[A Case of Clostridium difficile Enteritis with Ileostomy for Rectal Cancer Surgery].

A 74-year-old male presenting with bloody stools was diagnosed with advanced rectal cancer. He underwent robot- assisted low anterior resection and temporary ileostomy. Cefmetazole(CMZ)was administered during surgery and on postoperative day(POD)1. His postoperative course was generally good. On POD8, he developed abdominal fullness, vomiting, renal dysfunction, and hyperkalemia. Plain CT revealed small bowel ileus and outlet obstruction with ileostomy was suspected. A nasogastric tube was placed in the stomach, and a balloon catheter was inserted from the ileostomy to the oral side of the ileum. The patient went into shock on the same day and was transferred to a high-care unit. Contrast-enhanced CT indicated pneumatosis intestinalis of the small bowel and portal venous gas. However, the wall of the small bowel was enhanced, so the patient was observed carefully without attempting an operation. The patient's condition improved with systemic management. On POD10, a stool culture from the ileostomy tested positive for CD toxin. Clostridium difficile enteritis(CDE)was diagnosed. The condition improved with systemic control. On POD52, paralytic ileus recurred, and his stool tested positive for the CD toxin again. The ileus improved with conservative treatment. On POD70, the patient was transferred to the hospital for rehabilitation. We report a case of CDE with ileostomy for rectal cancer surgery.

[A Case of Ileal Perforated Peritonitis 50 Years after Radiotherapy for Uterine Cancer].

Here we report a rare case of peritonitis caused by radiation enteritis. The 82-year-old woman who underwent surgery and radiotherapy for uterine cancer in her 30s. Emergency operation was performed for the perforation of the ileum. The small intestine showed changes of radiation enteritis extensively on macroscopy. The first surgery was performed to resect the perforated ileum and make intestinal anastomosis at the change of radiation enteritis. However, suture failure was occurred, reoperation was performed after conservative therapy. Reoperation was performed extensively resection of the intestinal tract and made anastomosis where was mild change of radiation enteritis. Pathological findings of the intestinal stump revealed that the arterial vessels of the submucosal layer were highly thicken and the lumen of artery was stenosis and occlusion with severe changes of radiation enteritis at the first operation. Blood flow disorders by irradiation were presumed to be the cause of suture failure. On the other hand, the intestinal stump did not indicate thickened of vascular wall and lumen stenosis of the vessels, only edematous changes in the submucosal layer were observed at the reoperation. It was important to determine the surgical procedure with the change of radiation enteritis for gastrointestinal operation with abdominal irradiation.

A literature review and case report of severe and refractory post-colectomy enteritis.

BACKGROUND: Ulcerative colitis (UC)-related post-colectomy enteritis is a very rare condition that is characterized by diffuse small-bowel mucosal inflammation following colectomy and could be very dangerous. In previously reported cases, corticosteroid therapy seemed to be the optimal choice for inducing remission; however, the patient studied herein presented with severe diarrhoea and hypovolemic shock and failed to achieve full remission with corticosteroid therapy. CASE PRESENTATION: We describe the case of a patient with severe pan-enteritis presenting with life-threatening diarrhoea complicated with hypovolemic shock and acute kidney injury after colectomy and ileal pouch anal anastomosis (IPAA) for UC; this patient was successfully treated by ileostomy closure after failing to achieve full remission with corticosteroid therapy. Next, we review other cases of post-colectomy enteritis reported in the literature and propose a flow-chart for its diagnosis and initial treatment. CONCLUSION: Post-colectomy enteritis can be dangerous, and the early awareness of this condition plays a vital role. Additionally, in patients who do not respond well to corticosteroid or immunosuppressant therapy, early closure of the ileostomy and re-establishment of the natural faecal stream could be important considerations.

Pyloric obstruction due to massive eosinophilic infiltration in a young adult dog.

A 16-month-old dog was presented with chronic vomiting, anorexia, progressive weight loss, and melena. Exploratory laparotomy revealed a massive pyloric eosinophilic infiltration leading to pyloric obstruction that was treated successfully with pylorectomy. This is a novel clinical presentation of eosinophilic gastritis and highlights the need to consider it as a differential diagnosis for pyloric obstruction.

