Abe et al. Journal of Medical Case Reports 2012, 6:130 http://www.jmedicalcasereports.com/content/6/1/130 Page 4 of 5 Figure 5 Histopathological findings. The histopathological examination revealed a necrotic exudate on the surface of the colonic mucosa. Severe inflammation was also seen, resulting in the disappearance of the upper part of the colonic crypts. the diagnosis of pseudomembranous colitis by colon- oscopy. Because of the possibility of the extremely rapid progression of this disease, as we experienced in this case, and the much higher mortality risk asso- ciated with surgery in patients with shock than with- out it, we propose that fast-track care, or an alternative to the conventional treatment algorithm, is desperately needed. As this case has clearly revealed, the current algorithm for CDI does not facilitate the clinical management of fulminant pseudomembranous colitis, especially in critic- ally severe cases. Considering the increasing morbidity of the pathology and recent outbreak of virulent strains, such as BI/NAP1/027 [1], we stress that the timing of a surgical consult should be earlier and the indication for surgery broader. Early recognition of patients who are refractory to con- ventional medical therapy is important. Previous studies demonstrated significant predictors for fulminant colitis [1,4]. However, as far as postoperative patients in the surgical ward are concerned, clinical manifestation of CDI and predictors of fulminant colitis are not obviously distinguishable from symptoms seen in the uneventful postoperative course. In our case, for instance, the fre- quent bowel movement, which might have been the first symptom of CDI, was considered to have been the result of anal dysfunction after low anterior resection compli- cated with postoperative leakage. At present, it is practic- ally extremely difficult to identify refractory cases before systemic deterioration develops. ELISA-based assays for C. difficile toxin are rapid and specific and therefore have been widely used as a test for CDI [5]. However, the detection of this toxin in the stool does not automatically imply that CDI is severe or re- fractory to medical therapy. In order to assess the sever- ity of colitis and necessity for emergent surgery, an evaluation of the colon is essential. Therefore, we con- sider that both enhanced abdominal CT and colonoscopy should be promptly performed once a patient’s post- operative course becomes aberrant from the expected one. We believe that they are the most reliable modal- ities for the evaluation of inflammation of the colon. If colonoscopy reveals confluent, not spotty, pseudomem- branes in considerable parts of the large intestine, or CT demonstrates severe wall thickening or dilatation of the colon, emergent surgery might be the treatment of choice for survival. Conclusions We presented a case with fatal fulminant pseudomem- branous colitis. The clinical course rapidly progressed beyond the scope of the conventional management algo- rithm. It is important to recognize that, although rare, there is a type of extremely aggressive pseudomembran- ous colitis in which the waiting period for medical treat- ment might be lethal and, therefore, immediate surgery should be performed. We believe that colonoscopy and CT are helpful to decide the necessity of emergent surgi- cal treatment without delay. Consent Written informed consent was obtained from the patient’s family for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.