Cytomegalovirus ileo-pancolitis presenting as toxic megacolon in an immunocompetent patient: A case report

BACKGROUND Cytomegalovirus(CMV) enterocolitis presenting in the form of pancolitis or involving the small and large intestines in an immunocompetent patient is rarely encountered, and CMV enterocolitis presenting with a serious complication, such as toxic megacolon, in an immunocompetent adult has only been reported on a few occasions.CASE SUMMARY We describe the case of a 70-year-old male with no history of inflammatory bowel disease or immunodeficiency who presented with toxic megacolon and subsequently developed massive hemorrhage as a complication of CMV ileopancolitis. The patient was referred to our institute for abdominal pain and distension. Abdominal X-ray showed marked dilatation of ileum and whole colon without air-fluid level, and sigmoidoscopy with biopsy failed to reveal any specific finding. After 7 d of conservative treatment, massive hematochezia developed, and he was diagnosed to have CMV enterocolitis by colonoscopy with biopsy. Although the diagnosis of CMV enterocolitis was delayed, the patient was treated successfully by repeat colonoscopic decompression and antiviral therapy with intravenous ganciclovir.CONCLUSION This report cautions that CMV-induced colitis should be considered as a possible differential diagnosis in a patient with intractable symptoms of enterocolitis or megacolon of unknown cause, even when the patient is nonimmunocompromised.

Toxic megacolon associated Clostridium difficile colitis

Toxic megacolon is a severe complication of Clostridium difficile (C.difficile) colitis.As the prevalence of C. difficile colitis increases and treatments become more refractory, clinicians will encounter more patients with C. difficile associated toxic megacolon in the future. Here, we review a case of toxic megacolon secondary to C. difficile colitis and review the current literature on diagnosis and management. We identify both clinical and radiologic criteria for diagnosis and discuss both medical and surgical options for management. Ultimately, we recommend using the Jalen criteria in conjunction with daily abdominal radiographs to help establish the diagnosis of toxic megacolon and to make appropriate treatment recommendations. Aggressive medical management using supportive measures and antibiotics should remain the mainstay of treatment. Surgical intervention should be considered if the patient does not clinically improve within 2-3 d of initial treatment.

溃疡性结肠炎并发中毒性巨结肠误诊原因分析

目的提高对溃疡性结肠炎(ulcerative colitis,UC)及其严重并发症中毒性巨结肠的认识,减少误诊误治。方法回顾性分析1例UC并中毒性巨结肠的临床资料。结果患者因腹痛、腹泻、便血入院,在院外及我院按肠道感染处理效果不佳,经全腹CT、结肠镜、腹部立位X线平片等检查确诊UC并中毒性巨结肠、肠梗阻。患者最终因脓毒症性休克、多器官功能衰竭而死亡。结论 UC并中毒性巨结肠患者病情凶险,病死率高,应早期识别,择机手术,改善预后。

Treatment of acute severe ulcerative colitis using accelerated infliximab regimen based on infliximab trough level:A case report

BACKGROUND Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitisassociated with high levels of circulating tumor necrosis factor alpha, due to theintense inflammation and faster stool clearance of anti-tumor necrosis factordrugs. Dose-intensified infliximab treatment can be beneficial and is associatedwith lower rates of colectomy. The aim of the study was to present a case of apatient with ASUC and megacolon, treated with hydrocortisone and acceleratedscheme of infliximab that was monitored by drug trough level.CASE SUMMARYA 22-year-old female patient diagnosed with ulcerative colitis, presented withdiarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen.During investigation, a positive toxin for Clostridium difficile and colonic dilatationof 7 cm consistent with megacolon were observed. She was treated with oralvancomycin for pseudomembranous colitis and intravenous hydrocortisone forsevere colitis, which led to the resolution of megacolon. Due to the persistentsevere colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drugtrough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based onthe low infliximab trough level after one week from the first infliximab dose, thepatient received a second infusion at week 1, consistent with the acceleratedregimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical andendoscopic response after 6 mo of therapy, without the need for a colectomy.CONCLUSIONInfliximab accelerated infusions can be beneficial in ASUC unresponsive to thetreatment with intravenous corticosteroids. Longitudinal studies are necessary todefine the best therapeutic drug monitoring and treatment regimen for thesepatients.

Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes

BACKGROUND Clostridium difficile infection(CDI)occurs due to a dysbiosis in the colon.The appendix is considered a‘safe house’for gut microbiota and may help repopulate gut flora of patients with CDI.AIM To study the impact of prior appendectomy on the severity and outcomes of CDI.METHODS We retrospectively reviewed data of 1580 patients with CDI,admitted to our hospital between 2008 to 2018.Patients were grouped based on the presence or absence of the appendix.The primary aim was to(1)assess all-cause mortality and(2)the severity of CDI.Severity was defined as per the Infectious Diseases Society of America criteria.Logistic regression,and propensity score analysis using inverse probability of treatment weights(IPTW)was performed.RESULTS Of the 1580 patients,12.5%had a history of appendectomy.There was no statistical difference in mortality between patients with a prior appendectomy or without(13.7%vs 14%,P=0.877).However,a history of appendectomy affected the severity of CDI[odds ratio(OR)=1.32,95%confidence interval:1.01-1.75].On IPTW,this association remained significant(OR=1.59,P<0.05).On multivariable toxic megacolon(OR=5.37,P<0.05)and colectomy(OR=2.77,P<0.05).CONCLUSION Prior appendectomy may affect the severity of CDI,development of toxic megacolon and the eventual need for colectomy.Since treatment of CDI is governed by its severity,stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.

Fecal microbiota transplantation as potential first-line treatment for patients with Clostridioides difficile infection and prior appendectomy

Clostridioides difficile infection(CDI)is a global health problem.The association of appendectomy on the severity and prognosis of CDI has been reported in many literatures,but there are still contradictions.In a retrospective study entitled“Patients with Closterium diffuse infection and prior appendectomy may be prone to word outcomes”published in World J Gastrointest Surg 2021,the author found that prior appendectomy affects the severity of CDI.Appendectomy may be a risk factor for increasing the severity of CDI.Therefore,it is necessary to seek alternative treatment for patients with prior appendectomy when they are more likely to have severe or fulminant CDI.

Ulcerative Colitis in Sub-Saharan Africa: Analysis of 24 Cases in Dakar (Senegal)

Introduction: The aim of our study was to determine the socio-demographic, diagnostic and therapeutic aspects of ulcerative colitis (UC) in one of the largest gastroenterology departments in Senegal. Patients and Method: This was a retrospective and descriptive study based on the analysis of the records of patients hospitalized in the Hepato-Gastroenterology Department of the Grand Yoff General Hospital (Dakar, Senegal) between January 2013 and December 2019. All cases of UC were collected. Clinical, biological, endoscopic and histological data were collected, as well as treatment options. Results: We observed 24 cases, representing a prevalence of 0.87% of inpatients. The mean age of patients was 36 (ranged 18 to 73) and sex ratio 0.9 (13 females). The mean diagnostic delay was 1.6 years (ranged 4 months to 5 years). The clinical symptomatology was dominated by diarrhea with blood and mucus (18 cases). The Litchiger score on admission averaged 8 and 5 patients (20.8%) had severe acute colitis. Colonoscopy showed pancolonic involvement (Montreal E3) in 11 cases (45.8%) and severe endoscopic lesions (stage 3 of the Mayo endoscopic subscore) in 10 cases (41.6%). Therapeutically, 17 patients (70.8%) were initially treated with corticosteroids. Background therapy was 5-ASA in 17 patients (70.8%) and azathioprine in 7 patients (29.2%). Two cases of death (8.3%) were observed following colectasia with colonic perforations before emergency surgery could be performed. Conclusion: UC in our study was primarily among young adults with a slight female predominance. Diagnosis is often late. The lack of biotherapy requires close collaboration with surgeons for the management of severe forms.

中毒性巨结肠发病机制及内科治疗新进展

中毒性巨结肠(toxic megacolon,TMC)是由炎症性肠病(inflammatory bowel disease,IBD)引起的一种具有潜在致命性的并发症,目前治疗手段主要是外科手术治疗。作为内科医师,应对此类患者做到早期发现、合理内科过渡治疗、择机行结肠切除手术治疗、改善患者预后。我国很少有对TMC内科药物保守治疗及其发病机制研究的文章,本文复习相关国内外文献,就TMC的发病机制及其内科治疗新进展作一概述。

