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01-12-2019 | Clostridioides Difficile | ABDOMINAL RADIOLOGY

Clostridium difficile colitis: CT findings and differential diagnosis

Authors: Sara Guerri, Ginevra Danti, Gianluca Frezzetti, Edvige Lucarelli, Silvia Pradella, Vittorio Miele

Published in: La radiologia medica | Issue 12/2019

Abstract

Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.

Martin JSH, Monaghan TM, Wilcox MH (2016) Clostridium difficile infection: epidemiology, diagnosis and understanding transmission. Nat Rev Gastroenterol Hepat 13:206–216. https://doi.org/10.1038/nrgastro.2016.25 CrossRef

Di Bella S, Ascenzi P, Siarakas S, Petrosillo N, di Masi A (2016) Clostridium difficile Toxins A and B: insights into pathogenic properties and extraintestinal effects. Toxins (Basel) 8:134. https://doi.org/10.3390/toxins8050134 CrossRef

Depestel DD, Aronoff DM (2013) Epidemiology of Clostridium difficile infection. J Pharm Pract 26:464–475. https://doi.org/10.1177/0897190013499521 CrossRefPubMedPubMedCentral

Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B et al (2010) The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 23:529–549. https://doi.org/10.1128/cmr.00082-09 CrossRefPubMedPubMedCentral

Bartlett JG, Gerding DN (2008) Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Dis 46(Suppl 1):S12–S18. https://doi.org/10.1086/521863 CrossRefPubMed

Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al (2010) Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 31:431–455. https://doi.org/10.1086/651706 CrossRefPubMed

McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE et al (2018) Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 66:987–994. https://doi.org/10.1093/cid/cix1085 CrossRefPubMed

Centers for Disease Control and Prevention (CDC) (2005) Severe Clostridium difficile-associated disease in populations previously at low risk—four states, 2005. MMWR Morb Mortal Wkly Rep 54:1201–1205

Dupont HL (2013) Diagnosis and management of Clostridium difficile infection. Clin Gastroenterol Hepatol 11:1216–1223. https://doi.org/10.1016/j.cgh.2013.03.016quiz e73 CrossRefPubMed

10.

Burkart NE, Kwaan MR, Shepela C, Madoff RD, Wang Y, Rothenberger DA et al (2011) Indications and relative utility of lower endoscopy in the management of Clostridium difficile infection. Gastroenterol Res Pract 2011:626582. https://doi.org/10.1155/2011/626582 CrossRefPubMedPubMedCentral

11.

Abreu MT, Harpaz N (2007) Diagnosis of colitis: making the initial diagnosis. Clin Gastroenterol Hepatol 5:295–301. https://doi.org/10.1016/j.cgh.2006.12.032 CrossRefPubMed

12.

Farooq PD, Urrunaga NH, Tang DM, von Rosenvinge EC (2015) Pseudomembranous colitis. Dis Mon 61:181–206. https://doi.org/10.1016/j.disamonth.2015.01.006 CrossRefPubMedPubMedCentral

13.

Kirkpatrick ID, Greenberg HM (2001) Evaluating the CT diagnosis of Clostridium difficile colitis: should CT guide therapy? AJR Am J Roentgenol 176:635–639. https://doi.org/10.2214/ajr.176.3.1760635 CrossRefPubMed

14.

Horton KM, Corl FM, Fishman EK (2000) CT evaluation of the colon: inflammatory disease. Radiographics 20:399–418. https://doi.org/10.1148/radiographics.20.2.g00mc15399 CrossRefPubMed

15.

Fishman EK, Kavuru M, Jones B, Kuhlman JE, Merine DS, Lillimoe KD et al (1991) Pseudomembranous colitis: CT evaluation of 26 cases. Radiology 180:57–60. https://doi.org/10.1148/radiology.180.1.2052723 CrossRefPubMed

16.

Kirkpatrick ID, Greenberg HM (2003) Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. Radiology 226:668–674. https://doi.org/10.1148/radiol.2263011932 CrossRefPubMed

17.

Philpotts LE, Heiken JP, Westcott MA, Gore RM (1994) Colitis: use of CT findings in differential diagnosis. Radiology 190:445–449. https://doi.org/10.1148/radiology.190.2.8284397 CrossRefPubMed

18.

