From the Guidelines
Colonoscopy is indicated in the management of Clostridioides difficile (C. diff) infection for the administration of fecal microbiota transplant (FMT) in severe or fulminant cases not responding to standard therapy, as well as for diagnostic purposes in specific situations. The primary diagnostic methods for C. diff are stool tests, including PCR, enzyme immunoassay for toxins, or stool culture. However, colonoscopy may be considered when there is a high clinical suspicion for C. diff despite negative stool tests; to evaluate for pseudomembranous colitis in severe or fulminant cases not responding to standard therapy; to exclude other causes of diarrhea or colitis when the diagnosis is uncertain; or to assess for inflammatory bowel disease that might be mimicking or coexisting with C. diff infection 1. According to the AGA clinical practice guideline, in adults hospitalized with severe or fulminant C difficile infection not responding to antimicrobial therapy, the AGA suggests the use of conventional fecal microbiota transplant over no fecal microbiota transplant, with the first dose of FMT delivered via colonoscopy or flexible sigmoidoscopy 1. Some key points to consider when performing colonoscopy in C. diff infection include:
- The presence of pseudomembranes (yellow-white plaques on the colonic mucosa) is characteristic of C. diff colitis, though their absence doesn't rule out infection.
- Colonoscopy carries risks in severe C. diff cases, including potential perforation due to friable colonic mucosa, and should be performed with caution.
- The procedure should be limited to the necessary extent to obtain diagnostic information while minimizing risks of complications or disease transmission. Other studies support the use of colonoscopy in specific situations, such as when there is a high clinical suspicion for C. diff despite negative stool tests, or to evaluate for pseudomembranous colitis in severe or fulminant cases not responding to standard therapy 1. It's essential to weigh the benefits and risks of colonoscopy in each individual case, considering the severity of the disease, the patient's overall condition, and the availability of other diagnostic methods.
From the Research
Indications for Colonoscopy in C. diff Infection
- Colonoscopy is used to perform fecal microbiota transplantation (FMT) in patients with severe and severe/complicated Clostridioides difficile infection (CDI) who are at high risk for colectomy 2
- FMT via colonoscopy is a treatment option for patients with refractory CDI, particularly those who have not responded to oral vancomycin and fidaxomicin 3
- Colonoscopy may be used to guide the need for repeat FMT and continued vancomycin therapy in patients with severe and severe/complicated CDI 2
- The presence of pseudomembranes at colonoscopy may indicate the need for continued treatment or repeat FMT 2
Patient Selection for Colonoscopy
- Patients with severe and severe/complicated CDI who are at high risk for colectomy may benefit from FMT via colonoscopy 2
- Elderly patients with CDI may be good candidates for FMT due to their increased risk for treatment failure and high comorbidity burden 3
- Patients who have not responded to traditional anti-CDI antibiotics may be considered for FMT via colonoscopy 3
Treatment Outcomes
- FMT via colonoscopy has been shown to have high cure rates (70-90%) in patients with severe and fulminant CDI 3
- The use of FMT via colonoscopy may decrease the need for colectomy and reduce CDI-related mortality 3
- Recurrence rates may be lower with FMT via colonoscopy compared to other treatment options 4