Background Resources for January Case

Our current case focuses on whether C. difficile infection is possible in a patient with ileostomy. If you're not familiar with the procedure and terminology, it can be difficult to envision why the disconnect between the small intestine and colon matters in this particular case. The following freely available resources should help with visualizing the gastrointestinal anatomy and understanding the patient's situation.

Main Concepts
Anatomy of the Gastrointestinal Tract

MedlinePlus Medical Encyclopedia: Lower Digestive Anatomy (illustration)

National Digestive Diseases Information Clearinghouse: Your Digestive System and How it Works

MeSH Database: Gastrointestinal Tract

Ileostomy - surgical procedure involving part of the small intestine

National Digestive Diseases Information Clearinghouse: Ileostomy, Colostomy, and Ileoanal Reservoir Surgery

UW Medical Center Ostomy Care Service: Colostomy or Ileostomy (click on Colostomy/Ileostomy to download and view a slideshow with illustrations)

United Ostomy Association: Ileostomy Guide (PDF)

MeSH Database: Ileostomy

Clostridium difficile - a bacteria that lives in the large intestine

CDC: General Information About Clostridium difficile Infections

CDC: Clostridium difficile Information for Healthcare Providers

eMedicine: Clostridium difficile Colitis (the expected type of C. difficile infection; it was unusual in our patient, as the patient did not have a colon)

MeSH Database: Clostridium difficile

Diarrhea

National Digestive Diseases Information Clearinghouse: Diarrhea

MayoClinic: Antibiotic-Associated Diarrhea

MeSH Database: Diarrhea

Additional Topics
Ventilator-Associated Pneumonia - a specific kind of hospital-acquired pneumonia that develops in patients requiring mechanical ventilation

CDC: Ventilator-Associated Pneumonia

MeSH Database: The 2007 update of MeSH from NLM includes the new term, Pneumonia, Ventilator-Associated, which is new to MeSH this year.

Ischemic Colon - when blood flow to your large intestine is diminished or blocked, leading to low oxygen in the affected area

MayoClinic: Intestinal Ischemia

MayoClinic: Ischemic Colitis

American College of Gastroenterology: Intestinal Ischemia

MeSH Database: Colitis, Ischemic

More JMLA news

Some other news from the Journal of the Medical Library Association this week:

- The archives of the precursors to the JMLA are now available via the PubMed Central JMLA archives -- in addition to the issues under the journal's former title, the Bulletin of the Medical Library Association (1911-2001), readers can now access The Aesculapian (1908-1909) and the Medical Library and Historical Journal (1903 to 1907).

- MLA is also pilot testing a new pre-print area for articles from forthcoming issues - available via the members-only section of the site, MLA members can use their MLANET username (MLA ID#) and password to access several preprints from the April issue of the journal.

January case posted!

The January 2007 case study is now available in PubMed Central:

Walden RR, Jerome RN, Miller RS. Utilizing case reports to build awareness of rare complications in critical care. J Med Libr Assoc 2007 Jan;95(1):3-8.

"As the second installment in the JMLA's new case study column, this issue's case considers the role of the librarian in addressing a complex clinical question that requires extracting relevant evidence when the literature is almost exclusively limited to case reports. This case study also tackles the challenge of identifying an effective strategy for organizing and presenting case report details to answer a clinical question."

The preview of this case is available in this previous post. We'll post additional commentary in the upcoming days.

Please use the comments feature on this blog to send us your comments and questions!

Also, check out the other interesting articles in this month's JMLA.

January case teaser: persistent diarrhea in an ICU patient

The January 2007 issue of the Journal of the Medical Library Association will be arriving soon. An excerpt from this issue's case study:

The case

A 42 year old male was admitted to the ICU following a motor vehicle collision (MVC). The patient currently has a diverting ileostomy, after losing most of the colon to ischemia secondary to blunt trauma to his abdomen during the MVC. The patient developed ventilator-associated pneumonia (VAP) several days after the operation to remove a significant amount of ischemic colon and construct the ileostomy; he was treated with seven-day course of broad-spectrum antibiotics for the VAP.

After completing antibiotic therapy for the pneumonia, the patient developed diarrhea with high volume output from the ileostomy; despite consultation with the nutritionist and numerous interventions (e.g. administration of antidiarrheal agents) over the course of several days, the patient continues to have significant output from his ileostomy.

During morning rounds, one of the residents mentions that the team had sent a sample of the ileostomy output to be tested for Clostridium difficile. The team discusses the Clostridium difficile organism as one of the most common causes of diarrhea in the ICU, particularly in patients with a recent history of exposure to
antibiotics. However, C. difficile typically involves the colon rather than the small intestine, and the current patient has loss of continuity between the small intestine and colon because of the ileostomy.

The attending physician notes that he has not heard of C. difficile infection involving the small intestine and asks you, as the team’s evidence consultant, to explore whether the literature indicates that the small intestine can be involved in C. difficile infection and if such infection can develop despite loss of continuity with the colon (due to the presence of the ileostomy in this patient).

We'll post a link to the online case as soon as it is available via PubMed Central.

Stay tuned for additional commentary and discussion of the case...