Extrinsic surgical denervation inhibits Clostridium difficile toxin A-induced enteritis in rats

Clostridium difficile enteritis is caused by toxin A (TA) which stimulates substance P release and subsequent receptor activation. This receptor stimulation results in secretion, inflammation, and structural damage. However, it is unclear as to which subset of neurons is required to initiate substance P release following toxin stimulation. Five centimeter ileal segments were surgically denervated. After 10 days, three ileal loops were constructed in each rat: the denervated loop was injected intraluminally with 5 microg of TA and two intact loops were injected with TA or vehicle, respectively. Ileal secretion, myeloperoxidase activity, and histology were then assessed. Denervated ileal loops injected with TA had a 75% reduction in ileal secretion (P < 0.001), 92% reduction in myeloperoxidase activity (P < 0.01) and 96% reduction in histologic damage (P < 0.001) compared to innervated loops. There were no significant differences between the denervated loops injected with TA and those injected with vehicle. Extrinsic surgical denervation results in protection of ileal loops from TA enteritis. Furthermore, these results exclude the participation of intrinsic enteric nerves in TA-induced ileal damage. Finally, this suggests that extrinsic primary sensory neurons mediate the effects of intraluminal TA in the ileum.

Toxic pseudomembranous colitis in a patient with ulcerative colitis

Toxic colitis is a severe disease that may be caused by several inflammatory and/or infectious diseases. Ulcerative colitis is one of the most frequent causes of toxic colitis in the United States. Toxic megacolon complicating Clostridium difficile colitis is a rare occurrence with significant morbidity and mortality.

CASE REPORT

A 52-year-old male presented with rectal bleeding and tenesmus. He had been treated for amebiasis with metronidazole, and had improved. Two weeks later, symptoms recurred, and he was referred to our hospital. A sigmoidoscopy and biopsies demonstrated mucosal ulcerative colitis. He underwent treatment with systemic prednisone, mesalamine, and hydrocortisone enemas with adequate response. He was asymptomatic for 2 months, but later presented with a tender abdomen and rectal bleeding. Plain abdominal and thorax films showed colonic distention and free intraperitoneal air. Emergency laparotomy was performed, and an inflamed and distended colon, with free inflammatory liquid in the peritoneum, was found. A total abdominal colectomy with temporary ileostomy and Hartmann's pouch was performed. The histopathology analysis demonstrated a Clostridium difficile pseudomembranous colitis.

CONCLUSION

The presence of toxic megacolon due to Clostridium difficile in patients with ulcerative colitis is a rare complication that may be suspected in patients with initial relapse who are on antibiotics.

Pseudomembranous colitis: can CT predict which patients will need surgical intervention?

PURPOSE

Our purpose was to determine if patients with pseudomembranous colitis (PMC) requiring surgical intervention demonstrate radiographic features distinct from those of patients treated successfully with standard medical therapy.

METHOD

The indications for a CT study and the imaging findings from 17 patients who required laparotomy with colon resection for PMC were retrospectively reviewed. The CT findings were compared with the findings from 17 control patients (matched by clinical presentation) with PMC who were treated medically and did not require surgical intervention.

RESULTS

None of the CT findings evaluated in this study were significantly different between the surgical and nonsurgical groups. The CT findings evaluated for the surgical and nonsurgical groups, respectively, were as follows: wall thickness of the colon: 17.8+/-6.6 and 16.9+/-3.9 mm; largest caliber of the colon: 6.8+/-1.6 and 6.1+/-1.2 cm; presence of the accordion sign: 52.9 and 70.6%; heterogeneous contrast enhancement pattern (target sign): 57.1 and 57.1%; pericolonic stranding: 82.4 and 88.2%; ascites: 70.6 and 58.8%; pleural effusion(s): 64.7 and 64.7%; and subcutaneous edema: 64.7 and 64.7%.

CONCLUSION

Although none of the CT findings evaluated in this study was significantly different between the surgical and nonsurgical groups, CT was often the initial diagnostic modality in both groups. It is important for radiologists to recognize the CT appearance of PMC and suggest the diagnosis. However, patient triage may not be based solely on the CT findings.

