Abe et al. Journal of Medical Case Reports 2012, 6:130 http://www.jmedicalcasereports.com/content/6/1/130 Page 3 of 5 Figure 3 Colonoscopy on the fifth postoperative day. Colonoscopy demonstrated a colonic wall covered by thick pseudomembranes. A histopathological examination (Figures 4 and 5) revealed inflamed mucosa from the cecum to the rectum which was covered with a necrotic exudate, indicating pseudomembranous colitis. A postmortem autopsy was not carried out, because consent could not be obtained from the family. Discussion Pseudomembranous colitis has been reportedly increas- ing, mainly attributed to wide usage of broad-spectrum antibiotics [2]. The clinical symptoms range from mild Figure 4 Resected specimen. Pseudomembranes were seen on the surface of the entire colon. The inflammation was more intense in the proximal aspect of the colon, which revealed significant edematous thickening associated with thick pseudomembranes. diarrhea to complicated systemic deterioration known as ‘fulminant colitis,’ which results in death or an illness se- vere enough that death would be likely without urgent colectomy [3]. Clinical manifestation of CDI is non-spe- cific, including diarrhea, abdominal pain, fever, and leukocytosis. Disease-specific indicators include positive assay results for C. difficile toxin, colonic wall thickening revealed on CT and colonoscopic or histological identifi- cation of pseudomembranes [4]. According to the algorithm proposed by Jaber et al. [5], once CDI is suspected, the responsible antibiotic should be discontinued and treatment with oral vanco- mycin or metronidazole promptly started. Generally, the effect of medical treatment is evaluated 24 to 48 hours after its initiation; if it is considered to be ineffective, the indication for surgical treatment should be assessed. For patients requiring an operation, the mean time from onset of symptoms to diagnosis is 5.6 days. However, it is noteworthy that there are patients who do not respond to medical therapy and for whom the assessment period after the initiation of medical therapy merely delays the appropriate treatment for them, which is a total colec- tomy with creation of an ileostomy. Patients who eventually undergo surgery should do so without wasting time with ineffective medical treatment and before the deterioration of their general condition occurs. But, this causes a dilemma, as earlier surgical intervention may result in an increased number of sur- geries that could have been avoided by medical therapy. The generally accepted current algorithm for CDI reserves the surgical treatment for those with a deterio- rated condition, such as hypotension, which necessitates vasopressor treatment, or shock, either at the initial presentation or during medical therapy [5]. However, it is apparent that the surgical outcome would be disas- trous if the surgery was postponed until the deterioration of the general condition of the patient who was already sick [2,6]. In fact, surgical mortality is significantly higher in patients with shock compared to non-responders for medical treatment without shock [1]. It is well known that pseudomembranous colitis can develop in patients who have received only one dose of antibiotics [7,8]. Furthermore, although rare after minor operations, a surgical procedure is a risk factor of pseudomembranous colitis [9]. It is also reported that a substantial number of patients with fulminant CDI (36% to 75%) have a history of recent surgery [5]. Therefore, regardless of the severity of the surgery, all surgical patients should be managed as high-risk patients. The clinical course of this patient was so rapid that cardiopulmonary function collapsed before the standard assessment period had barely begun. Our patient deterio- rated into shock within a few hours of the start of med- ical treatment, which was initiated immediately after