PICTURES IN DIGESTIVE PATHOLOGY

 

Nodular colitis: endoscopic image, an unusual finding

Colitis infecciosa nodular: un hallazgo inusual

 

 

Luz Andrea Loza-Vargas¹, Henar Núñez-Rodríguez¹, Marina Benito-Sanz¹, Tomás Zamora-Martínez², Pilar Díez-Redondo¹ and Manuel Pérez-Miranda¹

Services of ¹Gastroenterology and
²Pathology. Hospital Universitario "Río Hortega". Valladolid, Spain

 

 

An 82-year-old male with a history of high blood pressure, COPD, chronic myeloid leukemia, and stage-4 chronic renal failure. Admitted to hospital for lower-limb cellulitis and severe COPD exacerbation, he received antibiotic therapy and bronchodilators. During his hospital stay he developed severe anemia and had a hematochezia event with no diarrhea.

A complete colonoscopy found small (4-7 mm) nacreous elevated lesions, circumferential in shape, in the cecum and ascending colon with some bleeding stigmata and submucosal bleeding suggestive of infectious colitis (Fig. 1). Stool culture was negative and Clostridium difficile toxins were positive. The condition was histologically confirmed (Fig. 2).

 

 

 

Infection with Clostridium difficile has a variable clinical presentation and a highest incidence among populations with risk factors (advanced age, antibiotic use, and comorbidity). The diagnosis is based on clinical and microbiological criteria (1,5).

Endoscopic study is a useful, fast diagnostic method for advanced infection by direct visualization (5). Typical (theoretical) findings include pseudomembranes, which look like strongly adhering plaques with a yellowish or white relief and up to 2 cm in diameter, which may be covered by mucus, as well as intestinal wall edema, erythema, friability and inflammation (4). It may affect the whole large intestine but is usually seen in the left colon, sigma and rectum (5).

We report this clinically unusual endoscopic image based on its characteristics and location. In 20-30% of cases, lesions involve the right colon (2,5). Findings are similar to those reported for infection with Clostridium difficile in immunocompromised patients (3).

In conclusion, in the presence of similar endoscopic findings C. difficile infection should be suspected, even though endoscopy is not a first-choice modality in this setting. However, it provides a diagnosis in severe cases or in patients with high clinical suspicion and a negative or inconclusive microbiological study.

 

References

1. Surawicz C, Brandt L, Binion D, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013;108:478-98. DOI: 10.1038/ajg.2013.4.         [ Links ]

2. Fauci AS, Braunwald E, Kasper DL. Principios de Medicina Interna. 16^a ed. México DF: Mc-Graw Hill Interamericana Editores; 2009. p. 851-4.         [ Links ]

3. Younus F, Steigbigel R. Nodular Clostridium difficile colitis. N Engl J Med 2004;350:e9. DOI: 10.1056/ENEJMicm010423.         [ Links ]

4. Korman TM. Diagnosis and management of Clostridium difficile infection. Semin Respir Crit Care Med 2015;36:31-43. DOI: 10.1055/s-0034-1398741.         [ Links ]

5. Vázquez-Iglesias. Endoscopia digestiva diagnóstica y terapéutica. 1^a ed. Madrid: Editorial Médica Panamericana; 2009. p. 637-54.         [ Links ]