Current status of surgical treatment for fulminant clostridium difficile colitis

Mortality rates attributable to fulminant Clostridium difficile(C.difficile) colitis remain high and are reported to be 38%-80%.Historically,the threshold for surgical intervention has been judged empirically because level I evidence to guide decision making is lacking.Studies of the surgical management of C.difficile infection have been limited by small sample size and the lack of a standard definition of fulminancy.Multiple small and medium-sized series have examined the surgical management of C.difficile.However,because of a lack of prospective,randomized studies,it has been difficult to identify the optimal point for surgical intervention in patients with severe fulminant C.difficile colitis.Our goal was to analyze the existing body of literature in an attempt to define host constellations,which would predict the development of the more aggressive form of this disease and hence justify an early or earlier surgical intervention.A Pubmed search was conducted using the keywords "fulminant","clostridium difficile","surgery",and "colitis".Reviews and Meta-analyses proposing indications for surgical consultation or operative management in patients with C.difficile colitis were included.After analyzing current literature,we identified a number of parameters that are associated with unfavorable outcomes.The parameters include age greater than 65 years old,peritoneal signs on physical examination,abdominal distension,signs of end-organ failure,hypotension less than 90 mmHg systolic blood pressure,tachycardia greater than 100 bpm,vasopressor requirement,elevated WBC count of greater than at least 16 × 10 9 /μL,serum lactate of greater than 2.2 mmol/L,and lastly,radiologic findings suggestive of pancolitis,ascites,megacolon,or colonic perforation.Even though fairly strong evidence exists in contemporary literature,we recommend use of these identified parameters with caution in clinical practice when it comes to the actual decision to treat certain patients more aggressively.The identified risk factors should be used to lower surgeons' threshold for operative treatment early in the course of the

血清基质Gla蛋白与溃疡性结肠炎患者黏膜炎症程度的关系及对中毒性巨结肠的预测研究

目的分析血清基质Gla蛋白(matrix Gla protein,MGP)与溃疡性结肠炎患者黏膜炎症程度的关系及对中毒性巨结肠的预测价值。方法选择2015年1月至2018年1月西安交通大学附属三二〇一医院收治的162例溃疡性结肠炎患者,根据Mayo内镜评分评价黏膜炎症程度,分为轻度组、中度组和重度组,比较3组PLT、平均血小板体积(mean platelet volume,MPV)、ESR、CRP和MGP水平,采用Pearson相关性分析探讨血清MGP水平与Mayo内镜评分的关系。随访36个月,观察中毒性巨结肠的发生情况,采用ROC曲线下面积(AUC)评价血清MGP对中毒性巨结肠的预测效能。结果轻度组(91例)PLT、ESR、CRP和MGP水平分别为(189.41±28.76)×10^(9)/L、22.19(15.75,28.74)mm/h、10.10(5.12,15.42)mg/L和11.12(6.12,16.25)nmol/L,中度组(39例)分别为(273.16±46.92)×10^(9)/L、38.45(28.75,45.75)mm/h、18.41(10.74,27.56)mg/L和20.35(15.41,27.15)nmol/L,重度组(32例)分别为(365.42±69.47)×10^(9)/L、62.30(47.10,75.45)mm/h、63.21(39.85,85.41)mg/L和29.47(20.12,32.15)nmol/L;重度组PLT、ESR、CRP和MGP水平明显高于轻度组和中度组,差异有统计学意义(P<0.05)。Pearson相关性分析显示,溃疡性结肠炎患者ESR(r=0.233,P=0.042)、CRP(r=0.221,P=0.045)和MGP(r=0.315,P<0.001)水平与Mayo内镜评分呈正相关(P<0.05);溃疡性结肠炎患者ESR(r=0.254,P=0.036)、CRP(r=0.267,P=0.033)水平与MGP水平呈正相关(P<0.05);多因素logistic回归分析显示,ESR、CRP和MGP是中毒性巨结肠的独立预测因素(P<0.05);ROC分析显示,血清MGP预测溃疡性结肠炎患者发生中毒性巨结肠的AUC为0.896,大于ESR的0.654和CRP的0.638,差异有统计学意义(Z=2.158、2.634,P均<0.001)。结论血清MGP水平与溃疡性结肠炎患者黏膜炎症程度呈正相关,其预测中毒性巨结肠发生的效能较好,值得临床重视。

Observations on a Giant Sigmoid Volvulus with Unusual Clinical Presentation and Challenging Postoperative Course: Case Report

Introduction: The present report describes a case of a giant sigmoid volvulus (SV) where acute respiratory distress was associated with toxic megacolon. Clinical features, surgical treatment and postoperative course deserved our attention and discussion. Presentation of Case: A 67-year-old man with psychiatric disturbances was admitted to our Department with severe respiratory distress due to an enormous abdominal distension caused by a sigmoid volvulus. Endoscopic derotation was unsuccessful and surgery immediately performed. After a wide colonic resection the patient underwent a prolonged treatment in the Intensive Care Unit. Death occurred 34 days after the operation for secondary infection of peritoneal effusion. Discussion: Main clinical features of SV pertain to abdominal compartment while in the present case acute respiratory distress was the prominent symptom;in the same time the severity of the case was due to the association of high abdominal pressure together with a toxic megacolon. Postoperative treatment consisted in ventilatory support, with a progressive shift from asssisted to spontaneous ventilation;repeated sessions of haemodialysis were necessary to manage renal failure up to recovery of the urine output. Bacterial trans location due to toxic megacolon was responsible of late infection of ascitic fluid. In spite of multiple antibiotic association according to bacterial cultures, intra-abdominal abscesses eventually developed causing fatal outcome 34 days after the first intervention. Conclusion: Severe clinical presentation required a prolonged and demanding postoperative course which was focused on the recovery of respiratory, cardiac and renal function even if fatal outcome was due to septic complications. Suspicion of late infection of ascitic fluid could arise from persistently high values of inflammation indexes and drive to an earlier drainage of the abdominal abscesses.

