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Difficulty: Very hardGastroenterology and Hepatology

A 74-year-old woman is evaluated in the intensive care unit for rapidly worsening abdominal distension and shock. She was admitted 10 days ago for community-acquired pneumonia and was treated with a 5-day course of intravenous ceftriaxone and azithromycin. Four days ago, she developed profuse, watery diarrhea and tested positive for *Clostridioides difficile* toxin. She was started on oral vancomycin therapy.

Over the past 12 hours, her diarrhea abruptly ceased, but she became increasingly lethargic and her abdomen became massively distended. She is now mechanically ventilated due to encephalopathy and shock. Her son, who is her legally appointed healthcare proxy, is at the bedside. The patient has a living will from five years ago stating she would refuse major surgery. However, her son states, "Right before she was intubated today, she explicitly told me to authorize any surgery necessary to survive this."

Temperature is 39.4°C (102.9°F), blood pressure is 78/45 mmHg (while receiving a high-dose norepinephrine infusion), and pulse is 132/min. The abdomen is tympanitic, markedly distended, and rigid, with diffuse rebound tenderness. Bowel sounds are absent.

Laboratory results:
Leukocytes: 45,000/mm345,000 / \text{mm}^3 (25% band forms)
Serum lactate: 6.8 mmol/L6.8 \text{ mmol/L}
Arterial blood gas:
pH: 7.187.18
pCO 2_2: 25 mmHg25 \text{ mmHg}
HCO 3−_3^-: 9 mEq/L9 \text{ mEq/L}

Abdominal radiograph reveals a transverse colon diameter of 11 cm with mucosal edema and loss of haustral markings. No free intraperitoneal air is visible.

Which of the following is the most appropriate next step in management?

  1. Subtotal colectomy with end ileostomyAnswer
  2. B
    Administration of high-dose nasogastric vancomycin, intravenous metronidazole, and vancomycin retention enemas
  3. C
    Escalation of antimicrobial therapy to intravenous meropenem, vancomycin, and anidulafungin
  4. D
    Transition to comfort-focused care in accordance with the documented living will
  5. E
    Urgent colonoscopic decompression of the dilated transverse colon

Answer

Subtotal colectomy with end ileostomy
This patient has fulminant Clostridioides difficile colitis complicated by toxic megacolon (transverse colon > 6 cm, abrupt cessation of diarrhea, rigid abdomen) and refractory septic shock. While maximal medical management (enteral vancomycin and intravenous metronidazole) is the initial therapy for severe C. difficile, this patient exhibits absolute indications for emergent surgery: hemodynamic instability requiring vasopressors, severe lactic acidosis (lactate > 5 mmol/L), marked leukocytosis (> 35,000/mm³), and peritonitis. The standard surgical procedure of choice is a subtotal colectomy with end ileostomy, which provides source control and is life-saving. Furthermore, the son's authorization for surgery is legally and ethically valid; recent, specific verbal wishes expressed to a legally appointed proxy supersede older written advance directives.

Step-by-Step Solution

1
Diagnose the complication
Fulminant Clostridioides difficile colitis with toxic megacolon
Patient presents with cessation of diarrhea, massive colonic dilation (>6 cm), extreme leukocytosis, and shock after initial C. difficile diagnosis.
2
Assess clinical stability and surgical indications
Patient requires emergent surgery
Presence of peritonitis (rigid abdomen), refractory shock on vasopressors, and severe lactic acidosis (lactate > 5 mmol/L) indicate impending perforation and medical failure.
3
Evaluate the ethical constraint regarding the patient's living will
Surgery is ethically and legally authorized
Recent, specific verbal wishes expressed by a competent patient to their legally appointed proxy supersede older, conflicting written advance directives.
4
Select the definitive intervention
Subtotal colectomy with end ileostomy
This is the standard-of-care life-saving surgical procedure for toxic megacolon secondary to fulminant C. difficile colitis.

Key Concept

Surgical indications for fulminant C. difficile colitis (Toxic Megacolon)
Estimated Time:1m 30s
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Topics

Gastroenterology and Hepatology

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