Abe et al. Journal of Medical Case Reports 2012, 6:130 http://www.jmedicalcasereports.com/content/6/1/130 III rectal carcinoma (T3N1M0). He had a past medical history of hypertension, cerebral hemorrhage and gastric ulcer and was taking a proton-pump inhibitor. On the day before the elective surgery, he received oral kanamycin and metronidazole as a chemical preparation. Additionally, immediately before the surgery, one dose of parenteral cefmetazole was given. Ileostomy closure was completed in 31 minutes without any intraoperative complications. His postoperative course was uneventful until the third postoperative day, when his body temperature rose to 37.8°C. His bowel movement became frequent at 15 times a day. However, because he had no other signs or symptoms suggestive of infection, and because frequent bowel movement is not uncommon after low anterior resections, especially after those complicated with post- operative leakage, careful observation was continued without further examination or additional treatment. On the fourth postoperative day, in addition to the aforementioned symptoms, he presented with epigastric and left lower abdominal pain. A computed tomography (CT) scan (Figure 1) revealed that subcutaneous fluid had collected adjacent to the surgical wound. CT also demonstrated a slightly distended colon without wall thickening. We immediately opened the surgical wound and drained the fluid, which was sanguineous. After the drainage, his body temperature returned to within the normal range (36.7°C). That night, at 10:30 p.m., his blood pressure fell to 77/59mmHg and intravenous infu- sion was started. Nevertheless, in the early morning of the fifth post- operative day, his blood pressure continued to drop, thus requiring vasopressor treatment to maintain his blood pressure. Again, a CT was done, which indicated severe colonic dilation (Figure 2). Laboratory data were normal except for mild liver dysfunction (aspartate transaminase, 68mU/mL; alanine transaminase, 45mU/mL) and leukocytosis (9,460 cells/μL). Even though CT demon- strated severe dilatation of the colon, the thickening of the colonic wall that is the typical finding associated with fulminant pseudomembranous colitis was not evident. Emergent colonoscopy up to the transverse colon revealed pseudomembranes associated with severe in- flammation (Figure 3). Pseudomembranous colitis was thus diagnosed, and oral vancomycin was administered. Until this time, no antibiotics had been given postopera- tively. In our institute, the enzyme-linked immunosorb- ent assay (ELISA) for C. difficile toxin is not available on weekends (the fifth postoperative days was a Saturday). The condition of our patient rapidly deteriorated so he was transferred to the intensive care unit at 10:30 a.m. After resuscitation, which included tracheal intubation and massive intravenous infusion along with multiple vasopressors, an emergent operation was done. The time Page 2 of 5 Figure 1 Abdominal computed tomography on the third postoperative day. A CT scan demonstrated that subcutaneous fluid had collected adjacent to the surgical wound and that the colon had become slightly distended and showed no wall thickening. interval between the drop of blood pressure and emer- gency surgery was 18 hours. During the laparotomy, a small amount of bloody asci- tes was observed and the large intestine was severely dilated, part of which was necrotic. The serosa of the small intestine was slightly inflamed but there was no sign of ischemia. Total colectomy with creation of an end ileostomy was then performed, after which our pa- tient was returned to the intensive care unit. However, he did not recover from the shock and died 26 hours after the surgery. Figure 2 Abdominal computed tomography on the fifth postoperative day. A CT scan revealed severe colonic dilation. The diameter of the transverse colon was over 6cm. However, colonic wall thickening was absent.