An elderly woman with pancreatic ductal adenocarcinoma (PDAC) underwent evaluation and treatment before surgery. She presented with obstructive jaundice that required endoscopic retrograde cholangiopancreatography (ERCP) and placement of a duodenobiliary stent. Biopsies obtained confirmed PDAC. The patient had multiple cardiovascular comorbidities and experienced an episode of acute cholangitis for which intravenous cefotaxime was initiated. During this preoperative period she developed Clostridioides difficile infection (CDI) and completed treatment with oral vancomycin, which was discontinued eleven days before the planned pancreaticoduodenectomy (PD).
Patients undergoing PD often carry elevated risk for CDI because biliary obstruction, recurrent cholangitis, exposure to broad-spectrum antibiotics, and long postoperative hospital stays create a fertile environment for C. difficile colonization and symptomatic infection.
Per routine surgical prophylaxis, the patient received cefazolin prior to surgery. On postoperative day (POD) 1, empirical antibiotic therapy with cefotaxime was restarted. By POD 3 the patient developed profuse watery diarrhea accompanied by fever and leukocytosis. Given her recent history of CDI, clinicians tested for recurrent infection; testing confirmed recurrent C. difficile.
Given the confirmed recurrence, targeted antimicrobial therapy was initiated with fidaxomicin. She was managed in an intensive care setting because of the severity of her clinical presentation.
The clinical picture—early postoperative profuse diarrhea, systemic inflammatory signs, and leukocytosis—together with a positive test established recurrent CDI. The treating team started fidaxomicin promptly as the first-line agent for the recurrent episode reported in this case. Despite initiation of therapy and escalation of supportive care in the intensive care unit, the patient’s condition worsened rapidly.
The case underscores that postoperative diarrhea after PD, particularly in patients with recent CDI, should prompt immediate testing for C. difficile to enable early diagnosis and treatment.
As the patient deteriorated clinically despite medical therapy, contrast-enhanced abdominal computed tomography (CT) was performed. CT imaging demonstrated severe pancolitis with marked colonic dilatation—most pronounced in the cecum—and features consistent with toxic megacolon, including submucosal edema and mucosal hyperenhancement. These imaging findings, in conjunction with the patient’s hemodynamic decline and failure to improve on antimicrobial therapy, indicated fulminant colitis with impending or established toxic megacolon.
Because of rapid progression to fulminant disease, the multidisciplinary team determined that emergency surgical intervention was necessary.
An emergency subtotal colectomy with end ileostomy was performed. Histopathological examination of the resected colon confirmed pseudomembranous colitis consistent with fulminant C. difficile infection. The operation was undertaken as a life-saving measure in the context of toxic megacolon and refractory fulminant CDI.
Following colectomy the patient eventually stabilized but remained frail. Given the stage of her pancreatic cancer and the severe perioperative course complicated by fulminant CDI, the tumor board recommended best supportive care rather than adjuvant chemotherapy.
The report notes that although surgical therapy can be life-saving for toxic megacolon, the overall physiologic reserve and comorbidities of patients must be considered when planning further oncologic treatment.
This case highlights several practical points for clinicians caring for patients undergoing PD:
Patients who have recent CDI and who require major hepatopancreatobiliary surgery represent a high-risk group for recurrent and potentially fulminant infection.
Perioperative and early postoperative exposure to broad-spectrum antibiotics (for example, cefotaxime in this case) may precipitate recurrence of CDI even when prior treatment was recently completed.
Early testing for C. difficile should be performed when significant postoperative diarrhea develops after PD, particularly in patients with prior CDI.
Rapid recognition of fulminant progression, timely imaging to evaluate for pancolitis/toxic megacolon, and prompt surgical consultation are critical because emergency colectomy may be necessary.
Multidisciplinary decision-making is required for balancing life-saving surgery against postoperative frailty and implications for cancer-directed therapy.
Figures provided in the article include the preoperative pancreatic mass on CT, CT images demonstrating pancolitis and colonic dilatation consistent with toxic megacolon, and a schematic summarizing high-risk patients and perioperative antibiotic recommendations.
Conflict of interest: the authors reported no relevant conflicts of interest in this publication.