P1323 - A Rare Case of Clostridioides difficile Enteritis in a Patient With Recurrent C. diff Status Post Loop Ileostomy

Abirami Thiyagarajan, MD¹, Ana Petrova, MD^2
1Ohio State University College of Medicine, Columbus, OH; ²Ohio State University, New Albany, OH

Introduction: Clostridoides difficile (C. diff) infection occurs in about 154 per 100,000 population and health care-associated C.diff infection occurs in 99.6 per 100,000 population. C. diff enteritis, however, is much rarer with about 32% mortality risk.

Case Description/Methods: A 58 year old female with a history of small cell lung cancer status post chemoradiation (four years prior), fulminant, recurrent C.diff status post loop ileostomy presents with altered mental status and acute kidney injury. One month prior to presentation, she presented with fulminant C. diff infection requiring diverting loop ileostomy and Pittsburgh protocol (vancomycin flushes into efferent limb of loop and intravenous Flagyl). She had also received oral vancomycin, and Fidaxomicin in the past for prior C. diff infections. She now presents with increased ostomy output. She empties the ostomy bag 2-3 times per day at baseline which has increased to emptying 6-7 times per day with dehydration, dizziness and confusion. C. diff PCR on admission was positive. Abdominal X-ray demonstrated gaseous dilation of small bowel loops. Subsequent CT scan demonstrated loop ileostomy and diffusely dilated small bowel loops extending to the ileostomy and decompressed colon.

The patient was started on Fidaxomicin without improvement. Fecal microbiota transplant was pursued due to concern for C.diff enteritis. Fidaxomicin was held and the patient underwent esophagogastroduodenoscopy with a 35ml stool sample flushed into jejunum about 100cm from the incisors. A few days later, the patients ostomy output became formed and decreased in frequency.

Discussion: C.diff enteritis is rare compared to C.diff colitis. Studies reviewing c.diff enteritis demonstrate that the median age of affected patients is around 55 years with 51% of patients with inflammatory bowel disease, 58% with a history of colectomy with ileostomy and 23% with a history of small and/or large bowel surgery. Older age and predisposing medical conditions were associated with mortality. This patient had multiple risk factors for C.diff including age, multiple underlying co-morbidities, history of prior C.diff infection and history of altered intestinal anatomy. She responded well to fecal microbiota transplant which was delivered via upper endoscopy due to her altered anatomy.


Disclosures:


Abirami Thiyagarajan, MD¹, Ana Petrova, MD². P1323 - A Rare Case of Clostridioides difficile Enteritis in a Patient With Recurrent C. diff Status Post Loop Ileostomy, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.