Outcomes following colectomy for Clostridium difficile colitis
Shirley Chana,*, Mark Kellyb, Sophie Helmec, James Gossaged, Bijan Modaraie, Matthew Forshawa
aDepartment of General Surgery, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
bDepartment of General Surgery, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
cDepartment of General Surgery, Queen Elizabeth The Queen Mother Hospital, St Peter’s Road, Margate CT9 4AN, UK
dDepartment of General Surgery, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
eDepartment of General Surgery, Medway Maritime Hospital, Windmill Road, Gillingham, Kent ME7 5NY, UK
a r t i c l e i n f o
Received 9 September 2008
Received in revised form
12 November 2008
Accepted 18 November 2008
Available online 27 November 2008
a b s t r a c t
Introduction: Clostridium difficile associated diarrhoea has become an important health problem in UK
hospitals but surgical intervention is rarely required. There is little evidence regarding best practice for
patients requiring surgical intervention. The aim of this multicentre study was to review our experience
in patients requiring surgery for C. difficile colitis.
Methods: Patients who underwent surgery for C. difficile colitis in 5 hospitals in Southeast England over
a 7-year period (1 teaching hospital and 4 district general hospitals) were identified from histopathology
databases. Data were collected regarding the presentation, indication for surgery and post-operative
Results: 15 patients (9 males; mean age¼71 years (range 35–84 years)) underwent surgery. 46% of
patients (n¼7) contracted C. difficile during their hospital admission for other medical reasons and 73%
of patients were initially admitted under other medical specialties. Diagnosis was only made preoper-
atively in 8 patients (53%). Indications for surgery were peritonitis and systemic toxicity (n ¼12), failure
of medical management (n¼2) and unresolving large bowel dilatation (n¼1). 12 patients underwent
total colectomy and the rest underwent segmental resection. All patients were admitted to the intensive
care unit post operatively with a mean stay of 6 days. 2 patients needed a second look laparotomy.
Mortality rate was 67% (n¼10), with all but 1 patient dying within the 30-day mortality period. The
mean length of hospital stay of survivors was 30 days (range 17–72).
Conclusions: Surgical intervention for C. difficile colitis remains uncommon. Total colectomy and end
ileostomy is the procedure of choice. The outlook for patients requiring surgery remains poor.
? 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Clostridium difficile is an anaerobic spore-forming gram positive
bacteria. It is the most common cause of infectious diarrhoea in
hospitalised and institutionalised patients.1It is resistant to alcohol
and, importantly, can only be eliminated by good hand washing. It
is common in surgical patients due to antibiotic usage. Broad
spectrum penicillins and cephalosporins are common aetiological
factors although the use of nearly all antibiotics has been impli-
cated.2,3Exposure to the normal commensal gut flora to antibiotics
allows colonisation of the gut with C. difficile and production of
enterotoxins. Symptoms arise from these enterotoxins producing
an inflammatory response in the gut mucosa. Symptoms can range
from asymptomatic colonisation to mild diarrhoea to severe colitis
associated with the formation of pseudomembranes (Fig. 1). The
vast majority of patients respond to conservative management
with either oral metronidazole or vancomycin, although in more
recent years a hypervirulent strain (the NAP1/027 strain) has
emerged which is resistant to fluoroquinolones and has an
increased mortality rate.4
A small proportion of patients infected with C. difficile mayfail to
settle with medical treatment and then may go on to develop
severe fulminant C. difficile colitis. The diagnosis of fulminant colitis
may be made endoscopically or radiologically in conjunction with
a positive C. difficile toxin.5,6Those patients who exhibit symptoms
and signs of sepsis or peritonism or develop complications such as
perforation or bleeding may require prompt surgical intervention.
In some cases, an emergency laparotomy is performed for perito-
nitis without a preoperative diagnosis of C. difficile colitis and the
diagnosis is only subsequently made histological.
There is little data regarding outcome of patients who have had
colectomy for C. difficile colitis. Mortality rates have been reported
* Corresponding author. Department of General Surgery, Guy’s and St Thomas’
NHS Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK.
Tel.: þ44 020 7188 7188.
E-mail address: firstname.lastname@example.org (S. Chan).
Contents lists available at ScienceDirect
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1743-9191/$ – see front matter ? 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
International Journal of Surgery 7 (2009) 78–81
to be as high as 80%.7There is also no standard procedure of choice
for this condition although total colectomy with end ileostomy
appears to be associated with a lower mortality and morbidity rate
than segmental resections.8,9Therefore the aim of this multicentre
study was to review our experience in patients requiring surgery
for C. difficile colitis.
Data were collected from 5 hospitals in Southeast England (1
teaching hospital and 4 district general hospitals) over a 7-year
period from 2000 to 2007. Patients who underwent surgery for
were collected regarding patient demographics, clinical presenta-
tion, laboratory indices and microbiological diagnosis. Indication for
surgery, type of surgery performed and post-operative outcomes
3.1. Patient demographics
Fifteen patients (9 males; mean age¼71 years (range 35–84
years)) were identified from our five hospitals during the study
period (total catchment population of approximately 2.8 million).
