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Bowel disorders
Published in Henry J. Woodford, Essential Geriatrics, 2022
Culture of the organism is difficult (and hence its name), is more expensive and takes longer (up to three days). Sigmoidoscopy may detect the pseudomembranes of PMC but the disease sometimes only affects the more proximal large bowel. Therefore, a colonoscopy would be required to adequately exclude all such changes. Given the frailty of this population and the increased risk of colonic perforation in the presence of inflammation, this procedure is rarely justified. A plain abdominal X-ray should be performed if megacolon is suspected. Abdominal CT scanning can show changes consistent with colitis. Repeat stool testing to look for clearance of toxins following symptom resolution is not appropriate as it may remain positive for several weeks even when the infection has resolved. Stool type and frequency should be monitored using the Bristol Stool Scale.
Emergency Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Alastair Brookes, Yiu-Che Chan, Rebecca Fish, Fung Joon Foo, Aisling Hogan, Thomas Konig, Aoife Lowery, Chelliah R Selvasekar, Choon Sheong Seow, Vishal G Shelat, Paul Sutton, Colin Walsh, John Wang, Ting Hway Wong
The abdominal x-ray shows a dilated transverse colon measuring 9 cm. His WCC is 18. What is the diagnosis?Acute colitis is diagnosed using Truelove and Witt's criteria (more than six bloody stools, Hb < 10.5, ESR > 30, temp > 37.8°C, HR > 90).Toxic megacolon is diagnosed if there is: >6 cm transverse colonic dilatationAny three of fever, tachycardia, leucocytosis, anaemiaAny one of dehydration, altered mental status, electrolyte abnormality or hypotensionThe microscopic hallmark is inflammation extending beyond the mucosa.
Toxic Megacolon in Crohn’s Colitis
Published in Savio George Barreto, Shailesh V. Shrikhande, Dilemmas in Abdominal Surgery, 2020
Toxic megacolon is a condition traditionally characterized by gross colonic distension in the setting of severe colitis culminating in septic shock. It may occur as a consequence of either inflammatory bowel disease (more so in ulcerative colitis than Crohn’s disease) or infective colitis (e.g. cytomegalovirus or Clostridium difficile) characterized by gross segmental or pancolonic distension greater than 6 cm [1]. The muco-submucosal barrier is lost with severe pancolonic inflammation resulting in colonic dysmotility, colonic dilation, fecal stasis, and bacterial translocation. This functional obstruction runs the risk of a megacolon and perforation of a thin-walled ascending colon and cecum. Often in pancolitis, diarrhea, with or without blood, prevails. Septic shock in colitis may not necessarily be accompanied by a megacolon. Hence, we tend to use the term “toxic colitis” to describe the condition of severe colitis causing shock, despite maximal antibiotic and anti-inflammatory treatment. Toxicity and the entity of a megacolon may exist independent of each other.
Adjuvant use of combination of antibiotics in acute severe ulcerative colitis: A placebo controlled randomized trial
Published in Expert Review of Anti-infective Therapy, 2021
Shubhra Mishra, Harshal S Mandavdhare, Harjeet Singh, Arup Choudhury, Jimil Shah, Sant Ram, Dimple Kalsi, Jayanta Samanta, Kaushal K Prasad, Arun K Sharma, Usha Dutta, Vishal Sharma
The clinical features of each patient including the stool frequency, severity of bleeding, signs and symptoms of systemic toxicity, cause of exacerbation, disease characteristics (duration and extent, previous medications) were recorded in a predesigned case report form. An unprepared sigmoidoscopy with minimal air insufflation was performed and biopsies were taken for exclusion of CMV colitis. The severity at the time of presentation was also assessed using the complete Mayo score (>10: severe, 6–10: moderate, 3–5: mild, <3: remission) [14]. Stool routine microscopy, culture, and ELISA for Clostridioides difficile (CDI) were performed on admission. Patients underwent daily abdominal X-ray to rule out megacolon. Inflammatory biomarkers including serum CRP, serum procalcitonin, and fecal calprotectin were measured on admission and on day three of treatment. Partial Mayo score for ulcerative colitis was also calculated on day three and the difference from day one was noted.
Hematopoietic stem cell transplantation for inherited bone marrow failure syndromes: alternative donor and disease-specific conditioning regimen with unmanipulated grafts
Published in Hematology, 2021
Yue Lu, Min Xiong, Rui-Juan Sun, Yan-Li Zhao, Jian-Ping Zhang, Xing-Yu Cao, De-Yan Liu, Zhi-Jie Wei, Jia-Rui Zhou, Dao-Pei Lu
The general characteristics of the SCN patients and donors are summarized in Tables 4 and 5. The male to female ratio was 5–3. The median age at diagnosis and HSCT was 2 months (range: 1 week–1 year) and 3.1 years (range: 2.1 years–15 years). The median disease course pre-HSCT was 3 years (range: 8 months–15 years). The median absolute neutrophil count (ANC) in PB was 150 (20–300)/L. Two patients had a family history – one with a congenital megacolon and one with development retardation. All patients had uncontrolled recurrent infection prior to HSCT. Lobectomy was performed in one patient due to severe pulmonary infection. One patient had colonic resection due to repeated infection of a congenital megacolon. ELANE deleterious genes mutations were detected in all patients. Two patients had mutations that were traced back to their parents. All patients received G-CSF treatment for a median of 36 months (range: 24 m–120 m) before HSCT and doses above the median dose of 8 μg/kg/day (range: 5–16 μg/kg/day).
Up-to-date surgery for ulcerative colitis in the era of biologics
Published in Expert Opinion on Biological Therapy, 2020
Takayuki Yamamoto, Michele Carvello, Amy Lee Lightner, Antonino Spinelli, Paulo Gustavo Kotze
The ability to predict clinical outcomes of medical rescue therapy is currently limited and several clinical parameters such as temperature, heart rate, abdominal pain, stool frequency, blood in the stool and colonic dilatation are essential to make a management decision. Preoperative optimization of the patients is indispensable to improve surgical outcomes and needs to be considered whenever feasible (Table 1). Nutritional risk screening is recommended to correct malnutrition prior to surgery. Preoperative anemia, fluid depletion and electrolyte disorders need to be corrected whenever possible. Thromboembolism prophylaxis prior to surgery is well supported by evidence [28]. Although the most common reason for surgery is failure of medical therapy, emergency surgery can be required for intestinal perforation, toxic megacolon and refractory hemorrhage. A three-stage approach is advisable for patients with ASUC; first stage, subtotal colectomy and ileostomy with the rectum left in situ; second stage, ileal pouch–anal anastomosis with defunctioning ileostomy (3–6 months after primary surgery); third stage, closure of ileostomy [29].