Sigmoid diverticular perforation in neurosurgical patients receiving high-dose corticosteroids

Silent Sigmoid Colon Diverticular Perforation: A Case Report

Colonic perforation is associated with high mortality rates, and it requires prompt diagnosis and intervention to ensure favorable patient outcomes. The condition usually presents with typical peritoneal signs and symptoms, but atypical presentations can be a diagnostic challenge. In this report, we present a case of sigmoid diverticulosis perforation in an elderly patient who had no symptoms after the perforation developed. This case highlights the importance of detailed history, physical examination, and a low threshold of suspicion in patients with risk factors for atypical presentations.

Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report

Patient: Male, 57

Final Diagnosis: Perforated diverticuli

Symptoms: Asymptomatic

Medication: —

Clinical Procedure: —

Specialty: Surgery

Intestinal Perforation in ACTH-Dependent Cushing's Syndrome

Previous studies have linked systemic glucocorticoid use with intestinal perforation. However, the association between intestinal perforation and endogenous hypercortisolism has not been well described, with only 14 previously published case reports. In this study, we investigated if intestinal perforation occurred more frequently in patients with ectopic ACTH syndrome and in those with a greater than 10-fold elevation of 24-hour urinary free cortisol level. Of 110 patients with ACTH-dependent Cushing's syndrome followed in two clinics in Canada, six cases with intestinal perforation were identified over 15 years. Age of patients ranged from 52 to 72, five females and one male, four with Cushing's disease and two with ectopic ACTH production, one from a pancreatic neuroendocrine tumor and one from medullary carcinoma of the thyroid. Five had diverticular perforation and one had intestinal perforation from a stercoral ulcer. All cases had their lower intestinal perforation when the cortisol production was high, and one patient had diverticular perforation 15 months prior to the diagnosis of Cushing's disease. As in previously reported cases, most had hypokalemia and abdominal pain with minimal or no peritoneal symptoms and this occurred during the active phase of Cushing's syndrome. Whereas all previously reported cases occurred in patients with 24-hour urinary free cortisol levels greater than 10-fold the upper limit of normal when measured and 11 of 14 patients had ectopic ACTH production, only one of our patients had this degree of hypercortisolism and four of our six patients had Cushing's disease. Similar to exogenous steroid use, patients with endogenous hypercortisolism also have a higher risk of intestinal, in particular diverticular, perforation and should be monitored closely for its occurrence with a low threshold for investigation and surgical intervention. Elective colonoscopy probably should be deferred until Cushing's syndrome is under control.

Socioeconomic characteristics and comorbidities of diverticular disease in Sweden 1997-2012

PURPOSE

This study aimed to evaluate the association of socioeconomic status and comorbidities with uncomplicated and complicated diverticular disease (DD) in Sweden.

METHODS

We identified all individuals aged ≥30 years in Sweden diagnosed with DD between 1997 and 2012 using the Swedish National Population and Housing Census and the Hospital Discharge Register. Data were analyzed by multivariable logistic regression, with individual-level characteristics as covariates.

RESULTS

A total of 79,481 patients (median age 66 [range 30-86] years) were hospitalized for DD, 15,878 (20%) of whom for complicated DD. Admissions for both uncomplicated and complicated DD were more common in women (p < 0.001). A low education level was identified as a risk factor for uncomplicated (unadjusted hazard ratio [HR] 1.79, 95% confidence interval [CI] 1.75-1.82; adjusted HR 1.22, 95% CI 1.19-1.24) and complicated DD (unadjusted HR 1.84, 95% CI 1.77-1.92; adjusted HR 1.26, 95% CI 1.21-1.32). Patients with the lowest income had a lower risk of hospitalization for uncomplicated (adjusted HR 0.94, 95% CI 0.91-0.96) and complicated DD (adjusted HR 0.87, 95% CI 0.83-0.92) than those with the highest income. The correlation coefficient between income and education was 0.25. Diabetes and cardiovascular disease were identified as protective factors against uncomplicated DD (adjusted HR 0.68, 95% CI 0.66-0.69 and HR 0.79, 95% CI 0.74-0.84, respectively).

