An unexpected complication following uterine artery embolisation.

A 35-year-old nulliparous woman underwent uterine artery embolisation (UAE) for heavy menstrual bleeding and anaemia due to fibroids, refractive to medical and surgical treatment.Bilateral UAE was performed after cephazolin prophylaxis and analgesia. Postoperatively, pain and abdominal bloating were prominent. Symptoms were initially treated as postembolisation syndrome, and analgesia was escalated. By the third day, pain was worsening and the woman developed marked tachypnoea and tachycardia, with raised inflammatory markers and lactate. An abdominal X-ray and CT showed dilated colon. A colonoscopy demonstrated severe mucosal ulceration down to the muscular layer.A subtotal colectomy and end ileostomy formation was performed with intraoperative findings of toxic megacolon with near perforation. The cause of the toxic megacolon, in the absence of previous bowel pathology, was attributed to pseudomembranous colitis as a consequence of single dose prophylactic antibiotic.

The efficacy of intracolonic vancomycin for severe Clostridium difficile colitis: a case series.

BACKGROUND: Clostridium difficile infection (CDI) unresponsive to the standard treatments of metronidazole and oral vancomycin requires aggressive medical management and possible surgical intervention including colectomy. Intracolonic vancomycin therapy has been reported to be particularly promising in the setting of severe CDI in the presence of ileus. This is a descriptive case series exploring the effect of adjunctive intracolonic vancomycin therapy on the morbidity and mortality in patients with moderate to severe CDI. METHODS: A retrospective chart review was conducted on 696 patients with CDI seen at a single institution. Each patient was assigned a severity score and 127 patients with moderate to severe CDI were identified. We describe the clinical presentation, risk factors and hospital course comparing those that received adjunctive intracolonic vancomycin to those that only received standard therapy. RESULTS: The group that received adjunctive intracolonic vancomycin had higher rates of toxic megacolon, intensive care unit (ICU) admission, and colectomy, and yet maintained a similar mortality rate as the group that received only standard treatment. CONCLUSION: The intracolonic vancomycin group experienced more complications but showed a similar mortality rate to the standard therapy group, suggesting that intracolonic vancomycin may impart a protective effect. This study adds further evidence for the need of a randomized controlled study using intracolonic vancomycin as adjunctive therapy in patients presenting with severe CDI.

[Phosphate Intoxication after Application of Enema--a Life-threatening Iatrogenic Complication]. / Phosphatintoxikation nach Klysmagabe--eine lebensgefährliche iatrogene Komplikation.

INTRODUCTION: Enemas are used in pediatric patients with constipation. Retention of phosphate containing enemas with prolonged resorption or reduced renal elimination of phosphate can result in life-threatening hyperphosphatemia with subsequent lethal hypocalcemia and acidosis. CASE PRESENTATION: We report the case of a 6-month-old child who received phosphate-containing enema to treat acute aggravation of constipation. The used enema here was not licensed for this age group. Phosphate intoxication resulted (phosphate 19.87 mmol/l) and presented like a sepsis. Hyperphosphatemia was treated by hemodialysis. A non-diagnosed Hirschsprung disease had led to prolonged resorption of phosphate containing enema and to an ileus and toxic megacolon that had to be operated. CONCLUSION: Insufficient elimination of phosphate containing enema can result in lethal or life threatening hyperphosphatemia, hypocalcemia and metabolic acidosis. These can be treated efficaciously by hemodialysis. Because of the high risk of intoxication in using enemas containing phosphate in infants or in patients with gastrointestinal or renal comorbidities, physicians treating constipation should choose enemas without phosphate but with ingredients with lower risk like glycerol or sorbitol in this age group.

Complicated Clostridium difficile colitis in children with cystic fibrosis: association with gastric acid suppression?

Patients with cystic fibrosis (CF) have several risk factors for Clostridium difficile colonization such as frequent hospitalization and exposure to a broad array of antibiotics utilized for the control, eradication, and prophylaxis of respiratory pathogens. However, despite this high rate of colonization, the occurrence of C. difficile infection (CDI) in CF is rare. We report three children with CF who presented with severe community-associated CDI. All three children had complicated courses and one died. These children were in good health without significant morbidities, and were not frequently hospitalized nor did they receive frequent antibiotic courses. The occurrence of 3 severe cases within a 15-month period prompted us to report these cases and review the literature in regard to CDI. We reviewed the CF GI tract as possible risk factors for a high rate of C. difficile colonization in individuals with CF. Since a high percentage of individuals with CF are on gastric acid blocking agents, we also focused on gastric acid suppression as a potential risk factor for CDI.

Psychiatric drug-induced fatal abdominal compartment syndrome.

