Portal pyaemia secondary to open haemorrhoidectomy: need for prophylactic broad spectrum antibiotics.

A 70-year-old man presenting with long standing grade 3 Haemorrhoids, underwent open haemorrhoidectomy under spinal anaesthesia. The patient passed stools on subsequent day and there was no bleeding per rectum. On day 5, he complained of dull aching upper abdominal pain. On physical examination, the abdomen was soft and there was mild tenderness in the epigastric region. Subsequently, he developed high temperature with chills and rigors. His condition failed to improve and the abdominal pain increased in severity. There was no pain in the perianal region and per rectum examination was normal. Leucocyte count rose to 12×10(9)/L and there were toxic changes on peripheral smear. Blood culture grew Staphylococcus aureus. Liver enzymes were mildly elevated. Coagulation profile was deranged. Fibrin degradation products were positive. D-dimer was high. CT revealed acute thrombosis of left portal vein and microabscesses suggestive of portal pyaemia.

Detection of Chlamydia pneumoniae in liver transplant patients with chronic allograft rejection.

BACKGROUND: Chlamydia pneumoniae is one of the possible pathogenetic factors of atherosclerotic processes. Foam cell arteriopathy is a generally accepted pathologic feature of chronic liver allograft rejection and has several similarities to the early lesions of atherosclerosis. The aim of the authors' study was to show any existing correlation between the occurrence of Chlamydia pneumoniae and the presence of foam cell arteriopathy in transplanted livers with chronic rejection. METHODS: Ten liver samples from patients with chronic liver rejection including foam cell arteriopathy and 10 liver samples from healthy individuals were analyzed for the presence of Chlamydia pneumoniae by specific immunohistochemistry and polymerase chain reaction (PCR). Liver samples from two transplant patients with chronic liver rejection without any evidence of foam cell arteriopathy and nine patients with acute liver allograft rejection were also investigated by PCR. RESULTS: In all 10 rejected liver samples, Chlamydia pneumoniae was detected by PCR, whereas only one of the healthy control samples and one of the samples with acute rejection were found to be positive. Immunohistochemistry showed similar results. The positive signals of Chlamydia pneumoniae were localized mainly in the hepatocytes, sinusoidal and perisinusoidal cells, and the cells of portal tracts, whereas most of the altered hepatic arteries showed no or very weak positivity. CONCLUSIONS: The results strongly suggest an association between the occurrence of Chlamydia pneumoniae and the presence of foam cell arteriopathy in transplanted livers.

Detection of portal and systemic bacteremia in dogs with severe induced hepatic disease and multiple portosystemic shunts.

OBJECTIVE: To determine existence of portal and systemic bacteremia in dogs with induced severe hepatic disease, compared with clinically normal dogs, before and after vena caval banding. ANIMALS: 6 control dogs and 10 dogs with induced severe hepatic disease and multiple portosystemic shunts (PSS). PROCEDURE: Dogs of the diseased group were given dimethylnitrosamine (2 mg/kg of body weight, PO) twice weekly until multiple PSS developed. Surgery was performed on dogs of both groups, and blood for baseline aerobic and anaerobic bacterial culture was collected from catheters placed in the portal and hepatic veins and caudal vena cava. All dogs underwent vena caval banding, and blood for aerobic and anaerobic bacterial culture was collected from the portal and hepatic venous catheters at 120, 240, and 360 minutes after banding. RESULTS: Compared with control dogs (16% gram-positive and 84% gram-negative bacteria), diseased dogs had significantly higher percentage of gram-positive bacteria (42% of positive culture results, P < or = 0.01) and significantly lower percentage of gram-negative bacteria (58% of positive culture results, P < or = 0.01) isolated. Pseudomonas aeruginosa was isolated most frequently from dogs of both groups; more than 1 organism was isolated from 5 dogs of each group. Antimicrobial susceptibility included that to aminoglycosides (particularly amikacin), fluorinated quinolones, and imipenem. CONCLUSION: Portal and systemic, predominantly gram-negative, bacteremia is present in catheterized, clinically normal dogs and dogs with dimethylnitrosamine-induced hepatic disease and multiple PSS.

[Portal and systemic bacteremia as a manifestation of the functional failure of the enteral barrier in acute intestinal obstruction]. / Portal'naia i sistemnaia bakteriemiia kak proiavlenie funktsional'noi nesostoiatel'nosti énteral'nogo bar'era pri ostroi neprokhodimosti kishechnika.

