Necrotizing colitis

[Antipsychotics-induced acute necrotizing enterocolitis: a case report]

The acute necrotizing enterocolitis (ANE) is a partial or total necrosis of the small and large intestine. This is a case report of an antipsychotic induced ANE.

Acute necrotizing colitis due to sigmoid colon cancer

When obstructive colitis becomes fulminant, it is known as ‘acute necrotizing colitis’. We report a rare case of acute necrotizing colitis due to sigmoid colon cancer, in which shock status occurred within ten hours of onset. A 79-year-old female with acute abdominal pain was transported to our hospital with acute shock. Abdominal enhanced computed tomography revealed thickening of the wall of the sigmoid colon and marked dilation of the proximal colon. Emergency surgery was performed with the intraoperative findings of severe sigmoid colon stenosis and proximal dilation of the colon without perforation, and a large volume of putrid ascitic fluid. The intestine was proximally dilated and black in color, from the sigmoid colon to the ileum 60 cm proximal to the terminal ileum, suggesting acute necrosis. Total colectomy with 80 cm resection of terminal ileum and ileostomy was performed. Whereas acute necrotizing colitis is a rare condition and its etiology remains obscure, the chronic ischemic state must play some role. Our patient was of advanced age and had diabetes mellitus and hypertension. These factors might lead to a chronic ischemic state of the bowel due to arteriosclerosis. In addition to the underlying condition, massive bacterial reflux into the ileum from the colon might cause the capillary vasoconstriction of the bowel that led to her critical state.

Necrotising colitis related to clozapine? A rare but life threatening side effect

We report here a case of a 34-year-old gentleman who developed right-sided necrotising colitis after clozapine usage. Anticholinergic activity is believed to the cause. We believe that in patients who have been consuming medications known to have an association with necrotising colitis, constipation with concomitant increasing abdominal pain, distension and fever should be treated with a strong index of suspicion. Consideration of necrotising colitis should prompt expeditious resection of the affected colonic segment.

Anorexia nervosa and necrotizing colitis

Anorexia nervosa is associated with a mortality approaching 5% in patients severely enough affected to warrant hospital care (Hsu, 1980). The main causes of death are inanition, electrolyte disturbances or suicide. We report here a case of necrotizing colitis associated with anorexia nervosa, an association which has not been described previously.

Analysis of the clinical features of ischemic colitis

Although ischemic colitis is not rare in the elderly with episodes of ischemia involving the heart and brain, clinical features of mild cases (transient type) have seldom been reported. Whereas the diagnostic findings of ischemic colitis are said to be longitudinal ulcers and stricture, longitudinal ulcers were noted only in 38% of the transient type in our series. For the correct diagnosis of the transient type, it was necessary to observe slight mucosal changes such as edema, congestion and petechiae by colonoscopy. It is emphasized that for the diagnosis of the mild transient type of ischemic colitis emergency colonoscopy must be performed as soon as possible after the onset of abdominal pain or rectal bleeding.

Acute necrotizing colitis and obstruction

Acute necrotizing colitis is a rare complication of colonic obstruction. Six cases occurring during a 20-month period are described. The presenting features were those of colonic obstruction with shock but without perforation. At laparotomy changes ranged from mucosal necrosis to frank gangrene in the colon proximal to the obstructing lesion. Gram stains of resected colon showed Gram-positive bacilli, resembling clostridia, invading the mucosa and submucosa. Two patients treated by defunctioning colostomy alone died but the remaining 4 survived after total colectomy. The cause is not known but raised intraluminal pressure may result in terminal mucosal ischaemia allowing anaerobic organisms to invade the bowel wall.

Pathogenesis of necrotising enteritis with special reference to intestinal hypersensitivity reactions

