Pseudomembranous colitis following resection for Hirschsprung's disease

Enterocolitis is the most common cause of significant morbidity and death in Hirschsprung's disease. Although most cases respond to nasogastric decompression, antibiotics, and colonic evacuation, some children have an unusually fulminant or protracted clinical course. Four cases are reported of pseudomembranous colitis (PMC) that developed 1 to 18 months (mean, 8 months) after definitive surgery for Hirschsprung's disease (Soave endorectal pull-though, 2; Duhamel procedure, 2). While all children presented with fever, abdominal distention, and diarrhea, indistinguishable from typical Hirschsprung's enterocolitis, the clinical course was fulminant in two cases, both of whom died of septic shock. Postmortem examination in both showed extensive colonic pseudomembranes despite identification of Clostridium difficile toxin and subsequent vancomycin therapy (initiated late in the clinical course). Two children in the series had protracted hospitalizations and eventually required diverting enterostomy despite recognition of C difficile toxin and treatment with enteral vancomycin, in one child necessitating multiple courses of antibiotic therapy. Awareness of the virulence of PMC associated with Hirschsprung's disease (even after definitive resection) should prompt submission of stool specimens from any child who presents with enterocolitis for both C difficile culture and toxin levels. On the basis of our experience it is our policy to initiate a prompt course of vancomycin by rectal lavage or nasogastric tube in all children with Hirschsprung's enterocolitis, pending culture results, in view of the significant morbidity and mortality exemplified by cases in this review.

Surgical management of fulminant pseudomembranous colitis

The presentation of pseudomembranous colitis ranges from mild self-limiting diarrhea to fulminant colitis with overwhelming sepsis. The management of the severe forms of this disease, including the role of surgical intervention, is poorly defined. To evaluate the management and outcome in severe cases, the authors reviewed the records of six patients (four women, two men) seen at The Toronto Hospital between 1985 and 1989 with pseudomembranous colitis manifesting as fulminant colitis. The patients ranged in age from 19 to 69 years (mean 52 years). All presented with nonbloody diarrhea, had peritoneal signs and were severely dehydrated, and all had received antibiotics between 4 days and 6 weeks before the onset of symptoms. The mean preoperative leukocyte count was 40.9 x 10(9)/L. Radiologically, the colon appeared to be dilated in three patients. Two patients were operated on immediately. The other four were treated medically, but three of them required surgery within 24 hours of presentation. Four (67%) of the six patients died. All four had been treated surgically. The mean age of the survivors was 28 years compared with 64 years for those who died. Pseudomembranous colitis can present as severe acute colitis and can carry a high mortality, especially in the aged. Surgical treatment may be required in those who fail to respond to medical management or have peritoneal signs.

Neonatal gastrointestinal perforations

Neonatal gastrointestinal perforation has been associated with mortality rates of 40% to 70%. Over the past 20 years, 81 infants (46 boys and 35 girls) were treated for a gastrointestinal perforation at this institution. Perforation occurred from birth to 50 days (average, 8.2 days). Etiologies included necrotizing enterocolitis (NEC) (68%), meconium ileus (10%), and idiopathic gastric perforation (7%). Seventy-six infants underwent surgical exploration and five infants, considered too small or too sick to withstand a laparotomy, were treated with peritoneal lavage only. There were 29 deaths, an overall mortality of 36%. Ninety percent of the death occurred in patients with NEC, while all patients with gastric perforations survived. There has not been a significant improvement in survival in recent years, partly because of an increase in the proportion of NEC-related perforations. However, there is a narrowing of the mortality gap between low birth weight and normal weight infants. As the risk inherent to laparotomy in neonates is decreasing, other factors, such as the underlying etiology or the site of perforation, play a more important prognostic role.

[Pseudomembranous colitis. Surgical treatment]

Pseudomembranous colitis is an inflammatory intestinal disease that is usually secondary to antibiotic treatment. The disease upsets the normal bacterial flora of the large intestine. Therapy consists of fluid replacement, discontinuation of broad-spectrum antibiotics and treatment with vancomycin or metronidazole. In severe or resistant cases surgical treatment is required. We describe one case history and give some guidelines for surgical treatment.