A complex investigation of 72 patients, with acute bowel obstruction (ABO) having clinico-laboratory signs and symptoms of endotoxicosis (ET), was carried out. It was proven that ABO was accompanied by profound decrease of the immuno-secretory function of the small bowel and its extensive bacterial contamination as a result of significant increase in the concentration of gram-negative symbiotic microflora, which leads to increased permeability of bowel barrier. Consequently there is massive translocation of the internal medium of the organism by enteral microflora and most of all in the portal zone and in the presence of inadequate hepatic barrier function--the systemic blood supply which corresponds to the clinical picture of endotoxic shock.

Candida arteritis: are GI endoscopic procedures a source of vascular infections?

A 53-year-old woman, 11 years after a renal transplant on chronic immunosuppression, presented with a sudden onset of a painless left groin mass. Ultrasound revealed a 3 cm common femoral artery pseudoaneurysm and a 3 cm saccular aneurysm of the infrarenal aorta. Operative repair was excision and patch angioplasty of the aortic aneurysm with internal iliac artery and interposition grafting of the femoral artery aneurysm with saphenous vein. Postoperatively, Candida albicans was identified in the aortic and common femoral arterial cultures. Candida infections often occur in patients with impaired cellular immunity due to seeding from urinary tract infections, vascular catheters, or manipulation of the gastrointestinal tract. Our patient, without any prior history of a fungal infection, had undergone a colonoscopy 3 weeks earlier. Without any other possible source being identified, the proposed mechanism for fungal entry into the vascular system was via the gastrointestinal tract, with seeding from the portal venous system. The exact medical and surgical management of these patients remains undefined, and a transplant vascular registry is really needed. However, immunocompromised solid organ transplant recipients undergoing gastrointestinal endoscopic procedures may be at a greater risk for the development of subsequent septicemia. Further reports are really needed to confirm the possible need in these patients for both periprocedural antibiotic and antifungal prophylactic coverage.

Effect of cardiogenic shock on pharmacokinetics and tissue distribution of ampicillin-sulbactam.

A reversible cardiogenic shock model in pigs investigated shock-induced changes in the pharmacokinetics and tissue distribution of ampicillin-sulbactam and the efficacy of this antibiotic regimen in eliminating enteric bacterial translocation. Sixteen pigs were randomly allocated to 3 groups: group I (shock, ampicillin-sulbactam, n = 6), group II (no shock, ampicillin-sulbactam, n = 6), and group III (shock, no ampicillin-sulbactam, n = 4). Nalidixic acid-resistant E. coli (60 x 10(6) CFU) were instilled into a jejunal loop created in each pig, and bacterial cultures were taken from thoracic duct lymph, periportal, and mesenteric lymph nodes. Ampicillin-sulbactam was administered intravenously at a standard dose of 3 g. Results showed that 1) ampicillin and sulbactam concentrations generally increase during cardiogenic shock; 2) cardiogenic shock does not increase ampicillin concentrations in jejunum and liver; 3) during resuscitation, thoracic duct lymph ampicillin concentrations decrease; and 4) during and immediately after cardiogenic shock, standard doses of ampicillin-sulbactam appear efficacious in eliminating translocated bacteria.

[Effect of intestinal decompression with intubation on portal and systemic bacteremia in patients with peritonitis]. / Vliianie zondovoi dekompressii kishechnika na portal'nuiu i sistemnuiu bakteremiiu u bol'nykh s peritonitom.

Examination of 55 patients, who underwent operation for generalized peritonitis of various etiology, included comparative appraisal of the degree of portal and systemic bacteremia and the leukocytic index of intoxication in patients with and those without nasointestinal intubation. It was found that the microflora of a paretic intestine was one of the most important factors of intoxication in patients with peritonitis in the postoperative period. Nasointestinal intubation in this case proved to be an effective method for reducing the degree of portal and systemic bacteremia and ensured a significant decrease of the degree of intoxication as compared to that in the control group.

The effect of experimental haemorrhagic shock on the bacterial content of thoracic duct lymph.

The effect of haemorrhagic shock on the simultaneous appearance of enteric micro-organisms in the central lymph and the portal blood was studied in 30 dogs. Irreversible haemorrhagic shock results in portal bacteraemia but the lymph remains sterile. Thoracic duct drainage is harmful and hastens the onset of irreversibility.