CONCLUSIONS

Patients with the lowest education level had an increased risk of hospitalization for DD. Further studies are needed to explore the association of diabetes and cardiovascular disease with uncomplicated DD.

[Radiotherapy for gliomas in adults: What are the stakes of the follow-up?]

Linked to the difference of prognosis, the terms and conditions of the follow-up of low-grade and high-grade gliomas treated by irradiation differ highly. Patients treated for a low-grade glioma have prolonged survival. In this case, monitoring of toxicities linked to the treatment is a major objective. Opportunistic infections and depression are corticosteroids side effects widely underestimated. Radionecrosis search and differentiation with recurrent disease are done by MRI. Perfusion and spectroscopy showing a choline/creatine ratio increase are in favour of disease recurrence. Cognitive status and quality of life must be evaluated during the follow-up. They have to be evaluated by adapted scales. Cognitive rehabilitation improves interestingly the post-treatment cognitive status. Pseudoprogression rates for high-grade gliomas are near 20%. MRI is the benchmark imaging for its diagnosis. Diffusion weight imaging and spectroscopy are actually the most interesting techniques.

Retrospective analysis of safety and feasibility of a 3 days on/11 days off temozolomide dosing regimen in recurrent adult malignant gliomas

AIMS

We report the safety and feasibility of a 3 days on/11 days off temozolomide regimen for the treatment of recurrent malignant gliomas.

PATIENTS & METHODS

Fifteen adult patients were treated; 14 were treated with 300 mg/m(2) and one treated with 250 mg/m(2).

RESULTS

We reviewed the toxicity, progression-free survival (PFS), overall survival and objective response rate. Two patients (13%) experienced grade 3 nausea/vomiting and six patients (40%) experienced grade 3 lymphopenia. Dose reduction and treatment delay occurred in eight (53%) cases. One patient discontinued treatment due to uncontrolled nausea/vomiting. Median PFS for glioblastoma patients was 4.1 months and 6-month PFS was 25%. Twelve patients exhibited stable disease (86%), one patient (7%) had progressive disease and one patient (7%) showed a partial response.

CONCLUSION

The '3 on/11 off' temozolomide regimen for recurrent high-grade gliomas was tolerable and warrants further study in a larger, prospective study.

Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking

Background

Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding.

Methods

A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed.

Results

Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities.

Conclusion

Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.

Medical management of brain tumors and the sequelae of treatment

Patients with malignant brain tumors are prone to complications that negatively impact their quality of life and sometimes their overall survival as well. Tumors may directly provoke seizures, hypercoagulable states with resultant venous thromboembolism, and mood and cognitive disorders. Antitumor treatments and supportive therapies also produce side effects. In this review, we discuss major aspects of supportive care for patients with malignant brain tumors, with particular attention to management of seizures, venous thromboembolism, corticosteroids and their complications, chemotherapy including bevacizumab, and fatigue, mood, and cognitive dysfunction.

Medical influences, surgical outcomes: Role of common medications on the risk of perforation from untreated diverticular disease

Numerous drugs, largely used in the wards or at home, have a significant influence on patients with untreated diverticular disease. The consequences can be disastrous, may require an emergency operation, postoperative intensive care, and overall influence the patient’s length of stay and the final outcomes. Bearing these considerations in mind the routine or chronic administration of pain-killers, steroids and non-steroidal anti-inflammatory should be balanced in patients with known diverticular disease as it normally happens with other conditions potentially affected by these drugs (i.e., peptic ulcer disease or chronic obstructive pulmonary disease). This is even more important in the old and frail patient where an eventual surgical treatment may not always be possible.

C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications

BACKGROUND

Diverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids.

METHODS

We analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT.

RESULTS

A total of 295 patients were included in the study. Two hundred and forty-three (82 %) were classified with uncomplicated (Hinchey 1a) and 52 (18 %) with complicated disease (Hinchey > 1a). Mean CRP levels were 133.5 and 63.5 mg/ml for those with complicated and uncomplicated disease, respectively (p < 0.001), and 139 and 60 mg/ml, respectively (p < 0.001) in the subgroup of patients taking aspirin (n = 61). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRP > 90 mg/ml had 88 % sensitivity and 75 % specificity for complicated disease.