Laparotomy for fulminant pseudomembranous colitis

Clostridium difficile-associated pseudomembranous colitis is an increasingly common nosocomial infection that usually responds to oral antibiotics. Presentation as an acute abdomen occurred in 12 patients, leading to 14 laparotomies. A distinctive clinical picture was observed: advanced age, recent treatment with antibiotics, fever, abdominal pain, tenderness, marked leukocytosis, and ileus. Only six of the 12 patients had diarrhea. Five were immunosuppressed. Abdominal computed tomographic scans revealed ascites and a massively thickened colonic wall. All four patients treated by subtotal colectomy survived. Four of 10 patients treated only with laparotomy or segmental colectomy died, four responded to medical therapy, and the conditions of two deteriorated but were salvaged by subtotal colectomy. Early diagnosis via endoscopy or computed tomography should obviate the need for exploratory operations. However, progressive toxic effects indicate failure of medical therapy and the need for subtotal colectomy.

Recombinant human granulocyte colony-stimulating factor promotes wound healing in a patient with congenital neutropenia

We report a patient with congenital neutropenia or Kostmann's Syndrome who suffered many complications after presenting with Clostridium septicum enterocolitis, including absence of wound healing. Because of several reports of the use of granulocyte colony-stimulating factor (G-CSF) in patients with various complications of neutropenia, we treated this patient with recombinant human (rh) G-CSF. We found that once rhG-CSF restored neutrophil counts to normal, progressive wound healing followed. Thus, rhG-CSF therapy may be useful in treating neutropenic patients with wound complications.

[Prognosis of surgery performed in premature infants with birth weights below 1500 gram]

On account of improved management in neonatal intensive care units, the survival rate is presently nearly 50% in babies with birth weights below 1,000 grams and 80% in the group with birth weights from 1,000 to 1,500 grams. A number of these babies require surgery, either for correction of congenital anomalies or for acquired necrotizing enterocolitis, which is an increasing burden in neonatal units. The present analysis of 24 babies weighing under 1,500 grams, operated on in the period 1981 to 1988 confirms that even extremely small babies tolerate the performed anesthesia and surgery well. In the group with anomalies (7 of 24) three died (43%). The causes of death do not appear to be related to the anesthesia or surgery. In the group with necrotizing enterocolitis (15 of 24) six died (40%). The cause of death was directly related to the septic condition in all cases, and the surgical trauma does not appear to have any negative influence. Unfavourable prognostic factors in this group were low Apgar scores within the first minute and preoperative weight loss.

Combined Sarcocystis and gram-positive bacterial infections. A possible cause of segmental enterocolitis in Thailand

Between 1981 and 1990, 22 intestinal specimens surgically resected due to segmental enterocolitis were collected and examined. Grossly, the specimens were classified into 3 groups 1) Acute inflammation with hemorrhage and necrosis 2) Constrictive lesion 3) False diverticulum with perforation. Mostly, there was unisegmental involvement, distributed in jejunum, ileum and ileocolon. Microscopically, small parasitic structures, interpreted to be unconventional excystation stage of Sarcocystis hominis, (Railliet and Lucet, 1891) Dubey 1976, were present on the luminal border and within the crypt-lining epithelial cells. At the ulcerated area, tissue invasion by Gram-positive bacteria were always seen and considered as second pathogen. Source of the parasite was likely from cyst-containing beef available in markets, (Bos indicus and Bubalus bubalis) along with consumption of undercooked beef. Antismooth muscle antibody, IgG class, with the titer ranging from 1:16-1:256 were detected in 45 per cent of the patients. This is considered as autoimmunity against intestinal smooth muscle damaged previously from subclinical inflammatory condition. Present information suggests a long-standing existence of Sarcocystis in the patients' intestine, associated with Gram-positive bacterial infection, as the mechanism producing segmental enterocolitis found in the Central region.

[Necrotizing enterocolitis--analysis of a case cohort]

During a period of 25 months 11 newborns treated at the children's university hospital of Münster (0.8%) underwent laparotomy for necrotizing enterocolitis (NEC). The cases appeared sporadically without forming "clusters" typical of infectious etiology. 10 of 11 cases were premature infants (median birth weight 1280 g) stressing the predisposing role of immaturity. Ischemic events occurred in all patients prior to the onset of symptoms. The introduction of surfactant-therapy during the study period did not influence the incidence apparently. Ultrasonography was superior to radiology with regard to detection of extraluminal gas. We differentiated two types of clinical courses (3 acute and 8 protracted). In 5 cases we noticed a relapse of clinical symptoms after uptake of oral feeding. 3 newborns died with septic shock. The median hospitalisation time was 88.5 days in the 8 survivors. Enterostomy was replaced by definite anastomosis after 67.5 days (median). Median daily weight gain was 16.6 g. Late complications like permanent stenoses of short bowel syndrome were not observed. Early surgical intervention according to the general rules of abdominal surgery seems important even in very low birth weight infants.

