2020 Volume 53 Issue 3 Pages 246-256
An 87-year-old man underwent transverse colectomy and distal gastrectomy to treat advanced transverse colon cancer and early gastric cancer. The leakage of gastroduodenal anastomosis occurred, which was treated with tube drainage and total parenteral nutrition. On the 27th day of hospitalization, he presented with fever of more than 38°C and we started ceftriaxone and intravenous vancomycin based on a culture of tube drainage. On the 33rd hospital day, he developed abdominal distention, right hypochondrial pain, fever, and severe inflammatory response, but no diarrhea. Under a diagnosis of sepsis due to leakage, we increased the ceftriaxone dosage, but liver dysfunction occurred. We changed the antibacterial agent to cefozopran, which did not improve the sustained fever and mild abdominal distention. On the 46th hospital day, he developed spike fever without diarrhea. A CT examination revealed dilatation and wall thickening of the entire colon and rectum. A sigmoidoscopic examination showed widespread pseudomembrane in the rectum and sigmoid colon. Severe Clostridium difficile colitis was diagnosed and oral vancomycin was started, but on the 50th day of admission, a deterioration of abdominal distention and a positive Clostridium difficile toxin assay in the stool was identified. Fulminant Clostridium difficile colitis was diagnosed. An urgent loop ileostomy was performed with two ileus tubes placed from the anal limb of the stoma to deliver vancomycin despite paralytic ileus. Colonic lavage with antegrade vancomycin enemas from the ileus tubes for ten days led to the complete remission of the pseudomembrane on the 59th hospital day.
