Defunctioning ileostomy for typhoid ileal perforations: Out of the frying pan into the fire?

Typhoid ileal perforation (TIP) is a common surgical emergency in low-middle income countries (LMICs). Its high surgical morbidity and mortality is due to its often late presentation or diagnosis, the patient's malnutrition, severe peritoneal contamination and unavailability of intensive care in most peripheral hospitals. This prompted the philosophy of minimizing the crisis by avoiding any repair or anastomosis, limiting the surgery in these physiologically compromised patients and performing only a temporary defunctioning ileostomy (DI) which could then be closed 10-12 weeks later.

Disseminated Histoplasmosis Causing Temporally and Spatially Discrete Gastrointestinal Perforations in an HIV-Negative Patient.

Histoplasma capsulatum is a dimorphic fungi endemic to the Ohio and Mississippi River valleys. Immunocompetent persons who become infected are generally asymptomatic or present with mild symptoms. Symptomatic disease is seen primarily in immunocompromised patients with pulmonary manifestations being the most common presentation. We present a case of a young HIV-negative male who required 4 exploratory laparotomies over the course of 4 months during 2 hospitalizations due to discrete perforations of the ileum and jejunum caused by biopsy-proven gastrointestinal histoplasmosis despite maximal medical therapy as well as a gastric perforation.

Synergistic Protective Effect of Konjac Mannan Oligosaccharides and Bacillus subtilis on Intestinal Epithelial Barrier Dysfunction in Caco-2 Cell Model and Mice Model of Lipopolysaccharide Stimulation.

As the first line of defense against intestinal bacteria and toxins, intestinal epithelial cells are always exposed to bacteria or lipopolysaccharide (LPS), whereas pathogenic bacteria or LPS can cause intestinal epithelial cell damage. Previous studies have shown that konjac mannan oligosaccharides (KMOS) have a positive effect on maintaining intestinal integrity, and Bacillus subtilis (BS) can promote the barrier effect of the intestine. However, it is still unknown whether KMOS and BS have a synergistic protective effect on the intestines. In this study, we used the LPS-induced Caco-2 cell injury model and mouse intestinal injury model to study the synergistic effects of KMOS and BS. Compared with KMOS or BS alone, co-treatment with KMOS and BS significantly enhanced the activity and antioxidant capacity of Caco-2 cell, protected mouse liver and ileum from LPS-induced oxidative damage, and repaired tight junction and mucus barrier damage by up-regulating the expression of Claudin-1, ZO-1 and MUC-2. Our results demonstrate that the combination of KMOS and BS has a synergistic repair effect on inflammatory and oxidative damage of Caco-2 cells and aIIeviates LPS-induced acute intestinal injury in mice.

Obstructed ileocaecal tuberculosis with splenic tuberculosis and solid pseudopapillary tumour of tail of pancreas in an immunocompetent woman.

A 22-year-old young woman presented with fever, lower abdominal pain and vomiting for 20 days. She had persistent fever and abdominal pain. Fever panel was negative. Clinical features were suggestive of subacute small bowel obstruction. Contrast-enhanced CT abdomen showed thickening of distal ileum, ileocaecal junction and caecum with conglomerate necrotic nodal mass in the ileocolic mesentry along with a lesion in the tail of pancreas. Patient was discussed with multidisciplinary team and decided to undergo a single-stage procedure after adequate nutritional optimisation. During optimisation, she underwent acute obstruction and hence taken up for emergency laparotomy proceeded to right haemicolectomy with distal pancreatectomy and splenectomy 4 weeks after the time of admission. Histopathology showed ileocaecal tuberculosis and solid pseudopapillary tumour with margins free of tumour. Approach of obstructed ileocaecal tuberculosis in the setting of incidental diagnosis of solid pseudopapillary tumour of pancreas in a moribund patient was challenging.

[A rare case of suppurative mesenteric adenitis associated with intussusception in a child: a clinical case]. / Un cas rare d'adénite mésentérique suppurée associée à une invagination intestinale chez un enfant: cas Clinique.

Some cases of suppurative mesenteric adenitis have already been described in the literature but not associated with intussusception. We describe the case of a 3-year-old boy presenting to the department of surgery at the University Hospital of Lubumbashi with bowel obstruction. He was visited elsewhere, in the previous 12 days, for diarrhea, vomiting, fever, coma and treated for cerebral malaria and blackwater fever. Surgery revealed an ileal intussusception and a suppurative mesenteric adenitis whose pyoculture revealed the presence of Enterobacter cloacae, sensitive to norfloxacin. We performed desinvagination, sucked the pus out into a syringe and excized completely the site of suppurative adenitis. The evolution of patient was good. The clinician must know that the association between suppurative mesenteric adenitis and intussusceptions exists. The diagnosis is not easy and there is the risk of developing acute peritonitis due to its fistulation in the abdominal cavity.

Distinct Microbiotas are Associated with Ileum-Restricted and Colon-Involving Crohn's Disease.

BACKGROUND: The etiology of inflammatory bowel disease is believed to involve a shift in the microbiota toward more proinflammatory species. Crohn's disease (CD) usually manifests as one of three phenotypes, involving inflammation of the terminal ileum, the colon, or both. However, what determines the particular phenotype and the level of disease activity remains unknown. In this study, we aim to characterize the intestinal microbiota associated with different CD phenotypes. METHODS: DNA was extracted from biopsies of 31 patients with ileal, ileocolic, or colon-restricted CD, and also from 5 non-inflammatory bowel disease control subjects, and analyzed by 16S rRNA gene amplicon pyrosequencing. Data were processed using the Quantitative Insights Into Microbial Ecology pipeline and analyzed using linear discriminant analysis with effect size estimation and PICRUSt algorithms. Two additional recently published cohorts were also analyzed in this study. RESULTS: Highly significant separation was observed between bacterial composition of ileal CD compared with CD with colonic involvement (genus level Bray-Curtis P = 0.005, R = 20%). This separation was unaffected by the biopsy's location or its inflammatory state, or by the patients' condition (remission or relapse). Faecalibacterium was strongly reduced in ileal CD compared with CD with colonic involvement, whereas Enterobacteriaceae were more abundant in the former. Fusobacterium relative abundance was strongly correlated with disease activity in patients with ileal-involving, but not in colon-involving, CD. CONCLUSIONS: Ileal and colon-involving CD sustain distinct microbiotas, suggesting that different mechanisms underlie the two major manifestations of CD. The potential contribution of Fusobacterium to inflammation in ileal CD should be further investigated.

A retrospective analysis of surgical treatment of mesh infection after repair of ventral hernia or defect.

This study aimed to summarize our experience in surgical treatment of mesh infection after repair of ventral hernia or defect. A retrospective analysis was conducted on clinical data of 22 patients who accepted surgical treatment of mesh infection after ventral hernia or defect repair. Included were 16 cases of infection after incisional hernia repair, 5 cases of infection after abdominal wall defect repair following abdominal wall tumor resection, and 1 case of infection with fistula caused by a parastomal hernia of an ileal neobladder repair with a prosthetic patch. All patients had received local dressing treatment for 2 to 24 months but were not healed. The affected mesh was removed successfully in all patients. Six patients had abdominal wall repair using the component separation technique; 4 patients were treated by strengthened repair with polypropylene mesh; 10 patients were repaired with human acellular dermal matrix; 1 patient received local dressing changes and vacuum sealing drain treatment without repair; and 1 patient received wound closure without strengthened repair. The postoperative hospital stay was 9-29 days (mean 16 days). After treatment, 19 patients recovered with primary wound healing and 3 patients recovered with secondary healing. All patients were followed up for 6-38 months (mean 26 months), and no ventral hernia or defect recurred except 1 case of lower abdominal bulge. Mesh infections after ventral hernia or defect repair are difficult to treat using prosthetic materials. For satisfactory results, surgery should be performed according to the specific condition of the individual.