CONCLUSIONS

The CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.

The risk of gastrointestinal perforations in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the BSRBR-RA

OBJECTIVES

To evaluate the risk of gastrointestinal perforation (GIP) in subjects with rheumatoid arthritis (RA) treated with antitumour necrosis factor (anti-TNF) therapy compared with non-biological disease-modifying antirheumatic drugs (nbDMARDs).

METHODS

Using data from the British Society for Rheumatology Biologics Register, we compared the incidence of GIPs between 11 881 anti-TNF-treated and 3393 nbDMARD-treated RA patients using Cox regression modelling. Hazard ratios (HRs) with confidence intervals (CI) were calculated. Adjustment was made for potential confounders including current steroid use. The study covered the time period between 2001 and 2011.

RESULTS

There were 42 (upper 20, lower 22) GI perforations: five in the nbDMARD cohort and 37 in the anti-TNF cohort. After adjustment, treatment with TNF antagonists was associated with an HR of 1.6 (95% CI 0.4 to 6.0) for all GIPs, 2.7 (95% CI 0.4 to 18.1) for lower GIPs and 0.9 (95% CI 0.1 to 5.8) for upper GIPs. Current use of steroids was the single most important predictor of GI perforation with an adjusted HR of 2.9 (95% CI 1.5 to 5.4), but this risk was confined to lower GIPs (HR 8.0, 95% CI 2.6 to 24.1).

CONCLUSIONS

We have not found a statistically significant association between anti-TNF treatment and the risk of GIP.

Complications of brain tumors and their treatment

The diverse medical and neurologic complications of central nervous system (CNS) neoplasms or their treatment cause significant morbidity and mortality. Thus, their recognition and appropriate management by all members of the interdisciplinary team engaged in the care of patients with brain tumors is essential in optimizing quality of life and extending survival. Recognition of the acute, early delayed, and late complications of brain irradiation is essential to optimize management and mitigate their clinical impact.

Steroid-induced sigmoid diverticular perforation in a patient with temporal arteritis: a rare clinical pathology

Corticosteroids are used in the treatment of many rheumatological diseases including temporal arteritis. The gastrointestinal perforation during corticosteroid treatment is a serious complication. Colon perforation after steroid use was first reported by Beck et al in 1950.1 Although the pathophysiological mechanism is not understood clearly, it is claimed that steroids probably by disturbing the intestinal mucosal barrier, facilitate the intestinal perforation. The long term treatment with corticosteroids increases the risk of colon perforation. We are presenting a patient who was taking corticosteroid due to temporal arteritis for two years and operated with sigmoid diverticular perforation.

Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers

PURPOSE

Perforated colonic diverticular disease is associated with a high rate of late sequel and mortality. The risk of colonic perforation may relate to intracolonic pressure and mucosal barrier function in the wall of diverticula. The use of substances affecting these parameters may therefore be associated with the risk of developing a perforation. The aim was to study the effect of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, calcium channel blockers, and antimuscarinics on perforation in diverticular disease.

MATERIALS AND METHODS

A review of 54 patients with colonic diverticular perforation-forming the case group-and 183 patients with verified colonic diverticular disease-forming the control group-was done. Patient characteristics and drug use was registered.

RESULTS

Case group and control group were comparable with respect to sex, age, and comorbidity. In multivariate analysis, the use of NSAIDs (OR 3.56; 95% CI 1.50-8.43), opioids (OR 4.51; 95% CI 1.67-12.18), and corticosteroids (OR 28.28; 95% CI 4.83-165.7) were significantly associated with perforated diverticular disease. Acetylsalicylic acid in cardiologic dose did not affect the rate of perforation (OR 0.66; 95% CI 0.27-1.61). The use of calcium channel blockers was associated with a reduced rate of diverticular complications (OR 0.14; 95% CI 0.02-0.95).

CONCLUSIONS

The administration of NSAIDs, opioids, and corticosteroids are associated with an increased risk of colonic diverticular perforation. Acetylsalicylic acid in cardiologic dose does not affect the risk of perforation. Calcium channel blockers are associated with a reduced risk of perforation.

