Fulminant Clostridioides difficile pseudomembranous colitis requiring subtotal colectomy after pancreaticoduodenectomy: A case report and mini-review

infection (CDI) is a serious complication of antibiotic therapy and hospitalization that can progress to toxic megacolon, necessitating emergency colectomy. Patients undergoing pancreaticoduodenectomy (PD) are particularly at high risk due to biliary obstruction, recurrent cholangitis, broad-spectrum antibiotic exposure, and prolonged postoperative stays. We report the case of an elderly woman with multiple cardiovascular comorbidities and recent CDI who underwent PD for pancreatic ductal adenocarcinoma (PDAC). Prior to surgery, she had an endoscopic retrograde cholangiopancreatography (ERCP) with duodenobiliary (DB) stent placement due to obstructive jaundice, and biopsies confirmed PDAC. Intravenous cefotaxime was initiated because of signs of acute cholangitis. She subsequently developed CDI and completed treatment with oral vancomycin, which was discontinued only 11 days before the PD. Standard prophylaxis with cefazolin was administered prior to surgery. On postoperative day (POD) 1, empirical antibiotic therapy with cefotaxime was initiated. By POD 3, she developed profuse watery diarrhea, fever, and leukocytosis, with confirmed recurrent CDI. Despite prompt fidaxomicin therapy and intensive care, she rapidly deteriorated. Computed tomography (CT) revealed severe pancolitis and toxic megacolon. Emergency subtotal colectomy with end ileostomy was performed, and histopathological examination confirmed the diagnosis. She eventually stabilized but remained frail, and the tumor board recommended best supportive care instead of adjuvant chemotherapy due to the disease stage and the severe course of CDI. This case underscores the need for early CDI testing in postoperative diarrhea following PD and for cautious perioperative antibiotic strategies in patients with recent CDI, as broad-spectrum antibiotics may precipitate fulminant recurrence.