10 patients were admitted under the care of other medical teams
and transferred to the care of the general surgeons. 5 patients were
admitted directly under the care of the general surgeons with
abdominal pain and distension. Of these 15 patients, 6 patients
presented with signs and symptoms consistent with C. difficile
infectionwhile 8 patients contracted C. difficile during theirhospital
admission for other reasons. 6 patients had their diagnosis
confirmed by positive stool toxin while 2 patients were diagnosed
byendoscopicfindings of pseudomembranous
remaining 7 patients’ diagnoses were made histologically after
colectomy. 14 out of the 15 patients were on broad spectrum
antibiotics prior to diagnosis with the remaining 1 patient on an
antifungal prior to diagnosis (see Table 1). Metronidazole was first
line treatment in 12 patients (80%) with vancomycin being used as
treatment in the remaining 3 patients.
3.2. Clinical and laboratory findings
Diarrhoea was reported in 9 out of 15 patients. The remainder
had abdominal pain and distension. The most common laboratory
Fig. 1. Colectomy specimen showing severe mucosal ulceration and pseudomembrane
Table 1Patient demographics and outcomes. Patient No
Duration of symptoms
Preoperative antibiotics Cipro,
Type of surgery
Renal failure No
Steroids aza No
No (but died
Length of stay (days)
Key: cipro¼ciprofloxacin, clarithro¼clarithromycin, fluclox¼flucloxacillin, benzxypen¼benzylpenicillin, cef¼cefuroxime, vanc ¼vancomycin, met¼metronidazole, flucon¼fluconazole, aza¼azathioprine.
S. Chan et al. / International Journal of Surgery 7 (2009) 78–8179
abnormality in our series was a raised urea and creatinine in 14
patients. A leucocytosis with a raised white cell count (WBC)
between 13.9 and 52.9 ?109/l (median WBC¼19.1?109/l) was
seen in 12 patients. 2 patients did not have a raised WBC due to
immunosuppression from steroid treatment or pre-existing renal
disease. 1 patient had a normal WBC despite not being immuno-
suppressed.12 patients had evidence of organ failure in at least one
system with 3 patients needing haemofiltration and 6 patients
needing inotropic support preoperatively. 9 out of 15 patients were
receiving critical care input on either HDU or ITU preoperatively.
Post operatively all patients were admitted to ITU.
Preoperative investigations included endoscopy (n¼2), plain
radiographs (n¼12) and CT scans (n¼4). Pseudomembranes were
seen on both patients undergoing flexible sigmoidoscopy. Large
bowel dilatation was seen in 10 patients on the plain abdominal
X-rays. One patient had no radiological findings of colitis and 1
patient had evidence of small bowel dilatation only. Of the CTscans
3 patients had features of colitis and 1 patient had thickened
oedematous small bowel loops. There was no radiological evidence
of perforation in any of the plain X-rays or CT scans.
3.3. Surgery and outcomes
Indications for surgery were peritonitis and systemic toxicity
(n ¼12), failure of medical management (n ¼2) and unresolving
large bowel dilatation (n ¼1). Mean time from onset of symptoms
to surgery was 5 days (range 1–21). 12 patients underwent total
colectomy and the rest underwent segmental resection (2 Hart-
mann’s procedures, 1 right hemicolectomy with double barrel
ileocolostomy). All patients were admitted to the intensive care
unit post operatively with a mean stay of 6 days (range 1–18 days).
2 patients needed a second look laparotomy: one for an ischaemic
stoma and the other for increasing metabolic acidosis with lapa-
rotomy findings of patchy ischaemic necrosis throughout the
remaining colon after right hemicolectomy. Mortality rate was
67% (n ¼10), with all but 1 patient dying within the 30-day
mortality period. The 9 patients who died within 30 days of
surgery all died from multi-organ failure. The patient who died
more than 30 days after surgery was discharged for rehabilitation
one month after colectomy but was readmitted 3 weeks later with
confusion and a urinary tract infection. He subsequently devel-
oped adhesional small bowel obstruction and was felt not to be fit
enough for further surgery and died two and a half months post
colectomy. The mean length of hospital stay of survivors was 30
days (range 17–72).
