Clinical Challenges in Emergency General Surgery: C Diff - When to Pull the Operative Trigger

It’s hospital day five. The patient looked better yesterday… but now she’s hypotensive, on vasopressors, acidotic, and spiraling toward multi-organ failure. The CT scan doesn’t show perforation or megacolon, but your gut tells you this is going south. Do you keep pushing medical therapy… or is it time to operate?

Join Drs. Rushabh Dev, Jeffrey Coughenour, Kevin Bartow, Raymond Okeke, and Desra Fletcher from the Emergency General Surgery team in Tiger Country at Mizzou as they tackle one of the deadliest and most challenging diseases acute care surgeons face: fulminant Clostridioides difficile infection.

In this Clinical Challenges episode, the panel discusses diagnostic stewardship, ASCRS recommendations, timing of operative intervention and technique, subtotal colectomy versus diverting loop ileostomy with lavage, and physiology that should push surgeons toward definitive source control.

Through a real-world high-risk case vignette, the team explores the hardest question in emergency general surgery: when to stop hoping medical therapy will work and pull the operative trigger.

Hosts

• Dr. Rushabh Dev FACS (Moderator, Surgical Attending) – Assistant Professor of Surgery, Associate PD ACS & SCCM Fellowship, SICU Medical Director, Lieutenant Commander United States Navy Reserve
• Dr. Jeffery Coughenour FACS (Surgical Attending) – Professor of Surgery and Emergency Medicine, Trauma Medical Director at the University of Missouri SOM
• Dr. Kevin Bartow FACS (Surgical Attending) –Professor of Surgery, Minimally Invasive Surgeon and General Surgery. Department of General Surgery at the University of Missouri SOM
• Raymond Okeke – Acute Care Surgery/Surgical Critical Care Fellow, University of Missouri School of Medicine
• Desra Fletcher – PGY 3 General Surgery Resident, University of Missouri School of Medicine

Learning Objectives
By the end of this episode, listeners should be able to:

• Define the spectrum of Clostridioides difficile infection (CDI), including non-severe, severe, and fulminant disease, and recognize the physiologic implications of fulminant colitis.
• Review contemporary diagnostic stewardship for CDI, including appropriate stool testing, pitfalls of PCR/NAAT interpretation, and the role and limitations of CT imaging in fulminant disease.
• Describe evidence-based medical management of fulminant CDI, including high-dose enteral vancomycin, intravenous metronidazole, rectal vancomycin for ileus, and principles of antimicrobial stewardship.
• Recognize the high-risk clinical features that should prompt urgent surgical evaluation, including worsening shock, vasopressor dependence, lactate elevation, organ failure, and evolving abdominal exam findings.
• Discuss the operative indications and timing for surgery in fulminant CDI and understand why delayed intervention contributes to mortality.
• Compare subtotal colectomy with end ileostomy versus diverting loop ileostomy with antegrade lavage, including current evidence, patient selection, limitations of the literature, and ASCRS recommendations.
• Review practical operative strategies for subtotal colectomy in unstable patients, including damage-control principles and common technical pitfalls.
• Apply clinical reasoning to a complex, high-risk case of fulminant CDI in a patient with decompensated cirrhosis, septic shock, and multi-organ dysfunction.

References

• ASCRS Clinical Practice Guidelines for *Clostridioides difficile* Infection (2021)
• Surgical Management of *Clostridium difficile* Colitis — Neal et al., 2011 (Loop Ileostomy + Lavage Protocol)
• Clinical Practice Guidelines for *Clostridioides difficile* Infection in Adults and Children (IDSA/SHEA, 2021 Update)
• Adjunctive Hyperbaric Oxygen and Surgical Outcomes in Necrotizing Soft Tissue Infections (Background discussion of severe infection physiology)
• Total Abdominal Colectomy Versus Diverting Loop Ileostomy for Fulminant CDI — Systematic Review & Meta-analysis
• Current Status of Surgical Therapy for Fulminant *Clostridioides difficile* Colitis
• Behind the Knife Episode 648 – Emergency General Surgery Journal Review: *Clostridioides difficile* Infection

Bottom line: Fulminant C. diff is one of the few EGS diseases where the hardest decision is not what operation to perform — it’s recognizing when medical therapy has failed before the patient becomes unsalvageable.

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