Fulminant ulcerative colitis in a healthy pregnant woman

This case report concerns a 25-year-old patient with6-7 bloody stools/d, abdominal pain, tachycardia,and weight loss occurring during the third trimester of pregnancy. Severe ulcerative colitis complicated by toxic megacolon and gravidic sepsis was diagnosed by clinical evaluation, colonoscopy, and rectal biopsy that were performed safely without risk for the mother or baby. The patient underwent a cesarean section at28+6 wk gestation. The baby was transferred to the neonatal intensive care unit of our hospital and survived without complications. Fulminant colitis was managed conservatively by combined colonoscopic decompression and medical treatment. Although current European guidelines describe toxic megacolon as an indication for emergency surgery for both pregnant and non-pregnant women, thanks to careful monitoring, endoscopic decompression, and intensive medical therapy with nutritional support, we prevented the woman from having to undergo emergency pancolectomy. Our report seems to suggest that conservative management may be a helpful tool in preventing pancolectomy if the patient's condition improves quickly. Otherwise, surgery is mandatory.

溃疡性结肠炎术后早期并发症的预防及处理

目的总结分析溃疡性结肠炎外科治疗术后并发症的发生原因及处理经验。方法回顾性分析1995年1月至2005年12月手术治疗26例溃疡性结肠炎的临床资料。因结肠出血、肠穿孔、中毒性巨结肠和吻合口瘘等并发症入院病人19例,内科治疗无效而无并发症入院病人7例。其中急诊手术12例,择期手术14例;全结肠直肠切除术11例,结肠部分切除和结肠单纯造口术15例。结果11例(18例次)病人术后出现并发症,并发症发生率为42.3%,急诊手术后并发症发生率较高,主要为切口并发症和吻合口瘘。4例吻合口瘘病人2例保守治疗痊愈,2例再次手术,共有2例病人死亡。结论全结肠直肠切除术是治疗溃疡性结肠炎的有效手段,合理掌握手术时机和采取合理的手术方式能够降低术后并发症的发生率。对于常见的吻合口瘘并发症,通过持续骶前灌洗、通畅引流以及有效的贮袋引流减压等保守治疗,可使吻合口瘘闭合。

溃疡性结肠炎合并中毒性巨结肠六例及文献复习

目的总结溃疡性结肠炎（UC）合并中毒性巨结肠患者的临床特点，为临床早期诊断、及时治疗提供依据。方法总结分析1983--2010年北京协和医院6例UC合并中毒性巨结肠病例的临床特点、治疗及转归，并结合国外相关文献进行分析。结果中毒性巨结肠在北京协和医院UC患者中发病率为0．7％（6／824），低于国外文献报道。其发病存在诱因，虽经内科保守治疗与手术治疗，但预后不佳。国外文献认为应积极评价患者临床情况，在正确的时机及时行手术治疗，有助于改善预后。结论早期识别UC合并中毒性巨结肠患者，并在正确的时机选择急诊手术或择期手术是改善患者预后的关键。

初发型溃疡性结肠炎致中毒性巨结肠五例分析

目的探讨初发型溃疡性结肠炎致中毒性巨结肠的临床表现及诊治方法。方法回顾性分析2003年6月至2008年10月收治的5例初发型UC致中毒性巨结肠患者的临床资料。结果5例患者首发症状均为腹痛、腹胀，因口服泻剂而诱发中毒性巨结肠，2例发生肠穿孔。4例女性患者出现神志异常，4例行磁共振检查，3例示腔隙性脑梗塞。该5例患者均接受手术探查，且在术前均未确立溃疡性结肠炎的诊断。5例均行部分结肠切除及肠造口术，平均手术2．4次。术后死亡1例。吻合口瘘1例，吻合口狭窄1例。结论腹痛、腹胀及服用导泻剂后临床症状加重是初发型溃疡性结肠炎致中毒性巨结肠常见的临床表现。