Colon perforation during antiangiogenic therapy for malignant glioma

Antiangiogenic drugs have emerged as effective treatment options for patients with recurrent malignant gliomas (MGs). Though this class of drugs is generally well tolerated, rare life-threatening complications, including thromboembolism, hemorrhage, and gastrointestinal (GI) perforation, are reported. We describe six cases of GI perforation among 244 glioma patients (2.5%) during treatment with antiangiogenic agents in combination with chemotherapy and corticosteroids. Two patients succumbed to this complication, and the others recovered. Because GI perforation is a life-threatening yet treatable complication, neurooncologists must have a low threshold to consider it in patients on antiangiogenic drug therapy who present with abdominal pain and other GI complaints.

Effect of systemic corticosteroids on elective left-sided colorectal resection with colorectal anastomosis

BACKGROUND

The impact of systemic steroid therapy on surgical outcome after elective left-sided colorectal resection with rectal anastomosis is not well known.

METHODS

We compared 606 consecutive patients including 53 patients who were on steroids and undergoing surgery between 1995 and 2005.

RESULTS

Postoperative mortality and anastomotic leakage rates were equivalent. The postoperative complications rate, especially infections, was higher in steroid-treated patients than in non-steroid-treated patients: 38% (20 of 53 patients) versus 25% (139 of 553 patients), respectively (P = .046). In the steroid group, univariate analysis revealed 3 significant risk factors for postoperative complications: blood transfusion, preoperative anticoagulation, and chronic respiratory failure. In a multivariate analysis, blood transfusion and chronic respiratory failure remained independent factors for postoperative complications.

CONCLUSION

Patients on steroids have a higher incidence of postoperative complications after elective left-sided colorectal resection with rectal anastomosis.

Comparison of Wallstent and Ultraflex stents for palliation of malignant left-sided colon obstruction: a retrospective, case-matched analysis

BACKGROUND

Self-expandable metal stents (SEMSs) are accepted palliation for malignant colon obstruction. Outcomes of different stent types is unknown.

OBJECTIVE

Our purpose was to compare outcomes after palliative placement of the Enteral Wallstent (EW) and the Precision Colonic Ultraflex (PCU) stent.

DESIGN

Retrospective study of all SEMS placement during a 7-year period.

SETTING

Tertiary care academic medical center.

PATIENTS

Malignant left-sided colon obstruction in which through-the-scope (TTS) or non-TTS stent placement was possible.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success rates, stent-related complications, reintervention.

RESULTS

Demographics, degree, site, and cause of obstruction were comparable. Technical difficulties were more frequent with EW than PCU (16% vs 9%, P not significant), insufficient stent expansion and stent misplacement being most common. Relief of obstruction occurred in all patients when placement was technically successful. Mean follow-up was 93 days (range 7-691 days). Early (<7 days) stent occlusion (6% vs 0%, P not significant) and migration (4% vs 0%, P not significant) occurred more frequently in the EW group. Self-limited hematochezia was more common with PCU (20% vs 2%, P = .002). Delayed complications (perforation, stent occlusion, migration, and erosion) occurred significantly more often in the EW group (38% vs 20%). Reintervention was needed more frequently for EW, endoscopic (40% vs 17%, P = .01) and operative (46% vs 26%, P = .03).

CONCLUSIONS

Enteral Wallstents and Precision Ultraflex Colonic stents adequately relieve colonic obstruction. Stent dysfunction, stent-related complications, and need for reintervention are higher after EW placement. Precision Colonic Ultraflex stents appear better suited for palliation of left-sided malignant colon obstruction.

Comorbidity is a major determinant of severity in acute diverticulitis

BACKGROUND

Acute colonic diverticulitis may be simple or very complicated. Not much is understood about what factors determine severity. Answering this question may have therapeutic implications.

METHODS

A retrospective review was performed consisting of teaching hospital admissions for simple or complicated acute diverticulitis. The intent was to identify characteristics of and differences between the 2 groups. The Charlson index was used to assess states of preexisting health (comorbidity).

RESULTS

In multivariate analysis, the presence of a major degree of comorbidity (Charlson score 3 or greater) was strongly associated with complicated disease (P = 0.02) as was the use of nonsteroidal anti-inflammatory drugs (P = .01). Deaths were not seen below age 50, and high Charlson score also strongly predicted mortality (P < .0001).