Primary anastomosis in the treatment of acute disease of the unprepared left colon

Between June 1, 1990 and December 31, 1996, 58 consecutive patients with unprepared colons were urgently explored for nontraumatic disease with intent to proceed with primary left-sided colonic anastomosis. Unprotected anastomoses were not attempted in 15 patients. The causes of exclusion included preoperative and intraoperative shock in three patients, and three patients were on long-term high-dose steroids, four had gross fecal contamination of the peritoneal cavity, four had large pelvic abscesses, and one had ischemic colitis. All 43 patients undergoing anastomosis without protective colostomy had stapled anastomoses. Indications included complicated diverticular disease in 32 cases. There were nine cases of obstruction from colorectal carcinoma and one obstruction due to sigmoid volvulus. There was one case of perforation from pseudomembranous enterocolitis. The most common complications were: atelectasis in nine cases, wound infection in two cases, and prolonged ileus in two cases. Pelvic abscess occurred in one case. There was one wound dehiscence. There was one anastomotic dehiscence, and there was no mortality. Operative time averaged 85 minutes and hospital length of stay 9.7 days. Primary anastomosis of the unprepared left colon is safe in most urgent and emergent situations, thus avoiding the significant morbidity and cost of colostomy closure.

High morbidity of enterostomy and its closure in premature infants with necrotizing enterocolitis

OBJECTIVE

To review the morbidity and mortality among 68 premature infants treated with enterostomy for necrotizing enterocolitis.

DESIGN

Data were collected retrospectively from hospital medical records to include the period between January 1, 1987, and September 30, 1997.

SETTING

Tertiary care children's hospital.

PATIENTS

A group of 68 infants aged 2 to 35 days (mean age, 12.5 days), weighing 1500 g or less, with necrotizing enterocolitis necessitating surgical enterostomy for treatment.

INTERVENTIONS

Creation of any enterostomy during exploratory laparotomy for necrotizing enterocolitis and subsequent closure.

MAIN OUTCOME MEASURES

Morbidity and mortality associated with infant enterostomy and its closure.

RESULTS

Thirty-nine infants underwent ileostomy with mucous fistula, 16 underwent ileostomy with a Hartmann pouch, 7 had jejunostomy with mucous fistula, 2 had colostomy with mucous fistula, and 4 had colostomy with a Hartmann pouch. Eighteen (26%) of the 68 infants died in the postoperative period of sepsis (n = 10), continuing necrotizing enterocolitis (n = 5), or respiratory distress (n = 3). Of the remaining 50 infants, complications developed in 34 (68%). These complications included strictures requiring further resection at the time of enterostomy closure in 20 infants; stricture of the enterostomy requiring surgical revision in 6; incisional hernia in 3; parastomal hernia in 4; enterostomal prolapse or intussusception in 6 and 1, respectively; wound dehiscence in 4; wound infection in 8; small-bowel obstruction requiring laparotomy in 2; and anastomotic complications in 2. Only 16 enterostomies were closed uneventfully, with 3 of these infants subsequently dying of sudden infant death syndrome between 6 and 8 months after the operation. Of the surviving infants, 3 (6%) continue to require home hyperalimentation.

CONCLUSIONS

Although enterostomy in infants with low birth weight with necrotizing enterocolitis may be lifesaving, it is also a major cause of morbidity. These data suggest the feasibility of a prospective study comparing resection and primary anastomosis with resection and enterostomy.

Long-term follow-up after bowel resection for necrotizing enterocolitis: factors affecting outcome

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common surgical emergency among newborns and is associated with a high morbidity and mortality. This study evaluates the long-term survival of infants requiring surgical intervention for NEC and factors affecting outcome.

METHODS

A retrospective review of infants requiring surgery for complications of NEC at a tertiary care, pediatric hospital over a 16-year period was performed. Patients were evaluated for early and late morbidity and mortality, length of intestinal resection, presence of the ileocecal valve (ICV), days of parenteral nutrition (PN), and growth.

RESULTS

Two hundred forty-nine patients were included, with an average gestational age of 30 +/- 5 (+/- SD) weeks and birth weight of 1.50 +/- 0.89 kg. The surgical mortality rate was 45%, with survivors (137) being larger (P < .001) and older (P < .001) at time of birth than nonsurvivors. Mortality rates varied inversely with gestational age and birth weight. Surgical survivors had an average of 21 +/- 26 cm of intestinal length resected. The ileocecal valve was preserved in 45% of infants. Growth was similar between infants with or without an ICV. Stratification of length of intestine resected showed that infants with larger resections had greater requirements for parenteral nutrition, but this had no influence on long-term growth at follow-up.

CONCLUSIONS

Survivors of NEC are characterized by greater gestational age, greater birth weight, and older postgestational age at surgery. Infants who underwent greater intestinal resections required longer periods of PN. The length of intestine resected or presence of the ileocecal valve had no overall bearing on long-term outcome.