[Surgical treatment of ulcerative-necrotizing enterocolitis in premature infants. Indications and results; apropos of 50 cases]

From 1984 to 1991, 50 premature infants needed surgery for necrotizing enterocolitis. In 36 cases, surgery was necessary in emergency (weight 700 to 3,000 g, mean term: 29 weeks). Surgical treatment consisted either in intestinal resection associated with enterostomy (n = 26, or enterostomy alone (n = 10). The results were as follows: 5 early deaths, 4 late deaths (3 due to extra-digestive causes), 22 good results with nutritional recovery after closure of enterostomy. At the present time, 5 children need parenteral nutrition or are waiting for closure of enterostomy. 14 infants needed a surgical treatment for late intestinal stricture (3 to 6 weeks) by resection with enterostomy (n = 7) or with immediate anastomosis (n = 7). 13 are alive without digestive sequelae and 1 died of neurological disease. According to our experience, early surgical treatment consists in enterostomy associated whenever possible with resection of necrotic intestine. Late strictures are at best managed by resection with immediate anastomosis.

Necrotizing enterocolitis following intrauterine blood transfusion

Intravascular intrauterine transfusion allows a more sophisticated and exact approach to the management of severe Rh hemolytic disease. This technique involves direct manipulation of the fetal umbilical vessels; its hazards include umbilical cord trauma and thrombosis or emboli. The consequences of such events in utero are largely unknown. In this case necrotizing enterocolitis occurred in a full-term infant after three intrauterine intravascular transfusions.

Cyclic neutropenia--unusual cause of acute abdomen. Report of a case

Cyclic neutropenia, a rare blood disorder, may be complicated by spontaneous necrosis of the cecum and ascending colon. We describe one such case, where a staged surgical approach achieved a successful outcome. The importance of recognition of this disorder is stressed, since this allows both performance of appropriate surgery and consultation with hematologic colleagues.

Changing trends in necrotizing enterocolitis. Experience with 302 cases in two decades

Three hundred two infants with necrotizing enterocolitis (NEC) were treated from 1972 to 1990. One hundred eighteen were treated medically while 184 infants required operation. Comparisons were made between two treatment periods, 1972 to 1982 (n = 176) and 1983 to 1990 (n = 126). Infants in the more recent era were of lower birth weight (1505 +/- 853 g versus 1645 +/- 836 g), earlier gestational age (30.4 +/- 4.7 weeks versus 32.4.5 weeks; [p less than 0.01]), had symptom onset at an older age (15.7 +/- 13.9 days versus 10.0 +/- 10.8 days; [p less than 0.001]), and a lower incidence of hyaline membrane disease (p less than 0.001). Fewer patients in the 1983 to 1990 group had acidosis (p less than 0.001) and severe oliguria (p less than 0.001). Operation was performed sooner after diagnosis in the second group (2.6 versus 3.8 days; [p less than 0.001]). Survival was unaffected by sex, maternal complications, or whether infants were inborn or transferred from other facilities. Improved survival (1983 to 1990) was observed in those infants between 24 to 27 weeks gestation (p less than 0.002) and those weighing less than 1000 g (p less than 0.001). Since 1983 portal vein air (PVA) on abdominal radiographs was used as an indicator for operation. Survival in infants with PVA has improved from 29% to 64% (p less than 0.02). Despite patients being more immature and weighing less, the overall survival rate improved from 58% (1972 to 1982) to 82% (1983 to 1990) (p less than 0.001). Operative survival rate improved from 51% to 75% (p less than 0.002). Long-term survival was 75% overall and 65% for surgical infants in the 1983 to 1990 group (p less than 0.05).

[Necrotising enterocolitis. Is there an ideal therapeutic intervention?]

Necrotising enterocolitis is a physiological and anatomic entity. The diagnosis is made during surgical intervention, based on macroscopic aspect, distinguishing to other necrotizing enteritis. Surgical intervention underwent on consequences of this medical disease which prognosis is very poor.

Pulmonary dysfunction in surgical conditions of the newborn infant

OBJECTIVE

To describe the pathophysiology of surgical conditions that are associated with respiratory insufficiency in the newborn infant.

DESIGN

Survey.

SETTING

Newborn ICU in a children's hospital.

PATIENTS

Twenty-four newborn infants (1 to 28 days old) who required endotracheal intubation and mechanical ventilation for operative procedures or postoperative ventilatory support.

INTERVENTIONS

Flow-volume curves obtained by manual inflation of the lungs, followed by forced deflation by negative pressure, and by passive expiration, under sedation and pharmacologic paralysis.

