Gut health and colon health are very important and affect one’s lifestyle and the quality of their life. One of the diseases that affects the colon is pseudomembranous colitis, which can lead to some serious complications.

Introduction

Definition of Pseudomembranous Colitis

Pseudomembranous colitis is a serious disease that affects the colon. Usually, the main reason for pseudomembranous colitis is the infection with Clostridium difficile that results from the prolonged use of broad-spectrum antibiotics. There are other reasons like colon obstruction, ischemic diseases(diseases that are caused due to decreased blood flow to some organs), uremia, and heavy metal poisoning.

Pseudomembranous colitis is formed of yellow to white nodules that cover the lining of the colon. When there is a disease or an infection, the release of inflammatory mediators is responsible for the formation of the pseudomembrane over the lining of the colon.

The diameter of the pseudomembrane can reach up to 2 centimeters. It is usually scattered over some parts of the colon, but in severe cases, it covers the whole colon.¹

Overview of Clostridium difficile (C. difficile) infection

Clostridium difficile bacteria are a part of the normal gut flora( a group of bacteria that are found normally in the human gut) but it is usually suppressed by other bacteria found in the gut. When there is an excessive use or prolonged use of broad-spectrum antibiotics, other bacteria in the gut flora are suppressed, so the Clostridium difficile can now act on the colon causing the pseudomembranous colitis.

Signs and symptoms caused by Clostridium difficile infection vary from being asymptomatic to fever, colitis, toxic megacolon, an increase in the number of white blood cells, abdominal pain and cramping, hypotension, colon perforation and in severe cases, it may lead to death.¹

Pathophysiology

Pathophysiological mechanisms

There are three steps for Clostridium difficile to cause pseudomembranous colitis, which are :

Disruption of normal gut flora

As mentioned earlier, Clostridium difficile is a part of the human’s normal gut flora, but it is suppressed by the other bacteria found in the gut flora. When the human starts to consume broad-spectrum antibiotics like penicillin, clindamycin, cephalosporins and fluoroquinolones. Also, if the body is subjected to chemotherapy or immunosuppressive drugs the gut flora gets disrupted as well.

The Clostridium difficile gets activated and starts to colonize the colon.

Toxin production by C. difficile

After the Clostridium difficile colonizes the colon, it releases toxins in the colon. These toxins enter the colon cells and start causing changes in the structure of the cells, leading to its death eventually also disrupting the junctions between cells, leading to the release of inflammatory mediators.

Inflammatory response

The release of the inflammatory mediators causes inflammation of the colon(colitis) and the formation of the pseudomembrane, leading to what is known as pseudomembranous colitis.¹

Clinical presentation

Symptoms

Pseudomembranous colitis symptoms are usually diarrhea with a 99% chance of occurrence, fever with 29% chance of occurrence, abdominal pain and cramps with 33% chance of happening and an increase in the white blood cell count with 66% chance of occurrence.²

Diarrhea

Diarrhea is the most common symptom of pseudomembranous colitis.

It is usually watery and accompanied by blood. In some severe cases, patients don't suffer from diarrhea, but they suffer from toxic megacolon, appendicitis( inflammation of the appendix).²

Also, Clostridium difficile infection that occurs after the prolonged use of antibiotics is the main cause of diarrhea.³

Abdominal Pain

One of the symptoms that sometimes accompany pseudomembranous colitis is abdominal pain and cramps, even if the patient does not suffer from diarrhea.³

Fever

Patients with pseudomembranous colitis also suffer an increase in temperature that can reach up to 40 degrees.³

Diagnosis

Diagnosis is the most important step. The correct diagnosis leads to the correct treatment of the disease. Multiple tests are used to diagnose Clostridium difficile infection.

The best test to diagnose it is the nucleic acid amplification test (NAAT), which includes the polymerase chain reaction (PCR) test and stool testing for glutamate dehydrogenase.¹

These tests have high sensitivity and are reliable.

Stool tests for C. difficile toxins

A stool sample is taken from the patient, and several tests are made upon it to detect the presence of the toxins produced by clostridium difficile to determine whether there is an infection or not.