Venous access via the renal vein: a technical innovation

A patient with difficult venous access is described in whom both haemodialysis and parenteral nutrition were required. To minimize the impact on transplant prospects, the renal veins were used for vascular access. The technique and rationale for this novel approach are presented.

Enteric defensin expression in necrotizing enterocolitis

Immaturity of local innate defenses has been suggested as a factor involved in the pathophysiology of necrotizing enterocolitis (NEC). The mRNA of enteric human defensins 5 (HD5) and 6 (HD6), antibiotic peptides expressed in Paneth cells of the small intestine, have significantly lower levels of expression in fetal life compared with the term newborn and adult. In the current study, intracellular HD5 was demonstrated by immunohistochemistry at 24 wk of gestation, but at low levels, consistent with findings at the mRNA level. These data suggest that the low level enteric defensin expression, characteristic of normal intestinal development, may contribute to the immaturity of local defense, which predisposes the premature infant to NEC. To test if levels of defensin expression are altered in NEC, specimens from six cases of patients with NEC and five control subjects (four patients with atresia and one with meconium ileus) were analyzed to determine HD5 and HD6 mRNA levels by in situ hybridization. Compared with the control group, the level of enteric defensin expression per Paneth cell assessed by image analysis was increased 3-fold in cases of NEC (p = 0.02, analysis of variance and covariance). In addition, the number of Paneth cells was increased 2-fold in the small intestinal crypts of NEC specimens compared with those of control subjects (p < 0.01, covariance analysis). In healthy tissue, peptide levels within Paneth cells paralleled mRNA levels through development. In tissue from infants with NEC, the steady state level of intracellular peptide was not increased in conjunction with the observed rise in defensin mRNA. A straightforward interpretation of this finding is that HD5 is actively secreted in this setting and the Paneth cells maintain a constant steady state level of intracellular peptide, but the possibility of translational regulation of peptide expression is also consistent with these data. The associations between NEC and enteric defensin expression reported here offer support for future studies to address the role of these endogenous host defense factors in the pathophysiology of this disease.

Successful treatment of liver hemorrhage in the premature infant

Intraoperative neonatal liver hemorrhage usually results in exsanguination and death. The parenchyma of a neonatal liver is fragile, and the capsule is very thin, unlike that in the pediatric and adult patient. This renders the treatment of a neonatal liver fracture almost universally unsuccessful. The current report describes two cases of successful management of intraoperative neonatal liver hemorrhage during surgery for necrotizing enterocolitis (NEC).

Neonatal necrotizing enterocolitis: the long-term perspective

Ten years' experience with neonatal necrotizing enterocolitis (NNEC) was reviewed retrospectively to determine long-term survival and quality of life and to analyze risk factors associated with in-hospital mortality. Institutional records were queried to identify all neonates who required emergent surgical intervention for NNEC. These records were then reviewed and survivors' families interviewed by phone to determine patient status, persistent gastrointestinal problems, and overall quality of life. Once identified, long-term survivors (LTSs) were compared to in-hospital deaths by the analysis of birth weight, gestational age, time interval from birth to diagnosis, indications for laparotomy, and extent of intestinal involvement. Between 1986 and 1996, 69 patients required surgical intervention for NNEC. Eleven patients were lost to follow-up. Of the remaining 58 patients, 31 were ultimately discharged home, with 28 patients having survived an average of 4.18 years. The acute, or in-hospital, mortality rate was 39.1 per cent. Infants who died did so within an average of 23 days postoperatively, and those who were discharged home required an average of 121 days of inpatient convalescence. Twenty-one of the 28 LTSs achieved a normal quality of life with no persistent health problems. One patient required a hepatic-intestinal transplant, and another six had minor problems with frequent diarrhea. Average birth weight, age at NNEC diagnosis, and gestational age were not significantly different between LTSs and those with acute deaths. Aggressive in-hospital care is warranted for infants with NNEC. The excellent quality of life achieved in 75 per cent of survivors implies that the expense of heroic surgical care for these seriously ill premature infants is a worthwhile investment.

Alterations in respiratory status: early signs of severe necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) presents with well-recognized signs of intestinal inflammation such as bilious vomiting, bloody stool, abdominal distension, and tenderness. The authors observed otherwise unexplained changes in the respiratory status requiring increased respiratory support during the 24 hours before direct evidence of the intestinal disorder in patients with severe NEC.

METHODS

To study this observation the authors collected data on 10 consecutive patients in whom NEC required an operation.

