PSEUDOMEMBRANOUS COLITIS REQUIRING SURGICAL INTERVENTION FOLLOWING TRIPLE THERAPY FOR

HELICOBACTER PYLORI

ERADICATION

R

AKESH

R

AI

*

AND

S

UNDEEPA

R

AI

†

*Liver Transplant Unit, Freeman Hospital, Newcastle and

†

General Surgery, Crosshouse Hospital, Kilmarnock, UK

Key words:

Clostridium difficile

,

Helicobacter pylori

, pseudomembranous colitis.

Abbreviation

: PMC, pseudomembranous colitis.

INTRODUCTION

Helicobacter pylori

infection of the stomach is being detected andtreated more often now than ever. The Maastricht Consensus Reportin its guidelines has broadened the indication for eradication of

H. pylori

infection to include certain patients with non-ulcer dyspepsia.

1

Recently, there has been an increasing number of reports ofpseudomembranous colitis (PMC) associated with differentcombination therapies (clarithromycin, omeprazole, and metroni-dazole; amoxycillin, metronidazole, bismuth subsalicylate andomeprazole) for eradication of

H. pylori.

2,3

In most of the cases,PMC was treated conservatively with successful outcome.

ANZ J. Surg.

2002;

72

: 917–919

CASE REPORT

918 ESLICK

ET AL

.

We report a case of atypical presentation of PMC followingtriple therapy (lansaprazole, metronidazole and clarithromycin)for eradication of

H. pylori

, which required surgical intervention.We have also reviewed the literature about

Clostridium difficile

colitis following

H. pylori

eradication.

CASE REPORT

A 43-year-old male patient was referred to the casualty depart-ment with a 3-day history of constipation, colicky abdominal painof 2 days duration associated with bilious vomiting. He was per-fectly well 3 days previously and had never had similar problemsin the past. He had attended another hospital 1 day before comingto our casualty department for the same problem. He was diag-nosed as having constipation and was prescribed bulk laxative.

One month before, he had undergone upper gastrointestinaltract endoscopy for dyspeptic symptoms in a different hospital.There was no evidence of ulcer on endoscopy, but CLO test waspositive. During the previous 7 days the patient had been takinglansaprazole (30 mg o.d), metronidazole (500 mg b.d) and clari-thromycin (500 mg b.d) for

H. pylori

eradication.On examination, he was apyrexial, and his pulse and blood

pressure were normal. The abdomen was distended and tender inthe right lower quadrant, bowel sound was decreased, but therewere no signs of peritonitis. Rectal examination showed an emptyrectum. Abdominal X-rays showed dilated large bowel loopsfrom the sigmoid colon to the caecum and faecal loading. ChestX-ray was normal. Routine blood tests, including white cellcount, haemoglobin, urea and electrolytes, were normal.

The patient was admitted and was kept nil orally; nasogastrictube aspiration was carried out and intravenous fluids werestarted. He was kept under close observation. Rigid sigmoidos-copy showed normal rectum up to 12 cm; examination beyondthat was unsuccessful because of faeces.

Within 24 h, the patient developed tachycardia and signs ofperitonism, and emergency laparotomy was carried out. Thewhole colon was hugely distended with thickened sigmoid colon,but there was no obstructive mass lesion. There was no perfora-tion and peritoneal contamination. A decompressive transversecolostomy was carried out. Postoperatively, colostomy was drain-ing watery stools. After a slight improvement in general con-dition 3 days postoperatively, his condition started deterioratingagain and he developed tachycardia, high temperature andabdominal signs of peritonitis. Emergency laparotomy wascarried out on the fourth day postoperatively. There was asmall perforation in the transverse colon and there were patchesof necrosis all over the colon. Subtotal colectomy and terminal

ileostomy was carried out. The patient made a successful recov-ery after surgery.

Histology of the resected large bowel showed classical featuresof PMC with evidence of necrosis suggestive of severe inflam-mation all through the large bowel.