The aetiological aspects of 83 sporadic cases of necrotising enteritis (NE) have been studied. Of 56 cases in which histology of the intestine was possible, eight showed appearances (oedema and local eosinophilia) suggestive of a type I hypersensitivity reaction, while in 37 the appearances were suggestive of a type III reaction. We suggest that these reactions, which were more common in children and young adults, were initiating factors in the intestinal necrosis. The type III reactions (submucosal arteritis, fibrinoid necrosis of arteriolar walls, intramural and perivascular infiltration with polymorphonuclear, mononuclear, and eosinophil cells, and submucous oedema) were in seven cases accompanied by extraintestinal lesions (hypercellularity of glomeruli, amorphous material in the Bowman's capsular space, tubular casts, mononuclear cell infiltration into the hepatic portal tracts, congestion and oedema of the lung) which were compatible with systemic immune complex disease. The mesenteric lymph nodes in 12 out of 15 cases with intestinal arteritis showed appearances indicative of a humoral immune response. We suggest that NE is a two-stage process. In stage 1, a necrotic focus is established in the intestinal mucosa-submucosa by 'initiating' factors of vascular (functional or organic) or microbial (exotoxic, endotoxic, or Shwartzman) origin. Functional circulatory insufficiency in the intestine is of particular relevance to necrotising enteritis in neonates and in adults with traumatic shock or cardiac insufficiency. The jejunal and--to a lesser extent--the ileal microcirculation appear to be particularly vulnerable to microcirculatory insufficiency. Ninety-seven per cent of our cases were of NE of the small intestine of which 76% involved the jejunum alone or as a part of a jejunoileitis. These 'initiating' factors act either singly or synergistically with 'promoting' factors (changes in the volume, composition, or pH of the diet, intestinal stasis, or bacterial factors) in the establishment of necrotic foci in the intestine. Stage 2 results from the colonisation of the necrotic foci by intestinal clostridia, the toxigenic capacity of which will determine the progress of the intestinal lesion. Clinically established NE is essentially gas gangrene of the intestinal wall. Our bacteriological findings (microscopic, cultural, and serological) support a pathogenetic role of Cl. welchii in the established stages of necrotising enteritis. Strains of Cl. welchii from NE cases had significantly higher histidine decarboxylase activity than strains from control sources; it is possible that the resultant histamine production could act as a promoting factor in stage 1. Neutralising antibody against the Wanowrie virus, an Asian arbovirus which produces haemorrhagic enteritis in mice, was absent in the paired sera from 10 cases examined.

Spontaneous ischemic colitis

Eighteen cases of spontaneous ischemic colitis are reviewed. The diagnosis was established according to the following criteria: 1) clinical background, 2) clinical characteristics, 3) morphologic characteristics, and 4) clinical and morphologic course. The last three constituted the diagnostic criteria. The cases were divided into mild-to-moderate, moderate-to-severe, and gangrenous categories. Although data on clinical background did not establish the diagnosis of spontaneous ischemic colitis, they were essential in strict diagnosis. Patients who had histories of Crohn's disease, chronic ulcerative colitis, and recent antibiotic administration were excluded from consideration. Appropriate stool examinations obtained in all of the mild-to-moderate and all except two of the moderate-to-severe cases excluded colitis due to pathogenic bacterial organisms or parasites. Spontaneous ischemic colitis generally occurs in older individuals; the average age in our patients was 60 years. Twelve of the 18 patients had at least some evidence of major cardiovascular disease.

Necrotising enterocolitis of the newborn--is it gas-gangrene of the bowel?

Necrotising enterocolitis (N.E.C.) of the newborn is thought to be caused by ischaemia of the bowel. This would favour the conversion of clostridial spores, which can occur very early in the intestinal tract of newborns, to toxin-producing, invading bacilli. The histology of resected gut specimens from 6 of 7 N.E.C. patients who had undergone operation was similar to that in cases of gas-gangrene of the bowel and that in experimentally provoked pneumatosis cystoides intestinalis. In one case Clostridium perfringens type A was cultured in great number by anaerobic technique. The clostridia in these cases may have played an important role in the development of N.E.C.

Acute gangrenous colitis proximal to obstructive cancer of the sigmoid colon

Two cases of massive gangrenous inflammation of the colon proximal to obstructive carcinomatous lesions, the so-called obstructive colitis, are reported. Because of the rarity of this condition, the etiological factors responsible for this entity are not yet clear. The detailed pathological and microbiological studies at the time of operation are essential to their further clarification.

Ischaemic enterocolitis: an expression of the intravascular coagulation syndrome

In 20 cases of ischaemic enterocolitis unassociated with lesions of major vessels, fresh thrombi were found in the small vessels of the bowel wall and were widespread in other tissues. The capillaries of the renal glomeruli and vessels in the lung were the commonest sites. Pseudo-membranous enterocolitis is shown to be an early or more slowly evolving but identical entity to other forms of so-called ischaemic enterocolitis. This is a condition which includes ischaemic enterocolitis, postoperative enterocolitis, necrotizing enterocolitis, and probably some cases of clostridial and staphylococcal enterocolitis. It is due to an episode of intravascular coagulation occurring principally in the gut wall but also elsewhere.

Ischaemic colitis

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Haemorrhagic necrosis of the intestine

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Ischaemic colitis

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