Ros PR, Buetow PC, Pantograg-Brown L, Forsmark CE, Sobin LH (1996) Pseudomembranous colitis. Radiology 198:1–9. https://doi.org/10.1148/radiology.198.1.8539357 CrossRefPubMed

19.

Kralovich KA, Sacksner J, Karmy-Jones RA, Eggenberger JC (1997) Pseudomembranous colitis with associated fulminant ileitis in the defunctionalized limb of a jejunal-ileal bypass. Report of a case. Dis Colon Rectum 40:622–624CrossRef

20.

Tsutaoka B, Hansen J, Johnson D, Holodniy M (1994) Antibiotic-associated pseudomembranous enteritis due to Clostridium difficile. Clin Infect Dis 18:982–984CrossRef

21.

Jacobs A, Barnard K, Fishel R, Gradon JD (2001) Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature. Medicine (Baltimore) 80:88–101CrossRef

22.

LaMont JT, Trnka YM (1980) Therapeutic implications of Clostridium difficile toxin during relapse of chronic inflammatory bowel disease. Lancet 1:381–383CrossRef

23.

Boland GW, Lee MJ, Cats AM, Ferraro MJ, Matthia AR, Mueller PR (1995) Clostridium difficile colitis: correlation of CT findings with severity of clinical disease. Clin Radiol 50:153–156CrossRef

24.

Barral M, Boudiaf M, Dohan A, Hoeffel C, Camus M, Pautrat K et al (2015) MDCT of acute colitis in adults: an update in current imaging features. Diagn Interv Imaging 96:133–149. https://doi.org/10.1016/j.diii.2014.04.008 CrossRefPubMed

25.

Ramachandran I, Sinha R, Rodgers P (2006) Pseudomembranous colitis revisited: spectrum of imaging findings. Clin Radiol 61:535–544. https://doi.org/10.1016/j.crad.2006.03.009 CrossRefPubMed

26.

Kawamoto S, Horton KM, Fishman EK (1999) Pseudomembranous colitis: spectrum of imaging findings with clinical and pathologic correlation. Radiographics 19:887–897. https://doi.org/10.1148/radiographics.19.4.g99jl07887 CrossRefPubMed

27.

Valiquette L, Pépin J, Do X-V, Nault V, Beaulieu A-A, Bédard J et al (2009) Prediction of complicated clostridium difficile infection by pleural effusion and increased wall thickness on computed tomography. Clin Infect Dis 49:554–560. https://doi.org/10.1086/600879 CrossRefPubMed

28.

Rodrigues FG, Dasilva G, Wexner SD (2017) Neutropenic enterocolitis. World J Gastroenterol 23:42–47. https://doi.org/10.3748/wjg.v23.i1.42 CrossRefPubMedPubMedCentral

29.

Ullery BW, Pieracci FM, Rodney JR, Barie PS (2009) Neutropenic enterocolitis. Surg Infect (Larchmt) 10:307–314. https://doi.org/10.1089/sur.2008.061 CrossRef

30.

Nesher L, Rolston KVI (2013) Neutropenic enterocolitis, a growing concern in the era of widespread use of aggressive chemotherapy. Clin Infect Dis 56:711–717. https://doi.org/10.1093/cid/cis998 CrossRefPubMed

31.

Frick MP, Maile CW, Crass GM, Delaney JP (1984) Computed tomography of neutropenic colitis. AJR Am J Roentgenol 143:763–765. https://doi.org/10.2214/ajr.143.4.763 CrossRefPubMed

32.

Shamberger RC, Weinstein HJ, Delorey MJ, Levey RH (1986) The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia. Cancer 57:603–609CrossRef

33.

Cubiella Fernandez J, Nunez Calvo L, Gonzalez Vazquez E, Garcia Garcia MJ, Alves Perez MT, Martinez Silva I et al (2010) Risk factors associated with the development of ischemic colitis. World J Gastroenterol 16:4564–4569. https://doi.org/10.3748/wjg.v16.i36.4564 CrossRefPubMed

34.

Washington C, Carmichael JC (2012) Management of ischemic colitis. Clin Colon Rectal Surg 25:228–235. https://doi.org/10.1055/s-0032-1329534 CrossRefPubMedPubMedCentral

35.