The incidence of C. difficile colitis appears to be rising both in
Europe and in the United States and Canada.10,11In the United
Kingdom the incidence of C. difficile infection has increased from
15,081 to 55,681 patients from 2000 to reach a peak in 2006.12This
is likely to be a consequence of both increasing use of broad
spectrum antibiotics, increasing awareness of this condition and
the introduction of mandatory reporting of all C. difficile infections
since 2004. The most important risk factors for C. difficile infection
are exposure to the hospital environment (especially ITU admission
and prolonged hospital stay) and antibiotic usage.1,13,14Other risk
factors predisposing to this condition also include increasing age
and the presence of comorbid disease.2,15,16
Due to the heightened awareness and media attention of
C. difficile infections in the UK the Healthcare Commission imple-
mented both the Saving Lives campaign17and The Health Act
200618to try and reduce C. difficile infections and other healthcare
associated infections. Recommendations to implement reduction in
C. difficile include prudent antibiotic prescribing, isolation of
patients and good infection control nursing (e.g. hand washing,
gloves and aprons) and enhanced environmental cleaning and use
of a chlorine containing disinfectant where there are cases of
C. difficile disease to reduce environmental contamination with the
Surgical intervention in terms of colectomy is rarely required in
patients with C. difficile colitis. Only 1–3.8% of patients infected
with C. difficile are reported to require colectomy.8,14,19However,
one series which specifically looked at critical care patients repor-
ted a colectomy rate of 20%.20Unfortunately, our hospital databases
were not sufficiently robust to allow us to determine the total
number of patients infected with C. difficile during the study period
Our mortality rate following colectomy was high (67%). It is
known that the outcome following colectomy for C. difficile colitis
is poor. Most series have reported mortality rates of 30–40%
although the mortality may reach 80%.7,21,22,23Some studies have
in patients who have undergone colectomy for C. difficile
colitis.24,25,26Lamontagne’s paper24compares ITU patients who
had undergone colectomy for CDAD matched to patients treated
in ITU with other medical problems. This group found that
leukocytosis >50, lactate >5, age >75 and shock requiring vaso-
pressors predicted 30-day mortality. In Byrn et al.’s paper25
univariate analysis determined that preoperative vasopressor
requirement, intubation, and mental state changes were signifi-
cant predictors of mortality and also that the group of patients
who died had a higher level of arterial lactate and longer length of
medical management. Our high rate of mortality may in some
part be accounted for by patient age and comorbidities but may
also be due to the need for emergency laparotomy without
a diagnosis. In our series 7 out of the 15 patients presented with
an acute abdomen require surgery without a preoperative diag-
nosis of C. difficile colitis. In four of these patients colitis or
C. difficile associated disease was suspected due to the presenting
complaint being diarrhoea and sepsis but no definitive diagnosis
Summary of previous reported series of colectomy for C. difficile.
Byrn et al.25
Hall and Berger26
Koss et al.7
Longo et al.27
Synnott et al.15
Lipsett et al.8
92% (n ¼67)
100% (n ¼36)
100% (n ¼14)
97% (n ¼65)
100% (n ¼5)
100% (n ¼13)
92% (n ¼11)
80% (n ¼58)
100% (n ¼36)
42% (n ¼6)
82% (n ¼55)
100% (n ¼5)
69% (n ¼9)
75% (n ¼8)
86% (n ¼63)
94% (n ¼34)
64% (n ¼9)
79% (n ¼53)
100% (n ¼5)
54% (n ¼7)
58% (n ¼7)
34% (n ¼25)
36% (n ¼13)
36% (n ¼5)
48% (n ¼32)
80% (n ¼4)
S. Chan et al. / International Journal of Surgery 7 (2009) 78–81 80
(either by positive stool toxin, radiologically or endoscopically) Download full-text
had been made before the need for surgery. The remaining 3
patients presented with peritonism necessitating laparotomy but
with no obvious diarrhoea. This is in keeping with a number of
already reported series25,27and further complicates the decision
making process for these patients. Two out of these four patients
had segmental resection rather than total colectomy and end
Experience in the surgical management of fulminant C. difficile
colitis is limited. Total colectomy rather than segmental resection
or non-resectional surgery such as ileostomy with placement of
catheters for irrigation of the colon, appears to be associated with
lower mortality rates.8,9,14,23As fulminant C. difficile colitis typically
causes pancolitis, segmental resection or non-resectional surgery
leaves behind diseased colon. In our series, the two patients who
underwent a second look laparotomy had segmental resections and
both were found to have ischaemia in the remaining colon. Our
numbers in this series are small. It was not possible to determine
the total numbers of patients who had contracted C. difficile asso-
ciated disease as our hospital databases were not robust enough
but our findings seem to reflect the general trends seen in other
Surgical intervention for C. difficile colitis remains uncommon
despite the growing incidence of disease due to C. difficile infection.
A proportion of patients will undergo emergency surgery without
a diagnosis. Having analysed our data and reviewed the literature
we would suggest having a low threshold of suspicion that patients
with C. difficile associated disease can go on to have fulminant C.
difficile colitis. Once diagnosed, early surgical intervention (if the
patient does not improve despite medical management) may
decrease mortality and morbidity. Total colectomy and ileostomy
should be considered to be the procedure of choice rather than
segmental resection. However, the outlook for patients requiring
surgery still remains poor.
Conflict of interest
The authors declare that they have no conflict of interests and have
received no financial support in writing this paper.
The authors declare that they have had no funding for this research.
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