RESULTS

Eight of these patients were recovering from respiratory distress syndrome (RDS). During the 24 hours before any direct sign of intestinal dysfunction seven of these eight had a respiratory prodrome needing increased respiratory support. Two patients required intubation and mechanical ventilation. Five needed increased supplemental oxygen. This prodrome included decreased oxygenation in seven, increased respiratory rate in five, and increased PCO2 in five, preceded by hypocarbia in three.

CONCLUSIONS

These changes in the respiratory condition revisit the concept of high output respiratory failure. This term was introduced to describe the respiratory failure in adult patients who suffer acute intestinal illness. Increased metabolic demand from the intestinal illness was thought to stress the ability of the patient to delivery oxygen and remove carbon dioxide. The ability of the respiratory system to meet the increased demands is limited by the intestinal dysfunction itself (abdominal pain and distension). In our patients recovering from RDS the pulmonary reserve is inherently limited. Because they are carefully monitored, it is easy to retrieve evidence of respiratory changes that precede the direct signs of intestinal disease. In the earliest stages of intestinal illness before the direct signs of intestinal dysfunction, these patients often manifest unexplained signs of respiratory compensation and decompensation and require increased respiratory support. Regardless of the pathophysiology, these alterations in respiratory status represent an early warning sign of NEC.

Advances in neonatal surgery

Neonatal surgery has reached a high degree of sophistication. We are now entering a new era of widespread screening of the unborn by means of ultrasound, with planned intrauterine, intrapartum, and immediate postpartum interventions. Many pediatric surgical centers are now focusing their investigative efforts on elucidating the cellular, molecular, and biochemical response to disease and therapeutic agents. The author presents the topic of neonatal surgery to some of the newer applications, techniques, and approaches.

The role of surgery in pseudomembranous enterocolitis

Pseudomembranous enterocolitis is an inflammatory bowel disorder caused by Clostridium difficile toxins. Classical presentation includes abdominal pain, pyrexia, diarrhoea and leucocytes. The management is mainly conservative but in extreme cases surgery is necessary. Resectional procedures (colectomy) carry a better prognosis than diversion procedures (colostomy). A careful history, a high index of suspicion, and early diagnosis and treatment would reduce the associated morbidity and mortality of this condition. The aetiopathogenesis, pathology, clinical presentation, diagnosis, differential diagnosis, complications, medical and surgical management are reviewed, and three case reports briefly discussed. A management algorithm is also suggested.

Timing of surgery for fulminating pseudomembranous colitis

BACKGROUND

With increasing antibiotic usage Clostridium difficile colitis is becoming more common. Surgery for fulminating C. difficile colitis, however, is rare because of the effectiveness of specific anticlostridial chemotherapy. Surgical outcome in five patients with fulminating C. difficile colitis involved in a recent outbreak of this disease is reported.

METHODS

Five of 138 patients developed fulminating C. difficile colitis unresponsive to medical therapy. All patients had antibiotics in the preceding period. Indications for operation in those who underwent surgery were systemic toxicity with a pyrexia, marked leukocytosis and abdominal signs leading to progressive organ failure, despite appropriate anticlostridial antibiotic therapy.

RESULTS

At operation all patients had a markedly oedematous colon with normal serosa but with acute mucosal colitis. All underwent subtotal abdominal colectomy and ileostomy. Progressive organ failure persisted in four, leading to death, giving a mortality rate of four in five in the operated group in comparison with 3.8 per cent (five of 133 patients) in those treated medically.

CONCLUSIONS

These results indicate that this increasingly common disease frequently leads to a fatal outcome in patients requiring surgery and implies that earlier surgical consultation may be necessary to improve survival in patients with fulminating C. difficile colitis unresponsive to antibiotic therapy.

Severe Clostridium difficile-associated colitis in young patients with cystic fibrosis

We report four patients with cystic fibrosis and fulminant Clostridium difficile-associated colitis: two died, and one required hemicolectomy. Three of four patients carried the N1303K mutation. Severe and fatal C. difficile colitis can occur in cystic fibrosis patients, possibly with a genotype-specific predilection (i.e., N1303K/other). Because cystic fibrosis patients may have a wide spectrum of gastrointestinal symptoms, disease caused by C. difficile must be considered when these patients have acute abdominal pain, diarrhea, or severe leukocytosis.

[Necrotizing gastroenteritis associated with inflammatory bowel disease]

Gangrene of the stomach is a rare and catastrophic event, usually attributed to local pathologic conditions. Although there are no cases documented in the literature, non-occlusive arterial ischemia is sometimes listed among the causes of necrotizing gastritis. We report a case of necrotizing gastroenteritis associated with a low flow state secondary to an episode of fulminant colitis, fecal peritonitis and septic shock. The patient recovered after staged resection of the involved segments of the gastrointestinal tract.