Obstruction pylorique causée par une infiltration éosinophilique chez un jeune chien adulte. Un chien âgé de 16 mois a été présenté avec des vomissements chroniques, de l'anorexie, une perte de poids progressive et la méléna. Une laparatomie exploratoire a révélé une infiltration éosinophilique pylorique massive qui causait une obstruction pylorique qui a été traitée avec succès par la pylorectomie. C'est une présentation clinique nouvelle de la gastrite éosinophilique et elle souligne le besoin de la considérer comme un diagnostic différentiel pour l'obstruction pylorique.(Traduit par Isabelle Vallières).

A case of ileus due to radiation enteritis 19 years after radiotherapy.

A 73-year-old female visited our hospital complaining of nausea and epigastric pain because of ileus. She had a history of two laparotomy procedures in her youth, interferon treatment for chronic hepatitis C, and radiation therapy for uterine cervical cancer 19 years ago. Transanal double-balloon enteroscopy demonstrated annular stenosis with ulceration of the anal side of the dilated small intestine. Therefore, surgical resection was performed, and late radiation enteritis was diagnosed on histopathological examination. We report a case of ileus due to radiation enteritis 19 years after radiotherapy.

Surgery for chronic radiation enteritis: outcome and risk factors.

BACKGROUND: Surgery is required in approximately one-third of patients with chronic radiation enteritis (CRE). The aim of this study was to explore the short- and long-term outcomes after surgery for CRE and risk factors of postoperative morbidity. METHODS: Clinical features and surgical outcomes of patients undergoing surgery for CRE were retrospectively reviewed. Risk factors of postoperative morbidity were analyzed using univariate and multivariate analysis. Survival and reoperation rates for CRE were evaluated. RESULTS: Among the 404 patients included, 351 patients (86.88%) received resectional surgery, whereas the remaining patients received conservative procedures. No differences were detected between patients with resection and those without resection with regard to major morbidity (P = 0.486) and surgical complications (P = 0.715). Laparoscopy resulted in a shorter postoperative hospital stay (P = 0.035). After multivariate analysis, history of hypertension (odds ratio [OR] = 2.490; P = 0.046), previous acute radiation enteritis (OR = 1.832; P = 0.033), intraoperative blood loss of more than 200 mL (OR = 2.235; P = 0.006), and thrombocytopenia (OR = 2.544; P = 0.016) were determined as independent predictors of postoperative major morbidity. During follow-up, 22 patients required reoperation for CRE recurrence, and the reoperation rate was significantly lower in patients receiving resectional surgery (P = 0.005). CONCLUSIONS: Resection is feasible for CRE with acceptable postoperative morbidity and lower reoperation rate. Correction of preoperative thrombocytopenia, minimizing intraoperative blood loss, and close monitoring of hypertensive patients and those with history of acute radiation enteritis are critical to reduce postoperative complications.

Ischemic necrosis of the tongue in surgical patients with septic shock: a case report.

BACKGROUND: As the tongue is a well-vascularized organ, ischemic necrosis of the tongue is a rare disease entity. Critically ill patients with profound shock may experience end-organ hypoperfusion, which might result in tongue necrosis. However, to our best knowledge, there are no reports regarding ischemic necrosis of the tongue in surgical patients with septic shock. CASE PRESENTATION: Two patients recently developed ischemic necrosis of the tongue in our surgical intensive care unit. Both patients had undergone emergent surgery for ischemic enteritis and developed postoperative septic shock. The first patient responded to critical treatment with a short period of circulatory shock, and the delivered dose of the vasopressor seemed to be acceptable. In contrast, the second patient developed postoperative refractory shock, and high-dose vasopressor treatment was required to maintain adequate tissue perfusion. Both patients developed ischemic necrosis of the tongue and died shortly after its emergence, despite vigorous resuscitation. CONCLUSIONS: We suggest that ischemic necrosis of the tongue is an under-reported manifestation of any type of circulatory shock, which may have a complex pathogenic mechanism. Clinicians should be aware of the possibility of ischemic necrosis of the tongue in patients with circulatory shock, even if the patient exhibits clinical improvement, as this awareness may facilitate estimation of their prognosis and preparation for clinical deterioration.