DISCUSSION

Clostridial colitis is increasing in incidence, possibly because ofincreases in antibiotic usage. It represents a significant health-care burden and causes significant morbidity and mortality.4However, C. difficile infection in patients treated outside hospitalis very rare. The incidence of C. difficile infection among patientsin the community treated with an oral antimicrobial agent hasbeen reported as 1–3 individuals per 100 000, compared with1–10% of hospitalized patients.5,6

The most common presentation of PMC is crampy abdominalpain and watery diarrohea.7 Several authors have reported thatpatients with PMC may present with systemic toxic effects andsigns of acute abdomen with or without the characteristic diar-rohea.8,9 This case shows an atypical presentation of PMC pre-senting with constipation without any signs of systemic toxicity.Within 24 h, the patient developed signs of toxic megacolon.Thus, constipation may be the early sign of progressive ileusdue to severe colitis, which later results in toxic megacolon orperitonitis.

There have been seven reports of clostridial colitis afterH. pylori eradication in the literature, involving eight patients(Table 1).

There have been two deaths from severe clostridial colitisfollowing H. pylori eradication therapy.10 In one patient, diarrhoeapersisted even after treatment with metronidazole, vancomycin andyeasts, and the patient died 1 month after infection. In another case, apatient died of pulmonary embolism while receiving treatment forclostridial colitis. Out of the eight reported cases, seven patients werealready on metronidazole for H. pylori eradication before developingclostridial colitis.3,11–14 In our case, the patient had also taken metron-idazole as one of the drugs for eradication treatment, but even thendeveloped C. difficile colitis. This is interesting as oral metronidazoleis the first drug of choice to treat C. difficile colitis. Metronidazole isan inexpensive and effective treatment. When used orally (250–500 mg 4 times daily, or 500–750 mg 3 times daily for 7–10 days),metronidazole has response and relapse rates comparable with thoseof vancomycin.15–17 Because of the cost of vancomycin and concernsabout the development of vancomycin resistance in other organismssuch as enterococci, metronidazole is the preferred first line of treat-ment.18 However, metronidazole has more adverse effects and is not

Table 1. Reported cases of Clostridium difficile colitis following Helicobacter pylori eradication

Reference No. patients

Age (years)

Drugs for eradication Presentation Treatment

Lau et al.11 1 73 Lansoprazole, amoxycillin, clarithromycin Anaemia VancomycinHarsch et al.12 1 86 Omeprazole, metronidazole, clarithromycin Diarrhoea VancomycinNawaz et al.3 1 67 Metronidazole, amoxycillin, ranitidine,

bismuth subsalicylateDiarrhoea Metronidazole

Roseveare et al.13 1 40 Bismuth chelate, metronidazole, amoxycillin Diarrhoea, peritonitis Subtotal colectomy, vancomycinArchimandritis et al.2 1 54 Omeprazole, metronidazole, clarithromycin Diarrohea Metronidazole yeastTeare et al.10 2 77, 78 Clarithromycin, metronidazole Diarrohea Metronidazole vancomycin, yeastAwad et al.14 1 61 Metronidazole, amoxycillin, bismuth Severe colitis Vancomycin

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CEREBELLOPONTINE ANGLE ARACHNOID CYST 919

recommended for children or pregnant women. It has been suggestedthat if there is no response after 2–3 days of metronidazole therapy,metronidazole should be switched to vancomycin because someC. difficile organisms are resistant to metronidazole.19

Parenteral therapy is less effective than oral therapy, but whenit is necessary (e.g. paralytic ileus), intravenous metronidazole(500–750 mg 3–4 times daily) is recommended, perhaps supple-mented by vancomycin, (500 mg 4 times daily), via a nasogastrictube or enema.20,21

As metronidazole resistance has been reported in cases ofC. difficile colitis, it may be one reason for C. difficile colitis afterH. pylori eradication treatment even when metronidazole hasbeen used in combination with other drugs.

Our report shows that H. pylori treatment can lead to life-threatening PMC requiring emergency surgery. Subtotal colec-tomy is the treatment of choice in such cases as has been previ-ously reported.15,22 This case highlights the issue that treatment ofa common condition can lead to a life-threatening complication.As more and more patients are treated for H. pylori infection,such complications may not be a rare event. Every physician pre-scribing treatment for H. pylori must be aware of the possiblecomplications in order to detect and treat it early.

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20. Oliva SL, Guglielmo BJ, Jacobs R, Pons VG. Failure of intra-venous vancomycin and intravenous metronidazole to preventor treat antibiotic-associated pseudomembranous colitis [letter].J. Infect. Dis. 1989; 159: 1154–5.

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