CONCLUSIONS

There are significant differences between patients presenting with simple and complicated diverticulitis, and the amount of associated comorbidity (as measured by Charlson score) appears to be a major one. Because of the high mortality seen in patients with Charlson scores 3 or greater and complicated diverticulitis, we believe that an early surgical approach should be considered for them, particularly if they are 50 or older.

Medical decompressive therapy for primary and metastatic intracranial tumours

Medical decompressive therapy (MDT) with corticosteroids and mannitol is often used in patients with primary or metastatic brain tumours. This review highlights the lack of sound evidence regarding the indications and dosage schedule of steroids, prolonged use of which may cause debilitating complications. The available evidence supports the short-term use of MDT for raised intracranial pressure or progressive neurological deficits, but in the absence of these symptoms, MDT is not recommended for stable focal deficits, abnormal higher mental functions, seizures, or as prophylaxis during cranial irradiation. A practical stepladder guideline (based on symptom severity) is proposed with a starting daily dexamethasone dose of 6 mg for non-severe headache and or vomiting; 12 mg for progressive focal neurological deficit with or without non-severe headache or vomiting; and 24 mg dexamethasone with mannitol for severe headache, vomiting, or altered consciousness. Depending on the clinical response, dose can be increased to the next step(s) or tapered every 48 h (more slowly in patients who are dependent on steroids). A scheme for the assessment of efficacy and toxicity prevention is also proposed. The proposed guidelines may be used as a template for further clinical research.

Epidemiology of perforated colonic diverticular disease

Perforated colonic diverticular disease results in considerable mortality and morbidity. This review appraises existing evidence on the epidemiology and mechanisms of perforation, highlights areas of further study, and suggests an epidemiological approach towards preventing the condition. Computerised searches were used to identify published articles relating to the epidemiology, pathophysiology, and clinical features of perforated colonic diverticular disease. Several drug and dietary exposures have potential biological mechanisms for causing perforation. Of these only non-steroidal anti-inflammatory drugs have been consistently identified as risk factors in aetiological studies. The causes of perforated colonic diverticular disease remain largely unknown. Further aetiological studies, looking specifically at perforation, are required to investigate whether cause-effect relationships exist for both drug and dietary exposures. The identification of risk factors for perforation would allow primary public health prevention, secondary risk factor modification, and early prophylactic surgery to be aimed at people at high risk.

Use of supplemental steroids in patients having orthopaedic operations

It is commonly thought that patients receiving exogenous glucocorticoids have suppression of the hypothalamic-pituitary-adrenal axis and need high supplemental doses of exogenous glucocorticoids (so-called stress steroids) to meet the demands of operative stress. Several reports have suggested that clinically important suppression of the hypothalamic-pituitary-adrenal axis is extremely uncommon and that the levels of glucocorticoids required for stress are much lower than previously believed. A prospective study of twenty-eight patients who had thirty-five major orthopaedic operations was conducted. No patient received stress steroids; they were given only the baseline immunosuppressive doses of glucocorticoids (mean dose, ten milligrams of prednisone). Clinical information (based on regular physical examinations for signs and symptoms of hypotension, myalgia, arthralgia, ileus, and fever) and laboratory data (serum sodium levels, eosinophil count, and twenty-four-hour urinary free-cortisol levels, determined at perioperative and non-stress postoperative time-periods) were obtained to document any evidence of adrenocortical insufficiency. There was no such evidence in any of the patients, who were monitored during their entire hospitalization. The levels of twenty-four-hour urinary free cortisol showed that all patients had endogenous adrenocortical function and, when this information was considered together with the clinical outcome, it was concluded that this level of function was sufficient to meet the demands of operative stress. Adrenocortical insufficiency in patients who have orthopaedic operations without receiving supplemental stress steroids appears to be much less common than previously thought. While biochemical testing of the function of the hypothalamic-pituitary-adrenal axis may sometimes reveal evidence of adrenal insufficiency, these tests do not predict the clinical outcome and may be too sensitive to guide decisions regarding treatment. Supplemental exogenous stress glucocorticoids may not be needed to meet the demands of operative stress in these patients.