[A Case of Eosinophilic Enteritis Needed to Distinguish from a Tumor of the Small Intestine].

A 75-year-old woman was diagnosed with aplastic anemia 6 months ago and was under follow-up at our hospital. She had originallypresented to our hospital because of ongoing diarrhea and abdominal pain. Her blood tests showed a rise in inflammatorymarkers (WBC count was 6,900/mL[eosinophil was 1.3%]and CRP was 8.60mg/dL). Her abdominal computed tomography(CT)scan showed gastric wall and small intestine edema as well as ascites. There was no evidence of free air. We diagnosed her with generalized peritonitis and performed an emergencyoperation . Intra-operatively, moderate amounts of yellowish ascitic fluid were noted, as was a diffuse reddening of the small intestine. We performed a partial resection of the small intestine. Histopathological examination showed transmural infiltration of inflammatorycells mainly comprising eosinophilic leukocytes. Eosinophils were also present in the ascitic fluid. Post-operative blood tests confirmed eosinophilic, and we diagnosed her with eosinophilic enteritis. She was started on corticosteroids and her symptoms improved immediately. We report a rare case of eosinophilic enteritis with a review of the pertinent literature.

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE), and neuromuscular and vascular hamartoma (NMVH): two sides of the same coin?

Multifocal stenosing enteritis, not related to Crohn's disease or drug intake, has been described under two different terms: "cryptogenic multifocal ulcerous stenosing enteritis" (CMUSE) and "neuromuscular and vascular hamartoma" (NMVH). We present three new cases of this condition and argue that the two terms reflect the same disease entity. Although etiology and pathogenesis of the disease remain largely unclear, obliterative vascular changes may play an important role.

Laparoscopic surgery for radiation enteritis.

BACKGROUND: The aim of this study was to determine the safety and feasibility of laparoscopic surgery for radiation enteritis-induced intestinal stenosis requiring ileocecal resection. METHODS: Clinical records of radiation enteritis patients that underwent laparoscopic ileocecal resection and ileo-ascending colonic side-to-side anastomosis in a single center from January 2012-February 2014 were retrospectively analyzed. Thirty patients were identified and matched by abdominal adhesion grade, age, gender, primary malignancy distribution, previous abdominal surgery history, and body mass index to 30 patients that underwent open surgery for the same procedure from August 2009-December 2011. General information, operative findings, and short-term outcomes were compared between the two groups. RESULTS: The conversion rate of laparoscopic surgery was 23.3%. The length of skin incision in the laparoscopic group was significantly shorter than that of the open surgery group (6.8 cm versus 15.8 cm, P = 0.001). Laparoscopic surgery significantly decreased recovery time to total enteral nutrition (10.3 d versus 15.6 d, P = 0.037); however, postoperative hospital stay was not significantly different between the two groups (28.2 d versus 32.4 d, P = 0.924). Intraoperative blood loss (125 mL versus 189 mL, P = 0.000) and operation time (138 min versus 171 min, P = 0.003) were significantly improved in the laparoscopic group compared with those in the open surgery group. Laparoscopic surgery did not significantly decrease postoperative morbidity but did decrease the pleural effusion rate. CONCLUSIONS: Laparoscopic surgery is feasible for treatment of radiation enteritis-induced intestinal stenosis with a relatively low conversion rate. Laparoscopic surgery is as safe as open surgery and is superior to open surgery with decreased skin incision length, operation time, intraoperative blood loss, and postoperative recovery time to total enteral nutrition.

[Operative and long term results after diseased bowel resection for chronic radiation enteritis complicated with intestinal obstruction].

