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Corresponding author: Jacques P. Heppell, MD, Department of Surgery, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (e-mail: heppell.jacques{at}mayo.edu).

Arch Surg. 2004;139:566.

Answer: Pseudomembranous Enterocolitis
Figure 1. Computed tomographic scan of the abdomen shows diffusely edematous bowel, hyperemic mucosa, and ascites.

View larger version (63K): [in this window] [in a new window] Figure 1.

Figure 2. Computed tomographic scan of the abdomen shows portal venous air.

View larger version (71K): [in this window] [in a new window] Figure 2.

Clostridium difficile is a gram-positive obligate anaerobe that produces 2 toxins: an enterotoxin (toxin A) and a cytotoxin (toxin B). Animal studies¹ demonstrate that both toxins are necessary for the clinical picture of antibiotic-associated colitis.

The presentation varies from an asymptomatic person who is a carrier to the patient with fulminate colitis. Clostridium difficile exists in an asymptomatic carrier state in approximately 3% of adults without evidence of toxin production.²

The possible causes for C difficile colitis include antibiotic therapy, human immunodeficiency virus infection, candidiasis, malignancy, chemotherapy, malnutrition, intestinal obstruction, decubitus ulcer, renal failure, and interventional procedures.³ The stool assay for cytotoxin is the most accurate method of diagnosis and has a sensitivity of 67% to 100% and a specificity of more than 85%.⁴ Because the assay results are not known for a few days, some authors suggest that endoscopy is more rapid and effective in establishing the diagnosis by its ability to demonstrate thick exudative plaques known as pseudomembranes.⁵ Findings on the computed tomographic scan include bowel wall thickening (>4 mm) and the presence of wall nodularity, fat stranding, or unexplained ascites. These findings have been reported to have a positive predictive value of 88%.⁶

The unique feature of our case was the distinctive pattern of portal venous gas identified on computed tomography of the abdomen, and a colectomy with ileostomy was performed.

Submissions Due to the overwhelmingly positive response to the "Image of the Month," the Archives of Surgery has temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid 2004. Thank you.

REFERENCES

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1. Libby JM, Jortner BS, Wilkins TD. Effects of the two toxins of Clostridium difficile in antibiotic-associated cecitis in hamsters. Infect Immun. 1982;36:822-829. FREE FULL TEXT 2. George WL, Sutter VL, Finegold SM. Toxigenicity and antimicrobial susceptibility of Clostridium difficile, a cause of antimicrobial agent–associated colitis. Curr Microbiol. 1978;1:55-58. 3. Buchner AM, Sonnenberg A. Medical diagnoses and procedures associated with Clostridium difficile colitis. Am J Gastroenterol. 2001;96:766-772. FULL TEXT | ISI | PUBMED 4. Marts BC, Longo WE, Venava AM, Kennedy DJ, Daniel GL, Jones I. Patterns and prognosis of Clostridium difficile colitis. Dis Colon Rectum. 1994;37:837-845. FULL TEXT | ISI | PUBMED 5. Fekety R, American College of Gastroenterology, Practice Parameters Committee. Guidelines for the diagnosis and management of Clostridium difficile–associated diarrhea and colitis. Am J Gastroenterol. 1997;92:739-750. ISI | PUBMED 6. Kirkpatrick ID, Greenberg HM. Evaluating the CT diagnosis of Clostridium difficile colitis: should CT guide therapy? AJR Am J Roentgenol. 2001;176:635-639. FREE FULL TEXT

SECTION EDITOR: GRACE S. ROZYCKI, MD