Although stool tests are helpful in the diagnosis of Clostridium difficile infection, it is of no help to use after treatment because they will still give positive results.¹

Colonoscopy findings

Colonoscopy visualizes the inside of the colon to detect the presence of pseudomembranes. It is used to make further confirmation of the diagnosis or when there is an urgency for an immediate diagnosis.²

Complications

If pseudomembranous colitis is not treated it can lead to some serious complications like severe hypotension, fever, severe increase in the number of white blood cells that lead a massive increase in the inflammation in the body, a prolonged ileus(incapability of oral intake), altered mental health and eventually might lead to death in old patients and patients with a compromised immune system.¹

Acute complications

Severe dehydration

The increased and continuous diarrhea can lead to dehydration. Dehydration is very serious if left untreated; it can cause urinary tract infection, kidney stones and can eventually lead to hypovolemic shock, which, if not urgently treated, can cause death.⁶

Electrolyte imbalance

The electrolytes, like sodium and potassium, are responsible for the signals between the cells.

Dehydration causes an imbalance in these electrolytes, causing seizures and involuntary muscle contractions, and sometimes it can be very severe, leading to loss of consciousness.⁶

Toxic megacolon

Toxic megacolon is a serious complication of pseudomembranous colitis. It causes paralysis of the smooth muscles responsible for the movement of the colon, leading to dilation and bloody diarrhea. The more inflammation and ulceration there are in the colon the more dilation that happens.⁵

Bowel perforation

Colon perforation can occur as a complication of severe pseudomembranous colitis due to the inflammation and ulcerations in the colon.

Septic shock

A severe decrease in blood pressure as a complication of pseudomembranous colitis can lead to septic shock, which is life-threatening and can lead to death.

Long-term complications

Recurrent infections

After resolution of the symptoms by the correct treatment, Clostridium difficile infection can recur due to the same reasons it occurred in the first time, especially when the patient is immunocompromised or an elderly patient.

There is a high chance, ranging between 40% to 65%, that a patient who got Clostridium difficile infection for a second time can get it again.⁴

Chronic diarrhea

Suffering from pseudomembranous colitis for a long period of time without treatment means suffering from chronic diarrhea, which will lead to dehydration with all its consequences.

Impact on quality of life

Having a bowel disease like pseudomembranous colitis massively affects the quality of life because it not only affects the colon and gut health but also starts to affect other organs and can even lead to altered mental health and death.

Risk factors

Medication-related risk factors

Broad-spectrum antibiotics

Broad-spectrum antibiotics are known to be one of the main reasons that cause pseudomembranous colitis. Using them recklessly or for a long period of time can disrupt the normal gut flora and give room for Clostridium difficile infection.

The most antibiotics reported to cause pseudomembranous colitis are clindamycin, ampicillin and cephalosporin.²

Proton pump inhibitors

Some studies found that proton pump inhibitors can cause pseudomembranous colitis, although the reason for this is not yet found.

Patient-related risk factors

Advanced age

It was found that old age is one of the most important and affecting risk factors of encountering a clostridium difficile infection. 

Old people usually suffer from bowel diseases and have a weak immunity that is why they are more at risk of having pseudomembranous colitis.

Underlying health conditions (e.g., immunosuppression, chronic kidney disease)

Immunocompromised patients are usually at high risk of getting infections, including getting infected with Clostridium difficile infection.

Patients with renal diseases are not only at risk of developing Clostridium difficile infection and pseudomembranous colitis but at a very high risk of death due to this infection.³

Previous C. difficile infection

Patients who have previously been infected with C. difficile are more likely to get re-infected with it.

Environmental and procedural risk factors

Hospital and long-term care facility exposure

Being hospitalized for a long time makes the patient more susceptible to some nosocomial infections, including getting infected with C. difficile. 

Recent surgery

A recent surgery exposes the patient to pseudomembranous colitis by 29-67%.²

Gastrointestinal procedures

Surgeries in the abdominal area make the patient at risk of getting post-surgery pseudomembranous colitis by 6-9%.²

Summary

Pseudomembranous colitis is a disease that occurs in the colon mainly caused by a prolonged use of broad-spectrum antibiotics. A bacterium called C. difficle is responsible for its occurrence. Pseudomembranous colitis causes several symptoms, like diarrhea and fever. It can have serious complications like toxic megacolon and bowel perforation.

Old age, use of antibiotics or recent surgeries can increase the risk of getting pseudomembranous colitis.