OBJECTIVE: To report operative and long-term results after surgery for chronic radiation enteritis and to evaluate the therapeutic efficacy of surgery and investigate the risk factors of postoperative survival rate. METHODS: The 120 CRE patients performed with diseased bowel resection from June 2001 to March 2011 were analyzed retrospectively and followed up by telephone. There were 22 male and 98 female patients and their age were 23-82 years (median 52 years). Their demographic data, the cancer history, the characteristics of radiotherapy received (total dose, defined as the cumulative dose of external and endocavity radiation), the time interval between the first symptoms and the first surgical procedure, postoperative complications, length of residual small bowel, postoperative survival rate were recorded. Evaluate the therapeutic efficacy of surgery and investigate the risk factors of postoperative survival rate. RESULTS: The postoperative overall complications and the incidence of moderate to severe complications (Clavien-Dindo Grade III-V) were 61.7% and 33.3%, respectively. The postopertive mortality was 2.5%. The survival probabilities were 96%, 60% and 37% at 1-, 5- and 10-years, respectively. At the end of follow up, the mean of body mass index (BMI) increased compared with the BMI of preoperatiive ((17.6 ± 3.0) kg/m(2) vs. (20.2 ± 3.0) kg/m(2), t = 6.01, P < 0.01). The 93% of patients can stop PN and regain full oral diet after operation (χ(2) = 164.1, P < 0.01). On multivariate analysis, survival was significantly decreased with residual neoplastic disease (HR = 4.082, 95%CI: 1.318-12.648), an American Society of Anesthesiologists score>3 (HR = 3.495, 95%CI: 1.131-10.800) and an age of chronic radiation enteritis diagnosis >70 years (HR = 2.800, 95%CI: 0.853-9.189). CONCLUSIONS: The survival of patients with chronic radiation enteritis complicated with intestinal obstruction after intestinal resection was good and was mainly influenced by underlying comorbidities. Majority of the patients can stop PN and regain full oral diet after operation.

Intraoperative appearance of radiation enteritis: What should be resected?

Radiation enteritis can appear up to 30 years after radiotherapy. Outside acute complications, it usually manifests itself as chronic intestinal obstruction. If medical treatment (corticosteroid therapy) fails, surgical treatment is indicated, namely resection of the affected bowel, with removal of the ileo-caecal valve.

Small Intestinal Perforation Secondary to Necrotizing Enteritis-An Under-Recognized Complication of Crohn's Disease.

Small bowel perforation is an uncommon but severe event in the natural history of Crohn's disease with fewer than 100 cases reported. We review Crohn's disease cases with necrotizing enteritis and share a case of a 26-year-old female who presented with a recurrent episode of small intestinal perforation. A PubMed literature review of case reports and series was conducted using keywords and combinations of "Crohn's disease," "small intestine perforation," "small bowel perforation," "free perforation," "regional enteritis," and "necrotizing enteritis." Data extracted included demographic data, pre- or postoperative steroid administration, medical or surgical management, and case fatality. Nineteen reports from 1935 to 2021 qualified for inclusion. There were 43 patients: 20 males and 23 females with a mean age of 36 ± 15 years old. 75 total perforations were described: 56 ileal (74.6%), 15 jejunal (20.0%), 2 cecal (2.7%), and 1 small intestine non-specified (2.7%). 38 of 43 patients were managed surgically by primary repair (11), ostomy creation (21), or an anastomosis (11). Of 11 case fatalities, medical management alone was associated with higher mortality (5/5; 100% mortality) compared to those treated surgically (6/38; 15.8% mortality; P < .001). Patient sex, disease history, acute abdomen, and pre- or postoperative steroid use did not significantly correlate with mortality. Jejunal perforation was significantly (P = .028) associated with event mortality while ileal was not (P = .45). Although uncommon, necrotizing enteritis should be considered in Crohn's patients who present with small intestinal perforation. These cases often require urgent surgical intervention and may progress to fulminant sepsis and fatality if not adequately treated.

Small bowel fibrosis and systemic inflammatory response after ileocolonic anastomosis in IL-10 null mice.