Several drugs used in psychiatry may induce constipation, paralytic ileus, or acute megacolon (Ogilvie's syndrome). We report here 2 cases of patients presenting with fatal abdominal compartment syndrome related to the absorption of antidepressants and benzodiazepines. Two patients (a 27-year-old man and a 57-year-old woman) with a previous psychiatric history and treatment with psychiatric drugs were admitted to the emergency department for coma. Both presented hypothermia; a hard, distended abdomen; and ischemia of the lower limbs. In both cases, the abdominal scan showed massive colonic dilatation without mechanical obstruction; there was even aortic compression and ischemia of the abdominal viscera. Emergency laparotomy with bowel decompression was performed in both cases, but multiple organ failure led to death in both patients. Psychiatric drugs may induce acute severe megacolon with life-threatening abdominal compartment syndrome.

Fatal Clostridium difficile infection associated with vinorelbine chemotherapy: case report and literature review.

Differentiating between chemotherapy-related diarrhoea and Clostridium difficile-associated diarrhoea (CDAD) can be extremely difficult. There is increasing evidence that CDAD can be seen in patients on chemotherapy without prior antibiotic usage. We report the first case of CDAD secondary to vinorelbine chemotherapy and review the literature.

Silver sulfadiazine induced Clostridium difficile toxic megacolon in a burn patient: case report.

A 53 yr old diabetic male presented with a 34% total body surface area (TBSA) deep partial- and full-thickness burns. On post burn days 4 and 9, all of his burns were excised and grafted. Although he had only been treated with topical antibiotics, he developed Clostridium difficile colitis after his second surgery that progressed to Toxic Megacolon and perforation. The incidence and treatment of Toxic Megacolon secondary to C. difficile is reviewed. Early diagnosis and treatment with colonoscopic decompression may obviate the need for surgery.

Toxic megacolon complicating chemotherapy for acute myeloid leukaemia.

A 43 year old woman in remission from acute myeloid leukaemia developed abdominal pain, severe melaena, diarrhoea and gram-negative septicaemia whilst severely pancytopenic following consolidation chemotherapy. Subsequently, serial abdominal X-rays showed a progressive toxic megacolon. Conservative management was attempted but, because of radiological evidence of increasing colonic dilatation and incipient perforation, an emergency defunctioning colostomy was performed. The patient recovered and 2 months later the caecostomy was reversed and a right hemicolectomy performed. This first described case of toxic megacolon following leukaemia treatment is compared with three previously described cases following cytotoxic chemotherapy for other conditions.

[Toxic megacolon in pseudomembranous colitis. Complicated course of antibiotic-induced Clostridium difficile colitis]. / Toxisches Megakolon bei pseudomembranöser Kolitis. Komplizierter Verlauf einer Antibiotika-induzierten Clostridium-difficile-Kolitis.

We report on a patient with antibiotic-induced pseudomembranous colitis aggravated by toxic megacolon. Colonoscopy not only rapidly permits the diagnosis to be established, but the relief of pressure achieved simultaneously also has a therapeutic effect. If treatment comprising parenteral fluid and electrolyte replacement in combination with oral vancomycin fails to effect an improvement, surgery becomes necessary. Current recommendations for treatment are discussed on the basis of a review of the literature. However, a major preventive measure remains the rational use of antibiotics.

Pseudomembranous colitis leading to toxic megacolon associated with antineoplastic chemotherapy. Report of a case and review of the literature.

Pseudomembranous colitis and toxic megacolon are rare complications of antineoplastic chemotherapy. Twelve cases of pseudomembranous colitis and four cases of toxic megacolon, both occurring as complications of chemotherapy, have been reported in the medical literature. These diseases occurred as separate and distinct entities. Fulminating pseudomembranous colitis leading to toxic megacolon in the setting of chemotherapy has not been previously reported. We report such a case, emphasizing its atypical presentation and rapid, fulminant course.

Toxic megacolon associated with anticancer chemotherapy.

The majority of gastrointestinal side effects associated with anticancer chemotherapy are relatively mild and self-limiting and can be managed empirically. However, severe side effects, such as necrotizing enterocolitis and ischemic colitis, sometimes do occur after chemotherapy. The authors present a case of toxic megacolon associated with anticancer chemotherapy. This is a relatively uncommon but potentially lethal complication of ulcerative colitis.

Toxic megacolon associated with methotrexate therapy.

We describe the case of a patient with psoriasis who developed severe colitis, with toxic megacolon, after a course of treatment with methotrexate. The duration of her colitis, which was eventually resolved by using conservative measures, was far greater than that of other drug-related complications, which included bone marrow depression, jaundice, and renal failure. The literature pertaining to this rare manifestation of methotrexate toxicity is reviewed. A prolonged illness and relative sparing of the distal colon appear to be characteristic of this form of colitis.