The histopathological mimics of inflammatory bowel disease: a critical appraisal.

The pathological diagnosis of inflammatory bowel disease (IBD) is often difficult because biopsy material may not contain pathognomonic features, making distinction between Crohn's disease, ulcerative colitis and other forms of colitides a truly challenging exercise. The problem is further complicated as several diseases frequently mimic the histological changes seen in IBD. Successful diagnosis is reliant on careful clinicopathological correlation and recognising potential pitfalls. This is best achieved in a multidisciplinary team setting when the full clinical history, endoscopic findings, radiology and relevant serology and microbiology are available. In this review, we present an up-to-date evaluation of the histopathological mimics of IBD.

Successful endoscopic hemoclipping of massive lower gastrointestinal bleeding from paratyphoid A fever.

Paratyphoid fever can be complicated by massive lower gastrointestinal bleeding with ileocolonic ulcerations, which are commonly localized using colonoscopy. The most common manifestations include multiple, variable-sized, round or oval-shaped, punched-out ulcers. Occasionally, massive lower gastrointestinal bleeding can occur from erosion of blood vessels. We present a rare case of severe lower gastrointestinal bleeding due to paratyphoid A fever that was successfully controlled with hemoclippings. A 30-year-old man experienced high fever and hematochezia whose blood culture showed Salmonella paratyphi A. A complete colonoscopy was successfully performed up to the level of the terminal ileum, which showed multiple, shallow, ulcerated lesions over the entire terminal ileum. A bleeding vessel was seen in one of the ulcers, with overlaying blood clots. Endoscopic hemostasis was successfully performed with four pieces of endoclip and without immediate complication. This report highlights the use of colonoscopy and endoscopic therapy with endoclips for lower gastrointestinal bleeding, which should be considered before surgery.

Intestinal tuberculosis in a child living in a country with a low incidence of tuberculosis: a case report.

BACKGROUND: Relatively common in adults, intestinal tuberculosis is considered rare in children and adolescents. The protean manifestations of intestinal tuberculosis mean that the diagnosis is often delayed (sometimes even for years), thus leading to increased mortality and unnecessary surgery. The main diagnostic dilemma is to differentiate intestinal tuberculosis and Crohn's disease because a misdiagnosis can have dramatic consequences. CASE PRESENTATION: A 13-year-old Caucasian, Italian female adolescent attended the Emergency Department complaining of abdominal pain, a fever of up to 38 °C, night sweats, diarrhea with blood in stool, and a weight loss of about three kilograms over the previous two months. Physical examination revealed a marked skin pallor and considerable abdominal distension with relevant discomfort in all the abdominal quadrant. Laboratory tests revealed a decreased white blood cell count with anemia and increased C-reactive protein levels. The Mantoux tuberculin skin test was negative. A chest X-ray and an abdominal ultrasonography did not reveal any significant findings. The patient underwent colonoscopy that showed diffuse mucosal congestion and significant blood loss, and laparatomy showed small bowel and colon loops with a whitish appearance. A biopsy of the ileal mucosa revealed inflammation with noncaseating granulomas possibly due to bacterial infection. Given the suspicion of an opportunistic bacterial infection in a child with chronic inflammatory bowel disease (possibly Crohn's disease), treatment with a third-generation cephalosporin was started. However, the abdominal pain, fever and poor general condition persisted and so, after 11 days, the patient underwent total body computed tomography and magnetic resonance imaging of the brain. On the basis of the radiological findings, miliary tuberculosis was suspected and bronchoscopy was performed and resulted positive for Mycobacterium tuberculosis. Miliary tuberculosis was confirmed and an effective treatment with four drugs was started. CONCLUSION: This case shows that the manifestations of intestinal tuberculosis can be very difficult to diagnose and mimic those of Chron's disease. Total body computed tomography and laparotomy with an intestinal biopsy for the detection of Mycobacterium tuberculosis are the means of avoid the risks of a misdiagnosis in children with unexplained chronic abdominal problems.

Prevalence, morbidity, and mortality patterns of typhoid ileal perforation as seen at the University of Nigeria Teaching Hospital Enugu Nigeria: an 8-year review.

BACKGROUND: Some recent studies have reported a decrease in mortality from typhoid ileal perforation. The present report aims to determine the prevalence, morbidity, and mortality of this disease in patients mostly drawn from a rural area. METHODS: This is a retrospective study of 50 patients treated between January 1999 and December 2007 at the University of Nigeria Teaching Hospital, Enugu, Nigeria. The variables studied included patient demographics, clinical features, intraoperative findings, complications, and mortality. Statistical analysis was done with SPSS version 13. RESULTS: Of the 50 patients included in the study, 22 were males with the highest rate in patients aged 20 years and younger. Fever was the commonest symptom and at initial presentation, the mean pulse and respiratory rates were significantly higher in the patients who subsequently died than in those who survived (P < 0.05). All the perforations occurred in the ileum; 62 % of the patients had solitary perforations, 28 % had double perforations, and 10 % had three or more. Fifty-eight perforations were treated by simple closure in two layers, 4 patients had ileal resection and anastomosis, and 2 underwent right hemicolectomy. The mean interval between operation and death was 1.7 days. The overall mortality rate was 30 %, but among those with three or more perforations, mortality was 100 %. CONCLUSIONS: Typhoid ileal perforation still carries a high mortality especially in rural areas. Those with tachycardia and tachypnea at presentation and those with three or more perforations are at a higher risk of dying from the disease.

Colonoscopic findings and management of patients with outbreak typhoid fever presenting with lower gastrointestinal bleeding.

Lower gastrointestinal bleeding (LGIB) along with intestinal perforation is a well-known complication of typhoid fever. Reports of colonoscopic appearance and intervention of typhoid perforation involve only few cases. This series reports the colonoscopic findings and the role of colonoscopic hemostatic interventions in controlling the bleeding ileocolonic lesions. During the typhoid fever outbreak in Sulaymaniyah City in Iraqi Kurdistan Region, we received 52 patients with LGIB manifesting as fresh bleeding per rectum or melena. We performed total colonoscopy with ileal intubation for all cases. The findings were recorded and endoscopic hemostatic intervention with adrenaline-saline injection and argon plasma coagulation was applied to actively bleeding lesion. These patients were young, 11-30 years of age, with female preponderance. Blood culture was positive in 50 %. Colonoscopic findings were mostly located in the ileocecal region, although other areas of the colon were involved in many cases. Twenty-four percent of the cases required endoscopic hemostatic intervention by adrenaline injection with argon plasma coagulation which was effective in all patients except one who died in spite of surgical intervention in addition of endoscopic hemostasis. Dual endoscopic hemostatic intervention can be a safe and effective management option for patients with LGIB due to typhoid fever.

Ileal perforation due to typhoid fever - review of operative management and outcome in an urban centre in Nigeria.

BACKGROUND: The management of ileal typhoid perforation is a challenging task in our environment. Lack of incidence data base and poor financial resources preclude adequate prevention of this public health menace. OBJECTIVES: For now the focus will remain the effective and strategic management of this complication to reduce the morbidity and mortality. METHODS: 86 cases of ileal typhoid perforation were seen over a two year period. Most were male children and male young adults. Data collection was by retrieving information from the medical records of Enugu State University of Science and Technology Teaching Hospital (ESUTH). All were resuscitated with 1v fluids, iv antibiotics, nasogastric tube suction and where indicated blood transfusions. Majority had bacteriological, biochemical, haematological and radiological investigations. Laparotomy was undertaken after adequate resuscitation. RESULTS: Most had been febrile for 2-6weeks prior to admission, with the majority having been labelled resistant malaria cases. Most presented more than 24 h after onset of peritonitis and were therefore explored late, some as late at 96 h. At laparotomy 97% had large volumes of pus and small bowel contents in the peritoneal cavity and 3% had localized intraabdominal abscesses. No attempt at healing or omental localization of the perforation was observed. Fifty two (60.5%) patient underwent simple closure, 18(21%) had ileal resection and enteroanastomosis, 7(8.1%) had tube ileostomy, 5(5.8%) had primary suture and proximal ileo-transverse anastomosis and 4(4.7%) limited right hemicolectomy. All had liberal peritoneal lavage with normal saline. The group that presented relatively early, with minimal pathological changes, had primary suture and mortality in this groups was 11.5%. The group with gross pathological changes seen mainly in patients that presented late had higher mortality rates, even as high as 50%. However our overall mortality rate was 18.6%. CONCLUSION: The authors affirm that typhoid ileal perforation must be treated surgically. Early presentation and diagnosis, adequate resuscitation, prompt surgery and vigorous post-operative management improved mortality rates. Clearly delays in presentation necessitating prolonged resuscitation and therefore delayed surgery affected mortality.

