P1145 - An Unusual Case of Clostridium Peritonitis From Small Intestinal Source

Sheema Rehman, DO¹, Ammad Chaudhary, MD¹, Nicolette Veracruz, MD¹, Eric Denha, MD¹, Julius Gumma, BS², Syed-Mohammed Jafri, MD^3
1Henry Ford Hospital, Detroit, MI; ²Michigan State University, Detroit, MI; ³Henry Ford Health System, Detroit, MI

Introduction: Clostridium infection of the small bowel is rare. We present an unusual case of refractory multispecies Clostridium enteritis and peritonitis following liver transplant in the setting of bowel obstruction.

Case Description/Methods: A 62 year old male with Crohn’s disease status post subtotal colectomy with end ileostomy and cryptogenic cirrhosis with hepatocellular carcinoma one month post orthotopic liver transplant presents with acute severe abdominal pain in setting of absent ostomy output, neutrophilic leukocytosis and elevated lactate. Imaging demonstrates mild small bowel dilation with apparent transition point. He is started on vancomycin and meropenum. He undergoes exploratory laparotomy with removal of 10cm of jejunum with patchy necrosis. Despite this, he develops refractory septic shock so he undergoes a second laparotomy. Fluid is sent for aerobic and anaerobic cultures. Ascitic fluid cultures show Clostridium difficile, butyricum and glycolicum. He is started on oral vancomycin and intravenous metronidazole for the enteritis and continued on meropenem to cover systemic clostridial infection. Eravacycline is added to cover for severe complicated clostridium. Repeat peritoneal fluid cultures two weeks later remains positive for clostridium so he is continued on oral vancomycin and switched from eravacycline to meropenem. Despite continued antimicrobial therapy, the patient has ongoing active infection with sepsis, multiorgan failure and ultimately passes away.

Discussion: Small bowel peristalsis and mechanical action of the ileocecal valve is thought to prevent colonization of the small bowel. In patients with altered small bowel anatomy, they may lose this protective function and thus bacterial colonization of the small bowel can start to resemble colon bacteria, increasing susceptibility to colonic pathogens. Our patient has many surgical factors increasing his risk for Clostridium with history of previous ileostomy and immunocompromised state from recent liver transplant with necrotic bowel. Previously reported cases of Clostridium in the small bowel postulate that ileal hypomotility and histologic changes in small intestine epithelium with alteration in fecal flow as seen in the setting of ileorectal anastomosis may predispose patients to this bacteria. Unfortunately, there is no clear antibiotic regimen for these patients and overall with small bowel Clostridium involvement this renders a poor prognosis as seen with our patient.


Disclosures:


Sheema Rehman, DO¹, Ammad Chaudhary, MD¹, Nicolette Veracruz, MD¹, Eric Denha, MD¹, Julius Gumma, BS², Syed-Mohammed Jafri, MD³. P1145 - An Unusual Case of Clostridium Peritonitis From Small Intestinal Source, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.