Acute fulminant pseudomembranous colitis which developed after ileostomy closure and required emergent total colectomy: a case report (Journal of Medical Case Reports)

IntroductionPseudomembranous colitis is known to be caused by Clostridium difficile; and, in 3-8% of patients, it lapses into an aggressive clinical course that is described as fulminant. We present herein a case of extremely rapid and fatal fulminant pseudomembranous colitis that developed after ileostomy closure, a minor surgical procedure. To the best of our knowledge, this is the first case report of fatal fulminant pseudomembranous colitis after closure of diversion ileostomy in an adult.Case presentationA 69-year-old man who had previously undergone low anterior resection and creation of diverting ileostomy for stage III rectal carcinoma was admitted for ileostomy closure. Preoperatively, he received oral kanamycin and metronidazole along with parenteral cefmetazole. The surgery and postoperative course were uneventful until the third postoperative day, when fever and watery diarrhea became apparent. The next day he presented epigastric and left lower abdominal pain. Computed tomography revealed a slightly distended colon. Later that night, his blood pressure fell and intravenous infusion was started.In the early morning of the fifth postoperative day, his blood pressure could be maintained only with a vasopressor. Follow-up computed tomography demonstrated severe colonic dilation. Colonoscopy confirmed the presence of pseudomembranous colitis, and so oral vancomycin was administered immediately. However, within 3 hours after the administration, his condition rapidly deteriorated into shock. Although emergent total colectomy with creation of an end ileostomy was performed, the patient died 26 hours after the surgery. The histopathological examination was consistent with pseudomembranous colitis. Conclusion: It is important to recognize that, although rare, there is a type of extremely aggressive pseudomembranous colitis in which the usual waiting period for medical treatment might be lethal. We consider that colonoscopy and computed tomography are helpful to decide the necessity of emergent surgical treatment without delay.