Intususcepción ileocólica en adulto secundaria a enterocilitis por Salmonella enteriditis / Ileocolic intussusception in an adult secondary to Salmonella enteriditis

Introduction: Intussusception is defined as the invagination of a segment of the gastrointestinal tract into an adjacent portion. Adult intussusception is rare accounting for only 5 percent or less of all causes of intestinal obstruction; in 90 percent of these cases a leading point will be demostrable. Case report: A female patient, 35 years-old, was admitted into our institution complaining of 5 days of colicky abdominal pain associated to diarrhea without peritoneal sing. Abdominal ultrasonography showed the classic features of intussusceotion; target or doughnut sing and the pseudokidney sing. The study was completed with a computed abdominal tomography scan, confirming the sonographic findings. The surgical exploration revealed that the terminal ileum, cecum, appendix, and 10 cm of ascending colon were intussuscepted into the remaining colon. Abdominal inflammatory free-fluid was aspirated for culture. A right hemicolectomy with primary anastomosis was performed. The culture report finding of the abdominal liquid was Salmonella enteritidis. The histology reported an edematous thickened terminal ileum wall with Peyer´s patches infiltrated by polymorphonuclear cells. Discussion: The cause of intussusception in patients with infectious enterocolitis caused by Salmonella enteritidis could be related to stimulation of the intestinal mucosa causing inflamatory changes of the Peyer´s patches resulting in an edematous mass in the terminal ileum acting as a leading point for intussusception. Although rare, Salmonella infections should be considered among the precipiting causes of adult ileocolic intussusception.

Introducción: La intususcepción se define como la invaginación de un segmento intestinal dentro otro segmento adyacente. En adultos, la intususcepción es infrecuente dando cuenta del 5 por ciento o menos de todas las causas de obstrucción intestinal; en estos casos se podrá demostrar una causa en 90 por ciento de los pacientes. Reporte de caso: Paciente femenino de 35 años de edad, hospitalizada por un cuadro clínico de 5 días de evolución con dolor abdominal cólico, diarrea y ausencia de signos de irritación peritoneal. La ecografía abdominal mostró los signos clásicos de intususcepción; el "signo del blanco o del donut" y el "signo del pseudo-riñon". El estudio se completó con una tomografía abdominal, la cual confirmó los hallazgos de la ecografía. La exploración quirúrgica demostró que el íleon terminal, ciego, apéndice y 10 cm de colon ascendente. Se encontró líquido inflamatorio que se aspiró para cultivo. La cirugía consistió en una hemicolectomía derecha con anastomosis primaria. El resultado del cultivo fue positivo para Salmonella enteritidis. La histología demostró edema y engrosamiento de la pared del íleon terminal con infiltración polimorfonuclear de las placas de Peyer. Discusión: La causa de intususcepción en pacientes con enterocolitis infecciosa por Salmonella enteritidis está relacionada con la inflamación de la mucosa intestinal y de las placas de Peyer, lo que resulta en una masa edematosa en el íleon terminal que actúa como "punto tractor" para la intususcepción. Las infecciones por Salmonella deben considerarse entre las causas precipitantes de intususcepción en adultos.