Theodoropoulou A, Koutroubakis I-E (2008) Ischemic colitis: clinical practice in diagnosis and treatment. World J Gastroenterol 14:7302–7308. https://doi.org/10.3748/wjg.14.7302 CrossRefPubMed

36.

Brandt LJ, Feuerstadt P, Longstreth GF, Boley SJ (2015) ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol 110:18–44. https://doi.org/10.1038/ajg.2014.395 CrossRefPubMed

37.

Di Grezia G, Gatta G, Rella R, Iacobellis F, Berritto D, Musto LA et al (2019) MDCT in acute ischaemic left colitis: a pictorial essay. Radiol Med 124:103–108. https://doi.org/10.1007/s11547-018-0947-7 CrossRefPubMed

38.

Iacobellis F, Berritto D, Fleischmann D, Gagliardi G, Brillantino A, Mazzei MA et al (2014) CT findings in acute, subacute, and chronic ischemic colitis: suggestions for diagnosis. Biomed Res Int 2014:895248. https://doi.org/10.1155/2014/895248 CrossRefPubMedPubMedCentral

39.

Berritto D, Iacobellis F, Mazzei MA, Volterrani L, Guglielmi G, Brunese L et al (2016) MDCT in ischaemic colitis: how to define the aetiology and acute, subacute and chronic phase of damage in the emergency setting. Br J Radiol 89:20150821. https://doi.org/10.1259/bjr.20150821 CrossRefPubMedPubMedCentral

40.

Dhatt HS, Behr SC, Miracle A, Wang ZJ, Yeh BM (2015) Radiological evaluation of bowel ischemia. Radiol Clin North Am 53:1241–1254. https://doi.org/10.1016/j.rcl.2015.06.009 CrossRefPubMedPubMedCentral

41.

Trompeter M, Brazda T, Remy CT, Vestring T, Reimer P (2002) Non-occlusive mesenteric ischemia: etiology, diagnosis, and interventional therapy. Eur Radiol 12:1179–1187. https://doi.org/10.1007/s00330-001-1220-2 CrossRefPubMed

42.

Salomao M, Dorritie K, Mapara MY, Sepulveda A (2016) Histopathology of graft-vs-host disease of gastrointestinal tract and liver an update. Am J Clin Pathol 145:591–603. https://doi.org/10.1093/ajcp/aqw050 CrossRefPubMed

43.

Naymagon S, Naymagon L, Wong S-Y, Ko HM, Renteria A, Levine J et al (2017) Acute graft-versus-host disease of the gut: considerations for the gastroenterologist. Nat Rev Gastroenterol Hepatol 14:711–726. https://doi.org/10.1038/nrgastro.2017.126 CrossRefPubMedPubMedCentral

44.

Ross WA, Couriel D (2005) Colonic graft-versus-host disease. Curr Opin Gastroenterol 21:64–69PubMed

45.

Kalantari BN, Mortelé KJ, Cantisani V, Ondategui S, Glickman JN, Gogate A et al (2003) CT features with pathologic correlation of acute gastrointestinal graft-versus-host disease after bone marrow transplantation in adults. AJR Am J Roentgenol 181:1621–1625. https://doi.org/10.2214/ajr.181.6.1811621 CrossRefPubMed

46.

Kennedy GD, Heise CP (2007) Radiation colitis and proctitis. Clin Colon Rectal Surg 20:64–72. https://doi.org/10.1055/s-2007-970202 CrossRefPubMedPubMedCentral

47.

Hayne D, Vaizey CJ, Boulos PB (2001) Anorectal injury following pelvic radiotherapy. Br J Surg 88:1037–1048. https://doi.org/10.1046/j.0007-1323.2001.01809.x CrossRefPubMed

48.

Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K et al (2017) 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis 65:1963–1973. https://doi.org/10.1093/cid/cix959 CrossRefPubMedPubMedCentral

49.

Thoeni RF, Cello JP (2006) CT imaging of colitis. Radiology 240:623–638. https://doi.org/10.1148/radiol.2403050818 CrossRefPubMed

50.

M’Koma AE (2013) Inflammatory bowel disease: an expanding global health problem. Clin Med Insights Gastroenterol 6:33–47. https://doi.org/10.4137/CGast.S12731 CrossRefPubMedPubMedCentral

51.

Langholz E (2010) Current trends in inflammatory bowel disease: the natural history. Therap Adv Gastroenterol 3:77–86. https://doi.org/10.1177/1756283X10361304 CrossRefPubMedPubMedCentral

52.

