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Wiener-Well Y, Kaloti S, Hadas-Halpern I, Munter G, Yinnon AM. Ultrasound diagnosis of Clostridium difficile-associated diarrhea. Eur J Clin Microbiol Infect Dis 2015; 34:1975-8. [PMID: 26173691 DOI: 10.1007/s10096-015-2439-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/26/2015] [Indexed: 01/05/2023]
Abstract
Clostridium difficile colitis is diagnosed using an immunoassay or polymerase chain reaction (PCR) assay for toxins A/B. Since ultrasound is frequently used as a screening test for hospitalized patients suffering from different abdominal morbidities, we searched for sonographic indicators of C. difficile infection (CDI). In a prospective and blinded case-control study, abdominal ultrasound was performed on hospitalized patients for whom stool samples were sent for C. difficile toxin immunoassay. All patients with positive toxin were included as the case group and patients with negative toxin comprised the control group. Sonographic parameters of both groups were compared. Demographic variables of the 67 patients in the toxin-positive group were similar to those of the 71 patients in the toxin-negative group. The sonographic parameters which were found to be associated with CDI included colonic wall thickening, appearing in 61 (91%) patients of the toxin-positive group versus 15 (21%) patients of the toxin-negative group (p < 0.001), and also internal ring (24 versus 0%, p < 0.001), external ring (15 versus 0%, p < 0.001), ascites (24 versus 10%, p < 0.001), and diminution of large bowel content (16 versus 1%, p < 0.001). Bowel wall thickening had high positive and negative predictive values (0.80 and 0.90, respectively), while the other features had only high positive predictive values (0.7-1.0). Abdominal ultrasound may contribute to the diagnosis of C. difficile colitis in patients developing hospital-acquired diarrhea.
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Affiliation(s)
- Y Wiener-Well
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, P.O. Box 3235, Jerusalem, 91031, Israel.
| | - S Kaloti
- Radiology Department, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - I Hadas-Halpern
- Radiology Department, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - G Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - A M Yinnon
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, P.O. Box 3235, Jerusalem, 91031, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
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Ash L, Baker ME, O'Malley CM, Gordon SM, Delaney CP, Obuchowski NA. Colonic abnormalities on CT in adult hospitalized patients with Clostridium difficile colitis: prevalence and significance of findings. AJR Am J Roentgenol 2006; 186:1393-400. [PMID: 16632736 DOI: 10.2214/ajr.04.1697] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the prevalence of an abnormal colon on CT in adult inpatients with Clostridium difficile colitis, compare the clinical presentation of these patients, and determine whether CT findings predicted the need for surgical treatment. MATERIALS AND METHODS Over a 21-month period, 152 of 572 inpatients with C. difficile colitis were identified and had CT scans performed within 2 weeks of the diagnosis. These were independently and retrospectively reviewed by two reviewers. Those with colonic wall thickness greater than 4 mm were considered positive (CT-positive patients) and were further reviewed for specific findings in the colon. All 152 patients with CT scans were also retrospectively reviewed using the hospital information system for certain clinical parameters, admitting diagnoses, and reasons for scanning. The following were compared using several statistical tests: clinical parameters in CT-positive and CT-negative patients and surgical and nonsurgical groups to determine if positive scans or surgical treatment could be clinically predicted; specific CT findings in CT-positive patients to see if an association was found with clinical parameters or surgical treatment; and admitting diagnoses and reasons for scanning in scanned and unscanned populations to see which patients were more likely to undergo CT. RESULTS Seventy-six (50%) of 152 scanned hospitalized patients with C. difficile colitis were CT-positive. These patients most often had segmental involvement (50 [66%] of 76 patients), with the rectum (60 [82%] of 73 patients) and sigmoid colon (61 [82%] of 74 patients) most often affected. Positive scans were associated with increased WBC, abdominal pain, and diarrhea. Patients with signs and symptoms of infection or abdominal complaints were more likely to be scanned. No statistical correlation was found between specific CT findings and clinical parameters or clinical parameters and patients requiring surgery. There was no predictive value of specific CT findings for surgical treatment. CONCLUSION Half of the patients scanned had an abnormal CT, with segmental colonic disease more common than diffuse. Positive scans were more likely in patients with leukocytosis, abdominal pain, and fever. Specific CT findings did not correlate with clinical parameters and could not predict surgical treatment.
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Affiliation(s)
- Lorraine Ash
- Division of Radiology/Hb 6, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA
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Gonenne J, Pardi DS. Clostridium difficile: an update. ACTA ACUST UNITED AC 2005; 30:134-40. [PMID: 15793312 DOI: 10.1007/s12019-004-0009-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2003] [Accepted: 02/16/2004] [Indexed: 01/11/2023]
Abstract
Clostridium difficile causes a spectrum of diarrheal illness with the potential for major medical consequences. Although most cases respond quickly to treatment, C. difficile colitis may be severe and life threatening. Recurrent disease represents a particularly challenging problem.
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Affiliation(s)
- Jonathan Gonenne
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Abstract
The purpose of this study is to determine the role of CT in the evaluation and in detecting complications in patients with toxic megacolon. A retrospective analysis of CT findings of 18 consecutive patients with toxic megacolon was performed. Underlying etiology included 12 patients with pseudomembranous colitis (PC), four patients with ulcerative colitis and two patients with cytomegalovirus colitis. Eleven patients were HIV+. CT features, correlation with severity of disease and development of complications were analyzed. Colonic dilatation with intraluminal air and/or fluid with a distorted colonic contour or an ahaustral pattern was seen in all patients. In four patients (22%), CT depicted complications-two colonic perforations and two septic thrombosis of the portal system. Six patients died (33%), three of whom had the above complications. The presence and degree of submucosal edema (accordion sign, target sign), wall thickening, degree of dilatation, nodular contour and ascites did not correlate with clinical outcome. Two thirds of patients with toxic megacolon had PC as the underlying etiology. CT was helpful in depicting diffuse colitis, and it was instrumental in detecting life-threatening abdominal complications, contributing to the management of these patients. CT abnormalities cannot be used to predict the clinical outcome unless complications develop.
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Affiliation(s)
- M Imbriaco
- Department of Radiology and National Research Council, University Federico, Naples, Italy
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Abstract
Clostridium difficile is a spore-forming toxigenic bacterium that causes diarrhea and colitis, typically after the use of broad-spectrum antibiotics. The clinical presentation ranges from self-limited diarrhea to fulminant colitis and toxic megacolon. The incidence of this disease is increasing, resulting in major medical and economic consequences. Although most cases respond quickly to medical treatment, C difficile colitis may be serious, especially if diagnosis and treatment are delayed. Recurrent disease represents a particularly challenging problem. Prevention is best accomplished by limiting the use of broad-spectrum antibiotics and following good hygienic techniques and universal precautions to limit the transmission of bacteria. A high index of suspicion results in early diagnosis and treatment and potentially reduces the incidence of complications.