MEASUREMENTS

Deflation flow-volume curves and passive expiratory curves were measured. Pulmonary function testing before and after bronchodilator administration (n = 11) began midway during the study period. Term and preterm groups served as controls.

MAIN RESULTS

Forced vital capacity (FVC) was decreased in all groups with surgical disease as follows: abdominal wall defects and necrotizing enterocolitis groups to 48.3% and 62.1% that of preterm, respectively; pulmonary hypoplasia group to 55.5% that of term (p less than .05). Maximal expiratory flow at 25% of FVC decreased in all groups: abdominal wall defects and necrotizing enterocolitis group, to 36.8% and 37.9% that of preterm, respectively (p less than .05); pulmonary hypoplasia group, 20.0% that of term (p less than .05). The ratio of maximal expiratory flow at 25% of FVC divided by FVC was significantly decreased in necrotizing enterocolitis and pulmonary hypoplasia groups compared with that of preterm and term groups, respectively, but not in the abdominal wall defects group. Maximal expiratory flow at 25% of FVC, but not FVC, increased significantly (36%, p less than .05) after bronchodilator nebulization, indicating the presence of airway reactivity. Respiratory system compliance was decreased significantly (p less than .05) in all surgical disease groups compared with the term group.

CONCLUSIONS

Bronchial reactivity contributes to decreased maximal expiratory flow at 25% of FVC, a feature also seen in premature infants with respiratory distress syndrome who later develop bronchopulmonary dysplasia. Babies who require chronic ventilatory support after operation and who have developed reactive airways may benefit from the administration of bronchodilators during postoperative ventilatory management.

[Non-obstructive necrotizing acute enterocolitis (apropos of a case report) )University Hospital Center Kamenge-Bujumbura)]

The authors report on a new case of acute necrotic non obstructive enterocolitis. Discussion is mainly centered on the nosological framework of this uncommon affection, occurring in an infectious background, and on its etiopathogenetic mechanism. Several hypothesis are formulated. Because of the seriousness of its prognosis, it is emphasized on the necessity of a rapid surgical intervention.

Maternal cocaine abuse and necrotizing enterocolitis: outcome and survival

Since 1987, multiple complications related to maternal cocaine abuse have been reported. Necrotizing enterocolitis-(NEC) of the newborn has been observed with increasing frequency. We report a comparative analysis of infants with NEC born to cocaine abusing mothers (n = 11) to a standard population of newborns with NEC (n = 50) treated in this institution from January 1987 to July 1989. We also evaluated whether prenatal cocaine abuse predisposes infants to NEC by performing a case-control analysis using 51 of 61 infants and controls matched for race, sex, and birthweight +/- 250g. Significant differences were apparent between the cocaine-affected infants (COC) and the noncocaine-affected infants (Non-COC) with regard to surgical intervention (72.7% v 38%, P less than .05), the presence of massive gangrene (54% v 12%, P less than .01), mortality (54.5% v 18%, P less than .01), and maternal age (28.13 +/- 3.82 years v 24.12 +/- 6.21 years P less than .05). No differences between these groups could be demonstrated for other known NEC risk factors such as gestational age, birthweight, feeding patterns, umbilical artery catheters, or asphyxia. In the matched case-control study, infants born to mothers who were cocaine abusers demonstrated a 2.5-fold increased risk of developing NEC (95% Cl = 1.17 to 5.32, P = .02) when compared with the noncocaine-exposed group. Maternal cocaine abuse appears to play a contributory role in the pathogenesis of NEC, its extent, and its outcome.

Necrotising colitis with perforation in diarrhoic patients treated with loperamide

Two cases of necrotising enterocolitis with perforation occurred in patients with paralytic ileus after loperamide therapy. The possible role of loperamide in the pathogenesis of the complications is suggested.

[Surgical therapy of neonatal necrotizing enterocolitis]

Between 1972 and 1988, a total of 57 patients with an average birth weight of 1988 g and an average gestational age of 34.1 weeks were operated on for neonatal necrotizing enterocolitis. In 48% of the cases, the critical indication for surgery was determined by clinical examination; in 52% of the cases, the indication was based upon a radiological diagnosis of pneumoperitoneum. The affected intestinal portions were first resected. Then, the proximal and distal limbs were sewn together and brought out through a separate short incision. Utilizing this procedure, the lethal rate sank from above 80% to below 30%. Taking into account unrelated causes of death, no significant increase in risk has been associated with the use of this procedure on prematurely born patients and patients exhibiting acute intestinal perforations.