseudomembranes.

 

Pseudomembranous Colitis

Video Endoscopic Sequence 27 of 30.

Confusing Terminology

Antibiotic-associated diarrhea

C. difficile is only one cause

Clostridium difficile-associated diarrhea

diarrhea + positive stool test

Clostridium difficile colitis

underlying pathologic process

Pseudomembranous colitis
- endoscopic demonstration of exudative lesions

Toxic megacolon
-radiologic and surgical diagnosis

 

Pseudomembranous Colitis

Video Endoscopic Sequence 28 of 30.

Unproven therapies

Tapering course of standard antimicrobials

Yeast (Saccharomyces boulardii) with AB

Cholestyramine

Lactobacillus acidophilus

Nontoxigenic C. difficile (oral)

Bacterial enemas

Rectal infusion of normal feces

 

Pseudomembranous Colitis

Video Endoscopic Sequence 29 of 30.

(Third Colonoscopy)

 

Pseudomembranous Colitis

Video Endoscopic Sequence 30 of 30.

(Third Look)

Pseudomembranous colitis was first described in 1893 when a patient with severe diarrhea was found to have "diphtheritic colitis" at autopsy. The condition was attributed to mucosal ischemia or viral infection until 1977, when it was reported that stool specimens from affected patients contained a toxin that produced cytopathic changes in tissue-culture cells. Within a year of that report, C. difficile, a spore-forming, gram-positive, anaerobic bacillus, was identified as the source of the cytotoxin.

 

Pseudomembranous Colitis

Endoscopic View of Pseudomembranous Colitis

A 26 year-old man, who was under course of antibiotic therapy underwent a watery diarrhea and sepsis.

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

Pseudomembranous Colitis.

A 43 year-old woman, Suffering of deformed rheumatoid arthritis, 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 showing.


image and video clip.

 

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