BACKGROUND: Crohn's disease recurrence after an ileocecal resection is common; yet, its pathophysiology is poorly understood and available treatment is suboptimal. The purpose of this study was to examine the bacterial, local, and systemic immune changes that follow ileocolonic anastomosis in a rodent model of Crohn's disease, the interleukin-10 gene-deficient (IL-10 null) mice. MATERIALS AND METHODS: We divided wild-type and IL-10 null mice into three treatment groups: ileocolonic anastomosis, sham operation (ileo-ileal anastomosis), and control group without an operation. We sacrificed mice at 6 and 15 wks after the operation. At 6 wks, we assessed bacterial changes using the denaturing gel electrophoresis and similarity coefficient calculation. At both time points, we examined the small bowel for inflammation and fibrosis with histology. We measured the interferon gamma secretion by splenocytes stimulated with gastrointestinal bacterial antigens and splenocyte composition as a marker of systemic response. RESULTS: At 6 wks, ileocolonic anastomosis resulted in increased similarity in bacterial species between the ileum and colon. The ileocolonic anastomosis did not lead to significant inflammation in the small intestine, but it resulted in an increased collagen deposition in all animals undergoing surgery, the most pronounced fibrosis of which was present in IL-10 null mice 15 wks after ileocolonic anastomosis. Furthermore, this was associated with significantly increased interferon gamma secretion by bacterial antigen-stimulated splenocytes and a decreased number of CD11+ cells in the same experimental group. CONCLUSIONS: Ileocolonic anastomosis leads to bacterial changes in the terminal ileum. In the genetically susceptible host, it is associated with small bowel fibrosis and systemic immune alterations. The composition of immune cells in the spleen is altered and splenocytes hypersecrete proinflammatory cytokine (interferon gamma) when challenged with gastrointestinal bacterial antigens.

A retrospective study of surgical treatment of chronic radiation enteritis.

BACKGROUND AND AIMS: We assessed the role of surgery in the management of patients with intestinal obstruction or enterocutaneous fistula after chronic radiation enteritis (CRE) referred to our department, a specialist gastrointestinal surgical center, and analysis was made for the success of surgery. METHODS: A retrospective analysis was made of 156 patients receiving radiation therapy for malignancy from Jan 2000 to Nov 2010, among which 134 received surgery for intestinal or urinary complications. The demographic data, nutritional status, previous surgery, disease location and clinical manifestations, concomitant urinary complications, and surgical procedures were analyzed. RESULTS: Although malnutrition was prevalent (84/156, 53.9%) in this group of patients, the majority of them (101/134, 75.4%) recovered uneventfully after surgery following nutrition therapy, and resection and anastomosis (102/134) was the predominant surgical procedure for radiation injury to the ileocecal region. Sixteen patients received surgery for radiation-induced urinary complications. There were 36 postoperative morbidities (26.87%), mainly wound complications (21/134), intestinal obstruction (5/134), and anastomotic dehiscence (3/134). CONCLUSIONS: Surgery is justified for patients with bowel obstruction or fistula after CRE. A comprehensive perioperative management, especially perioperative nutrition therapy was important for the success of the surgery.

Side-to-side isoperistaltic strictureplasty for chronic ischemic enteritis: report of a case.

Chronic ischemic enteritis can cause intestinal strictures, but extensive resection of the small intestine may leave patients with short bowel syndrome. Thus, the importance of preserving diseased small bowel is now recognized. We report a case of successful side-to-side isoperistaltic strictureplasty (SSIS), performed to prevent short bowel syndrome, in a patient with ischemic enteritis caused by strangulated intestinal obstruction. SSIS is useful for preserving the intestinal absorptive function in patients with a long narrowed bowel loop caused by ischemic change. To our knowledge, this is the first report of the successful treatment of a long stricture resulting from ischemic enteritis, achieved by performing SSIS.

Risk of recurrence after surgery for chronic radiation enteritis.

BACKGROUND: Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE. METHODS: Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality, reoperation for recurrent enteritis and risk factors for reoperation were analysed. RESULTS: Of 107 patients (94 women; 87·8 per cent) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76·6 per cent). Forty-nine ileocaecal resections (45·8 per cent) were performed. Overall and surgical morbidity rates were 74·8 per cent (80 patients) and 28·0 per cent (30) respectively. Fourteen patients (13·1 per cent) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54 per cent respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2·72, 95 per cent confidence interval 1·57 to 4·86), anastomotic leakage (OR 2·53, 1·54 to 4·42) and male sex (OR 3·57, 1·82 to 7·29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4·48, 2·52 to 8·31). CONCLUSION: Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis.