An Unusual Case of Clostridioides Peritonitis From Small Intestinal Source

Document Type

Conference Proceeding

Publication Date

10-25-2023

Publication Title

Am J Gastroenterol

Abstract

Introduction: Clostridioides infection of the small bowel is rare. We present an unusual case of refractory multispecies Clostridioides enteritis and peritonitis following liver transplant in the setting of bowel obstruction. Case Description/Methods: A 62-year-old man with Crohn’s disease status post subtotal colectomy with end ileostomy and cryptogenic cirrhosis with hepatocellular carcinoma 1 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 Clostridioides 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 Clostridioides 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 Clostridioides with history of previous ileostomy and immunocompromised state from recent liver transplant with necrotic bowel. Previously reported cases of Clostridioides 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 Clostridioides involvement this renders a poor prognosis as seen with our patient.

Volume

118

Issue

10

First Page

S2326

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