M&M Conference Michelle Hamel, PGY-5

Complication Complication: Death secondary to C difficile colitis Date: 4/25/2015 MRN: 6707357 Faculty/Resident: Goldberg, Aquilina/Hamel Procedure: total abdominal colectomy

Details of case Case: 73 y/o female w/ h/o COPD, DM, afib on eliquis, hypothyroidism, HTN and pacemaker placement, transferred from OSH to MCV on 4/22/15 with C diff colitis and parital small bowel obstruction. Outside hospital course: Patient presented to ED 4/20/15 c/o fever, abdominal pain and malaise. Patient had recently suffered ankle fracture on 4/8/15 and had been sent to rehab. Patient hypotensive to 69/38 in OSH ED. Found to have UA consistent with UTI. Was admitted and started on levofloxacin and ceftriaxone. WBC on admission was 35. On HD 2, patient passing liquid stool. C diff positive; transferred to MCV

Past histories PMH: COPD, DM, afib on eliquis, hypothyroidism, HTN, pacemaker placement PSH: gastric bypass, ankle ORIF, cholecystectomy SH: previous smoker and occasional EtOH Meds: Symbicort, bumetanide, digoxin, diltiazem, Cymbalta, gabapentin, glimepiride

Hospital course Patient transferred on 4/22/15. Patient c/o abdominal pain upon arrival to MCV; patient states that she has had intermittent abdominal pain/nausea and emesis since her gastric bypass in 1999, and this is near her baseline. She also states that she has had abdominal distension for 8 weeks and this is stable 1 episode of diarrhea while in ICU, then no further bowel movements.

Physical exam On arrival: Vitals: BP 88/50, T 37, HR 101, RR 19, Sat 99% on 2L Gen: Obese female in nad Abd: soft, mildly tender in LLQ and epigastrium, distended. No rebound or guarding

labs WBC 39.5 Hgb 11.4 Plt 725 Na 132 K 4.8 Cl 102 Bicarb20 BUN 33 Creat 1.53 Glu 196 Lactate 1.9

imaging

imaging

Hospital course Patient started on iv flagyl, PO vancomycin and vancomycin enemas NGT placed but with minimal output On HD 2, Patient’s abdominal exam remained benign. She was receiving fluid boluses and hypotension improved, but patient continued to have low UOP. WBC trended down to 32 from 39. No further diarrhea On am of HD 3, WBC increased to 56, patient became hypotensive again, requiring pressors and abdominal pain increased

Hospital course Patient taken to OR on am of HD 3. Toxic megacolon found intraoperatively with necrotic areas of colon. Murky fluid throughout abdomen with contained perforation in RLQ. Patient became more unstable during the case, with increased pressor requirements and with cardiac arrhythmias Colon resected, patient left in discontinuity and abthera placed

Hospital course Despite supportive care, patient became more unstable over the next day. Family made the patient DNR and patient expired on POD 1. Surgical Pathology: severe pseudomembranous colitis with areas of transmural necrosis

In individual studies, early operative intervention before development of shock or organ failure (pressors, renal failure, need for intubation, altered mental status) Conclusion: Significant reduction in mortality when operation performed before the need for vasopressors What type of operation should be performed? Total abdominal colectomy or subtotal colectomy associated with decreased mortality versus partial colectomy (weaker evidence)

Conclusions: In patient with C difficile colitis, consider operative management before patient develops pressor requirement or other signs of end organ dysfunction Consider total abdominal colectomy or subtotal colectomy at time of operation rather than partial colectomy

Analysis of complication Patient suffered delay in operative management of C. difficile colitis, resulting in death