Toxic megacolon due to fulminant Clostridium Difficile colitis

A 92 year-old male patient was submitted for an elective right nephrectomy for kidney adenocarcinoma. Postoperatively, a three-day hospitalization in the ICU was required during which ampicillin/sulbactam was prophylactically administrated. From the 7th to the 9th postoperative day, he developed extensive abdominal distention, diffuse abdominal pain, diminished bowel sounds, fever (> 38.9°C), elevated leukocytosis (WBC 46,200 cells/µL), signs and symptoms compatible with systemic toxicity (hypotension and tachycardia), but no diarrhea. Plain Abdominal X-ray disclosed a toxic mega- colon (transverse colon diameter > 10 cm) and absence of air in the rectal lumen, without radiological signs of obstructive ileus or volvulus. Colonoscopy with minimal gas insufflation, showed an inflamed and edematous mucosa with numerous discrete raised nodular lesions covered with yellow exudates up to the splenic flexure in a dilated and non-peristaltic bowel (Fig. 1). Stool cultures were positive for clostridium difficile.