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Affiliation(s)
- S F Yassin
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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Gore RM, Miller FH, Yaghmai V, Berlin JW, Newmark G. Inflammatory conditions of the colon. Semin Roentgenol 2001; 36:126-37. [PMID: 11329655 DOI: 10.1053/sroe.2001.23047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- R M Gore
- Department of Radiology, Northwestern University Medical School, Chicago, IL, USA
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Kawamoto S, Horton KM, Fishman EK. Pseudomembranous colitis: spectrum of imaging findings with clinical and pathologic correlation. Radiographics 1999; 19:887-97. [PMID: 10464797 DOI: 10.1148/radiographics.19.4.g99jl07887] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pseudomembranous colitis (PMC) is a potentially life-threatening acute infectious colitis caused by one or more toxins produced by an unopposed proliferation of Clostridium difficile bacteria. PMC is characterized by the presence of elevated, yellow-white plaques forming pseudomembranes on the colonic mucosa. These plaques can be visualized at both pathologic analysis and endoscopy. Plain radiography, contrast enema studies, and computed tomography (CT) are useful in the evaluation of PMC. Plain radiography of the abdomen can demonstrate polypoid mucosal thickening, "thumbprinting" (wide transverse bands associated with haustral fold thickening), or gaseous distention of the colon. A toxic megacolon with distention and occasionally pneumoperitoneum may be seen in the most severe cases of PMC involving perforation. At contrast enema studies, the primary finding in mild cases of PMC is small nodular filling defects representing the mucosal plaques. With more extensive colonic involvement, the plaques are larger and coalesce to form an irregular bowel wall margin. Mural thickening and wide haustral folds caused by intramural edema may also be seen. A contrast enema study is contraindicated in patients with severe PMC due to the danger of perforation. Common CT findings include wall thickening, low-attenuation mural thickening corresponding to mucosal and submucosal edema, the "accordion sign," the "target sign" ("double halo sign"), pericolonic stranding, and ascites. Familiarity with these imaging characteristics may allow early diagnosis and treatment and prevent progression to more serious pathologic conditions.
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Affiliation(s)
- S Kawamoto
- Department of Radiology, Saitama Medical School, Japan
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Kawamoto S, Horton KM, Fishman EK. Pseudomembranous colitis: can CT predict which patients will need surgical intervention? J Comput Assist Tomogr 1999; 23:79-85. [PMID: 10050813 DOI: 10.1097/00004728-199901000-00017] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to determine if patients with pseudomembranous colitis (PMC) requiring surgical intervention demonstrate radiographic features distinct from those of patients treated successfully with standard medical therapy. METHOD The indications for a CT study and the imaging findings from 17 patients who required laparotomy with colon resection for PMC were retrospectively reviewed. The CT findings were compared with the findings from 17 control patients (matched by clinical presentation) with PMC who were treated medically and did not require surgical intervention. RESULTS None of the CT findings evaluated in this study were significantly different between the surgical and nonsurgical groups. The CT findings evaluated for the surgical and nonsurgical groups, respectively, were as follows: wall thickness of the colon: 17.8+/-6.6 and 16.9+/-3.9 mm; largest caliber of the colon: 6.8+/-1.6 and 6.1+/-1.2 cm; presence of the accordion sign: 52.9 and 70.6%; heterogeneous contrast enhancement pattern (target sign): 57.1 and 57.1%; pericolonic stranding: 82.4 and 88.2%; ascites: 70.6 and 58.8%; pleural effusion(s): 64.7 and 64.7%; and subcutaneous edema: 64.7 and 64.7%. CONCLUSION Although none of the CT findings evaluated in this study was significantly different between the surgical and nonsurgical groups, CT was often the initial diagnostic modality in both groups. It is important for radiologists to recognize the CT appearance of PMC and suggest the diagnosis. However, patient triage may not be based solely on the CT findings.
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Affiliation(s)
- S Kawamoto
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University Medical School, Baltimore, MD 21287, USA
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Abstract
The use of antibiotics in patients with cystic fibrosis is widespread, and fecal carriage of Clostridium difficile occurs in up to 50% of these patients; however, antibiotic-associated colitis appears to be a rare occurrence. The reasons why this is so remain unknown. A case of antibiotic-associated colitis occurring in a patient with cystic fibrosis is described. Possible mechanisms for the rarity of antibiotic-associated colitis are reviewed and implications for prompt diagnosis and therapy are discussed.
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Affiliation(s)
- C S Pokorny
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, N.S.W., Australia
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Affiliation(s)
- T K Oei
- Department of Radiology, Maastricht University Hospital, Netherlands
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Jones B, Wall SD. GASTROINTESTINAL DISEASE IN THE IMMUNOCOMPROMISED HOST. Radiol Clin North Am 1992. [DOI: 10.1016/s0033-8389(22)02509-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Gore RM. CT of Inflammatory Bowel Disease. Radiol Clin North Am 1989. [DOI: 10.1016/s0033-8389(22)02156-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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