[Complicated amebic liver abscess--course and therapy]

We report on a case of an amoebic liver abscess acquired during a holiday in Bali. Transdiaphragmatic migration and consecutive atelectasis of the right lung caused respiratory insufficiency, requiring immediate surgical intervention. Complications consisted of massive bleeding into the colon concomitant with a reactivated CMV-infection. In addition, toxins of Clostridium difficile and enterohaemorrhagic E. coli were seen in the faeces. In contrast to the majority of uncomplicated cases of amoebic liver abscess, usually treated with amoebicidal drugs only, surgical intervention was clearly indicated in our patient.

Inflammatory cytokine mRNAs in surgical specimens of necrotizing enterocolitis and normal newborn intestine

Coagulation necrosis, inflammation, and hemorrhage are pathologic hallmarks of necrotizing enterocolitis (NEC). Because cytokines are peptides that mediate inflammatory cell recruitment and amplify the immune response, several of the inflammatory cytokines have been implicated in NEC. We hypothesized that mRNA levels for the interrelated cytokines interleukin-1 beta (IL-1 beta), tumor necrosis factor-alpha (TNF-alpha), IL-6, and the neutrophil chemotactic factor IL-8 would be increased in NEC and would be associated with the presence of inflammation. In this study, we determined the relative levels and localization of mRNA for these cytokines in surgical pathology archival intestinal tissue from 29 premature infants with acute NEC and 15 control infants with congenital intestinal malformations using a novel quantitative in situ hybridization technique. Compared with controls, there were higher IL-1 beta mRNA levels in full-thickness sections and higher TNF-alpha mRNA levels in full-thickness and mucosa sections of acute NEC samples, suggesting a potential role for these cytokines in the pathogenesis of local inflammation in NEC. IL-6 and IL-8 mRNA levels were similar in samples of control and acute NEC cases. Analysis of covariance including all subjects showed that the presence of acute inflammation was associated with increased IL-1 beta mRNA levels in mucosa (P = .035) and increased IL-8 in full-thickness sections (P = .005) and mucosa (P = .01). In four of five NEC cases in which intestinal specimens were available from reanastomosis surgery, cytokine mRNA levels decreased to low or undetectable levels. These data suggest that the inflammatory cytokines are involved in neutrophil recruitment and augmentation of the inflammatory response in neonatal intestine.

[Necrotizing enterocolitis (NEC)]

Necrotizing enterocolitis is a serious abdominal disease in infants during the first 2 months of life. The earliest radiographic finding on frontal abdominal films is initially distension of the small bowel, secondly of the colon, and pneumatosis intestinalis. Pneumatosis intestinalis is not pathognomonic for necrotizing enterocolitis; it can occur throughout life in different abdominal diseases. It can be a serious prognostic sign for abdominal ileus, but it may also occur in non-critically ill patients. Radiographic diagnosis in childhood is achieved with a frontal film of the abdomen in the prone position, and to detect a possible perforation, a left lateral abdominal decubitus exposure is necessary. Sonography and duplex sonography are helpful in evaluating progressive changes, the clinical course and the differential diagnosis.

Pseudomembranous colitis with associated fulminant ileitis in the defunctionalized limb of a jejunal-ileal bypass. Report of a case

Presented is what is believed to be the first reported case of a defunctionalized limb of small intestine serving as a reservoir for Clostridium difficile. Because of the altered intestinal continuity, the ensuing enteritis and colitis failed to respond to nonoperative management. Current treatment strategies are reviewed. Surgical intervention, including restoration of normal gastrointestinal continuity, should be considered early in the hospital course of this patient population.

Laparotomy or drain for perforated necrotizing enterocolitis: who gets what and why?

Between 1974 and 1988, 86 newborns with perforated necrotizing enterocolitis (NEC) were treated by either laparotomy (usually involving a bowel resection and a temporary stoma) or a peritoneal drain under local anesthesia. The survival of babies in the laparotomy group was 57% versus 59% in the drained group. However, for neonates less than 1,000 g survival in the drained group was 69% compared to 22% for the laparotomy group (P <.01). As the weight of the babies increased over 1,000 g, the survival in the laparotomy group increased to 67%. There was no significant increase in survival in infants over 1,500 g. The highest neonatal mortality risk is generally found among babies weighing less than 1,000 g at birth with a gestational age of less than 30 weeks. This risk increases even more when perforated NEC is added to the prematurity. With the use of peritoneal drainage, survival in this group can approach that of larger neonates.