Hedrick TL, Friel CM (2013) Colonic Crohn disease. Clin Colon Rectal Surg 26:84–89. https://doi.org/10.1055/s-0033-1348046 CrossRefPubMedPubMedCentral

53.

Childers BC, Cater SW, Horton KM, Fishman EK, Johnson PT (2015) CT Evaluation of acute enteritis and colitis: is it infectious, inflammatory, or ischemic? Resident and fellow education feature. Radiographics 35:1940–1941. https://doi.org/10.1148/rg.2015150125 CrossRefPubMed

54.

Maddu KK, Mittal P, Shuaib W, Tewari A, Ibraheem O, Khosa F (2014) Colorectal emergencies and related complications: a comprehensive imaging review—imaging of colitis and complications. Am J Roentgenol 203:1205–1216. https://doi.org/10.2214/AJR.13.12250 CrossRef

55.

Delabrousse E, Ferreira F, Badet N, Martin M, Zins M (2013) Coping with the problems of diagnosis of acute colitis. Diagn Interv Imaging 94:793–804. https://doi.org/10.1016/j.diii.2013.03.012 CrossRefPubMed

56.

Cheung O, Regueiro MD (2003) Inflammatory bowel disease emergencies. Gastroenterol Clin North Am 32:1269–1288. https://doi.org/10.1016/S0889-8553(03)00095-5 CrossRefPubMed

57.

Greenstein AJ, Sachar DB, Gibas A, Schrag D, Heimann T, Janowitz HD et al (1985) Outcome of toxic dilatation in ulcerative and Crohn’s colitis. J Clin Gastroenterol 7:137–143CrossRef

58.

Jalan KN, Sircus W, Card WI, Falconer CW, Bruce CB, Crean GP et al (1969) An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology 57:68–82CrossRef

59.

Gerding DN, Muto CA, Owens RC Jr (2008) Treatment of Clostridium difficile infection. Clin Infect Dis 46(Suppl 1):S32–S42. https://doi.org/10.1086/521860 CrossRefPubMed

60.

Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al (2013) Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 108:478–498. https://doi.org/10.1038/ajg.2013.4 CrossRefPubMed

61.

Sayedy L, Kothari D, Richards RJ (2010) Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endosc 2:293–297. https://doi.org/10.4253/wjge.v2.i8.293 CrossRefPubMedPubMedCentral

62.

Peng Z, Ling L, Stratton CW, Li C, Polage CR, Wu B et al (2018) Advances in the diagnosis and treatment of Clostridium difficile infections. Emerg Microbes Infect 7:15. https://doi.org/10.1038/s41426-017-0019-4 CrossRefPubMedPubMedCentral

63.

Debast SB, Bauer MP, Kuijper EJ (2014) European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect 20(Suppl 2):1–26. https://doi.org/10.1111/1469-0691.12418 CrossRefPubMed

64.

Kawamoto S, Horton KM, Fishman EK (1999) Pseudomembranous colitis: can CT predict which patients will need surgical intervention? J Comput Assist Tomogr 23:79–85CrossRef

65.

Ash L, Baker ME, O’Malley CM, Gordon SM, Delaney CP, Obuchowski NA (2006) Colonic abnormalities on CT in adult hospitalized patients with Clostridium difficile colitis: prevalence and significance of findings. AJR Am J Roentgenol 186:1393–1400. https://doi.org/10.2214/AJR.04.1697 CrossRefPubMed

Title: Clostridium difficile colitis: CT findings and differential diagnosis
Authors: Sara Guerri
Ginevra Danti
Gianluca Frezzetti
Edvige Lucarelli
Silvia Pradella
Vittorio Miele
Publication date: 01-12-2019
Publisher: Springer Milan
Keywords: Clostridioides Difficile
Graft-Versus-Host Disease
Graft-Versus-Host Disease
Computed Tomography
Computed Tomography
Crohn's Disease
Published in: La radiologia medica / Issue 12/2019
Print ISSN: 0033-8362
Electronic ISSN: 1826-6983
DOI: https://doi.org/10.1007/s11547-019-01066-0

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Springer Medicine

Clostridium difficile colitis: CT findings and differential diagnosis

Abstract

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Abstract

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