Case Report Metastatic Lobular Breast Cancer Mimicking Colitis
An unusual case of colitis
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Transcript of An unusual case of colitis
An unusual case of colitisAn unusual case of colitis
DM, 55yoDM, 55yo
Previously well woman was referred by GP for lower abdominal pain and vomiting
Noticed increasing flatus 5/7 priorLoose BM x 3/7 relieved by immodiumCrampy abdominal pain ++Multiple episodes of N+V
HistoryHistory
Nil anorexia/weight lossNo recent exposure to C.difficile or
gastroenteritis No recent travelLast antibiotic use was 6/12 ago –
flucloxacillin & amoxicillin for paronychia
Past Medical/Surgical HxPast Medical/Surgical Hx
PMHx/PSHx: Cholecystectomy
Meds: Nil
Allergies: NKDA
FHx: Nil
SHxSHx
Married, no childrenNon-smokerNon drinker
O/EO/E
HR: 116 bpm, regularBP: 120/64 mmHgRR: 20/minT: 36.3 CSats: 98% RA
O/EO/E
Normal heart and chest exams
Abdomen: Moderately distended Soft Generalised tenderness maximal over lower
abdomen. Guarding present over same area Tinkling BS PR normal
Blood investigationsBlood investigations
Hb: 11.3 WCC: 9.26 Urea: 8.3 Na: 131 K: 3.4 Cr: 8.6 CRP: 541
Bili : 8 ALT : <10 Alk Phos : 20 Amylase : 29
RadiologyRadiology
CXR showed prominent bowel loop beneath left hemidiaphragm
PFA – grossly distended loops of bowel
DdxDdx
Colitis (infective vs inflammatory)
Gastroenteritis
Initial managementInitial management
Aggressive fluid resuscitationNGTClose monitoring of fluid balanceIV hydrocortisone, IV ciprofloxacin, IV
metronidazole and oral vancomycinUrgent CT abdomen done on 17/6/9
CT abdomenCT abdomen
Oedematous, fluid filled right colonFree fluid in abdomen and loculated
collection in pouch of DouglasBilateral ovarian cystsBilateral pleural effusions
Flexi sigmoidoscopyFlexi sigmoidoscopy
Normal mucosaNo distal colitisFull colonoscopy not performed due to risk
of perforation
CourseCourse in hospital in hospital
Within 24 hours of admission, patient developed tachypnoea, RR: 26 and raised JVP. Coarse bibasal creps. BP: 137/89, HR: 100 bpm
R/v by respiratory team – Acute Lung InjuryTransferred to ICU
Microbiology and IDMicrobiology and ID
C. diff toxin negative?infective vs inflammatory processDecision: treat until C. diff can be r/oIV metronidazole, PO vancomycin for
C.difficile IV piperacillin/tazobactam in case of
abdominal sepsis
Microbiology and IDMicrobiology and ID
Day 9 post admission, Clostridium perfringens was isolated from 3 faeces samples taken on 17/6/9
Clindamycin was added on to antimicrobial therapy.
Course in hospital Course in hospital
Patient showed definite improvement clinically while on clindamycin
Abdominal pain was settling, but abdomen was getting progressively distended with ascites
Weight– 80kg. Abdominal girth - 105cm
DischargeDischargePatient improved clinically with good
nutrition and appropiate antibiotics.
Discharged to convalescence f/u in OPD. Abdo girth 92cm. Weight 60kg.
Provisional final diagnosis: Acute colitis possibly secondary to Clostridium perfrigens
IntroductionIntroduction
Aetiology of colitis:
1. Inflammatory- Ulcerative colitis- Crohn’s disease - Indeterminate colitis
2. Ischaemic
IntroductionIntroduction3. Infective:-Enterotoxigenic E. coli-Shigella-Salmonella-Campylobacter-C. difficile-Yersinia enterocolitica
4. Radiation
Clostridium perfringens colitisClostridium perfringens colitis
Clostridium perfringens colitisClostridium perfringens colitis
C. perfringens produces at least 17 types of exotoxins (Type A, Type B, Type C etc)
250,000 cases of mild, self limiting gastroenteritis in the US caused by C perfringens Type A
‘Pigbel’ disease – necrotising enteritis associated with C perfringens Type C in severely protein deprived population in the Pacific – often fatal
Sobel J et al. Necrotizing enterocolitis associated with clostridium perfringens type A in previously healthy north american adults. J Am Coll Surg. 2005 Jul;201(1):48-56.
Bos J et al. Fatal necrotizing colitis following a foodborne outbreak of enterotoxigenic Clostridium perfringens type A infection. Clin Infect Dis. 2005 May 15;40(10):e78-83. Epub 2005 Apr 14.
Disease process: 1. Ingestion of food containing preformed toxins, 2. overgrowth of C. perfringens post antibiotic therapy1 or sporadically leading to disease in susceptible hosts
Diagnosis: C. perfringens growth in culture and isolation of toxin
Treatment: Metronidazole +/- clindamycin
1. Borriello SP, Larson HE, Welch AR, Barclay F, Enterotoxigenic Clostridium perfringens: a possible cause of antibiotic associated diarrhoea. Lancet 1984;1:305-7
Future?Future?
Siggers RH et al. Early administration of probiotics alters bacterial colonization and limits diet-induced gut dysfunction and severity of necrotizing enterocolitis in preterm pigs. J Nutr. 2008 Aug;138(8):1437-44.
Medical studentsMedical students
Remember the aetiology of colitisDifferential diagnosis of lower abdominal
pain & distensionTreatment for C. perfringens colitis