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Fulminant Colitis
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Michael F. Musso, Adrian W. Ong
Criteria for operative intervention in C. difficile FC have not been well defined. Peritonitis, perforation, toxic megacolon, and hypotension are clear indicators, but these may not be present in many patients. A retrospective study found that age ≥70 years, WBC of >35,000 or <4,000/μL or bandemia, and need for intubation or vasopressors predicted mortality in FC [4]. When all three criteria were present, mortality was 57% vs. 0% when all three were absent. Lamontagne et al. [5] reviewed 165 patients with C. difficile colitis requiring intensive care unit admission. Risk factors for mortality were age ≥75 years, WBC of ≥50,000 µL, immunosuppression, need for vasopressors, and a lactate level of ≥5 mmol/L. Colectomy reduced adjusted odds of death by 78%. Subgroup analyses showed that colectomy was of mortality benefit in those aged ≥75 years, WBC >20,000 µL, and lactate of >2.2 and <5 mmol/L. They and others found that 75–80% of patients with a lactate of >5 mmol/L died whether or not there was operative intervention. These studies suggest that certain clinical criteria may signal the need for expeditious operation.
Surgery for Necrotizing Enterocolitis
Published in David J. Hackam, Necrotizing Enterocolitis, 2021
Scenario 1 refers to the “classic presentation” of NEC, the presentation that comes to mind when most practitioners think of this disease. This is the patient, typically of 28 to 30 weeks' gestational age, who has been in the NICU for 3 to 4 weeks now and is essentially stable and doing well. The child may have been fed a little breast milk at first, but then when the breast milk supplies ran out, the child was transitioned to formula, which may have been fortified 24 hours previously. Out of nowhere the child develops abdominal distension, vomits, and then passes a bloody or blood-tinged stool (Figure 10.1). The blood work reveals a normal blood panel, including an unremarkable leukocyte count except for a mild bandemia, a stable hemoglobin (Hb), and often a drop in platelet count, although overall platelets are still within the normal range. A stat abdominal x-ray reveals the presence of pneumatosis that is localized to the right lower quadrant, extending up to the liver region (Figure 10.2). The child is made NPO, broad-spectrum antibiotics are started, and x-rays are repeated every 6 hours. Twelve hours later, the x-ray reveals a patch of free air in the right lower quadrant and under the liver (Figure 10.3). A diagnosis of Bell stage III is confirmed, and an exploratory laparotomy is performed. At exploration, patchy small bowel disease is encountered throughout the small bowel (Figure 10.4), with a few areas of discreet necrosis, and with perforation within 10 cm of the ileocecal valve (ICV). The diseased segments of the ileum are resected, and an ileostomy and mucus fistula are brought out through the wound as stomas (see later). There is minimal bleeding, and the entire operation takes under an hour.
Pylephlebitis treated with apixaban
Published in Hospital Practice, 2019
Graham R Hale, Leon Alan Sakkal, Taki Galanis
On physical examination, the patient was slightly lethargic and vitals were within normal limits. Occasionally, the patient would undergo episodes of high fevers (Tmax: 103.7F), with rigors, chills and profuse sweating. The patient reported intermittent left lower quadrant abdominal pain and constant left shoulder pain that increased with contact posterior to the mid axillary line and superior to the left flank region. The left shoulder demonstrated full range of motion, with no loss of strength or sensation. The abdomen was non-tender and non-distended with no masses appreciated on exam. Initial laboratory studies demonstrated bandemia, elevated inflammatory markers, mild elevation in transaminases, and low iron and iron binding capacity. Blood cultures reported slow growing anaerobic gram positive cocci, further speciated using MALDI-TOF as Parvimonas micra. For the course of his inpatient stay, the patient was given acetaminophen as needed for episodes of pyrexia, and 5000 units of subcutaneous unfractionated heparin every 12 hours for DVT prophylaxis. Coagulation values were as follows: PT: 15.9 seconds, PTT: 34 seconds, and platelet: 221,000.
Invasive Group B streptococcus: multiloculated perinephric abscesses treated with percutaneous drainage
Published in Journal of Community Hospital Internal Medicine Perspectives, 2018
J. Isaac Peña-Garcia, Sana Shaikh, Alexandre Lacasse
Eleven days later, he was brought in due to lethargy, nausea, non-bilious non-bloody emesis, anorexia, and progressive diffuse abdominal pain. He remained afebrile with stable vitals. Physical examination was remarkable for encephalopathy, worsened cachexia, and excruciating right-sided abdominal and flank tenderness. Laboratory data showed leukocytosis (10.8 [4.4–10.7 × 10E9 cells/L]) with bandemia (17% [0–11%]), mild thrombocytopenia (130 [153-416 × 10E9 cells/L]), azotemia (BUN 26 [7–21 mg/dL], creatinine 1.2 [0.5–1.3 mg/dL]), hyperkalemia (5.6 [3.5–5.1 mmol/L]), anion gap metabolic acidosis (16 [22–31 mmol/L]), hyperlactatemia (3.8 [0.7–2.1 mmol/L]), hypoalbuminemia (1.7 [3.4–5 g/dL]) with low prealbumin (<3.0 [20–40 mg/dL]), hyperammonemia (88 [<34 µmol/L]), and hyperglycemia (273 [74–106 mg/dL]). Hemoglobin A1c was elevated (10.8 [4.2–6.3%]), establishing a new diagnosis of diabetes mellitus (DM). Urinalysis showed persistent pyuria (WBC 20–50 [0–2 cells/HPF]). Prior urine culture was consistent with urogenital flora (<10,000 colony forming unit/mL).
Conquering the pneumococcal nemesis with oral antibiotics
Published in Journal of Community Hospital Internal Medicine Perspectives, 2020
Rana Garris, Rushdy Abanoub, Firas Qaqa, Chirag Rana, Nirmal Guragai, Habib A. Habib, Fayez Shamoon, Mahesh Bikkina
58-year-old African American male presented with altered mental status, low-grade fever and hemoptysis. Patient was disheveled and smelled of alcohol with urine toxicology positive for opioids. He had bilateral coarse rhonchi with decreased breath sounds over the lung bases. A grade 2/5 holosystolic murmur was appreciated along the apex. Labs demonstrated marked leukocytosis with bandemia, normocytic anemia, and thrombocytopenia. Computerized tomography (CT) of chest showed diffuse interstitial infiltrates throughout both lung fields with bilateral pleural effusions and atelectasis of the lower lobes (Figure 1). Blood cultures were positive for pansensitive Streptococcus pneumoniae. Urine antigen was also positive for pneumococcus IgG. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) demonstrated severe mitral valve regurgitation with eccentric and posteriorly directed jets and 1.34 cm X 1.27 cm vegetation on the anterior mitral leaflet and 0.96 cm X 1.05 cm on the posterior mitral leaflet (Figure 2(a,b)). He was started on IV ceftriaxone 2 g every 24 h and cardiothoracic surgical consult was placed for significant valve destruction and heart failure. After 3 weeks of inpatient treatment, he wished to leave against medical advice, because of family and financial responsibilities. After risk counseling, he opted to leave with oral antibiotics, amoxicillin 1 g every 8 h and levofloxacin 750 mg daily for 4 weeks. On 3-month follow-up visit, he reportedly finished all oral antibiotics, and had abstained from alcohol and heroin use. His repeat blood cultures were negative and repeat echocardiogram showed a well-organized and calcified mitral valve consistent with healed vegetation and mild mitral regurgitation (Figure 3).