From the Guidelines
Patients with Primary Sclerosing Cholangitis (PSC) who are colonized with Clostridioides difficile should undergo annual surveillance colonoscopy starting at the time of PSC diagnosis, regardless of their C. diff status. This recommendation is based on the increased risk of colorectal cancer in PSC patients, as highlighted in the ECCO statement 8F 1 and further supported by the ECCO-ESGAR guideline 1. The colonoscopy preparation should proceed normally, but additional infection control measures should be implemented to prevent C. diff transmission.
Before the procedure, the patient should be placed on contact precautions with healthcare providers using gloves and gowns. The endoscopy suite should be thoroughly disinfected after the procedure using sporicidal agents effective against C. diff spores. Antibiotic prophylaxis is not routinely recommended unless there are other indications. If the patient has active C. diff infection (not just colonization), the colonoscopy should be postponed until the infection resolves, typically after completing appropriate antibiotic treatment such as oral vancomycin 125 mg four times daily for 10-14 days.
Key considerations for the management of PSC patients colonized with C. diff include:
- Annual surveillance colonoscopy starting at the time of PSC diagnosis
- Implementation of infection control measures to prevent C. diff transmission
- Postponing colonoscopy in cases of active C. diff infection until the infection resolves
- The use of sporicidal agents for disinfecting the endoscopy suite
- The importance of contact precautions for healthcare providers
The increased colonoscopy frequency for PSC patients (compared to the general population's 10-year interval) is justified by their higher risk of developing colorectal cancer, with the risk beginning immediately after PSC diagnosis rather than developing over time, as noted in ECCO statement 8E 1.
From the Research
Screening Colonoscopy for PSC when Colonized with C. diff
- The presence of Clostridioides difficile (C. diff) in a patient with Primary Sclerosing Cholangitis (PSC) does not directly influence the recommendations for screening colonoscopy, as the primary concern is the increased risk of colorectal cancer associated with PSC and inflammatory bowel disease (IBD) 2, 3, 4, 5.
- Patients with PSC and IBD should begin colon cancer screening at a young age, typically around 15 years old, due to the high risk of colorectal cancer 6.
- The frequency of screening colonoscopy for patients with PSC and IBD is generally recommended to be every 1-2 years, depending on the individual's risk factors and disease severity 2.
- It is essential to note that C. diff colonization may increase the risk of complications during colonoscopy, such as infection or exacerbation of IBD symptoms; therefore, appropriate precautions and management strategies should be taken into consideration when performing screening colonoscopy in these patients.
- There is no direct evidence to suggest that C. diff colonization affects the diagnosis or management of PSC; however, it is crucial to manage C. diff infection promptly to prevent complications and ensure the patient's overall health and safety 3, 4, 5.