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Background
Clostridium difficile enteritis is a rare but potentially life-threatening condition, and the outcomes are poorer when the diagnosis is delayed. A literature review performed by a group of authors in 2013 identified 83 documented cases of C. difficile enteritis with a mortality rate of 23%. 1 With the vast majority of cases reported in the last decade, the incidence of C. difficile enteritis appears to be rising, particularly in patients with inflammatory bowel disease undergoing bowel surgery. 2 3 A number of other predisposing factors have also been described.
CT is increasingly used in this group of patients, and therefore, the familiarity of the radiologist with this condition should facilitate timely diagnosis. However, to the best of our knowledge, the published data on the imaging manifestations of C. difficile enteritis are limited, with only a single radiological paper describing four cases available. 4 Therefore, we present a case of C. difficile enteritis in a predisposed, postoperative patient with a background of Crohn's disease, managed with multiple antibiotics. Thepatient had three consecutive CT studies performed prior to onset of symptoms, during the peak of abdominal sepsis and 35 days later following treatment. This allows documentation of the transition of the small bowel wall from normal to abnormal state followed by radiological, clinical and microbiological resolution. The colon remained normal.
Case presentation
A 51-year-old Caucasian woman presented to our institution with signs of small bowel obstruction (SBO). She had a history of distal colonic Crohn's disease with a colovaginal fistula, which was managed with a defunctioning loop ileostomy and combination therapy of infliximab and azathioprine. Her admission CT revealed uncomplicated adhesive SBO caused by a band adhesion proximal to the ileostomy, but at this time, there was no evidence of any significant bowel wall thickening ( figure 1 ).
The patient was admitted and underwent laparoscopic adhesiolysis; however, she became septic postoperatively. She was transferred to the intensive care unit, and despite multiantibiotic therapy (amikacin, vancomycin and piperacillin-tazobactam), she deteriorated and had increasing stoma output.
Investigations
A second CT was performed, 5days after the initial CT, which showed a striking interval change in the small bowel appearance: although not dilated, there was extensive diffuse transmural oedema, with a hyperenhancing 'shaggy' mucosal surface, and a moderate amount...