EP.TU.688The fate of the rectal stump following subtotal colectomy for acute colitis

Aims Acute severe colitis requires surgery in approximately thirty percent of cases. Subtotal colectomy with end ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Controversy surrounds the optimal short and long-term management of the distal rectal stump. This study reviews the clinical outcomes and the fate of the rectal stump in this patient cohort. Methods Analysis of prospective data of patients who underwent emergency subtotal colectomy for severe acute colitis between 2010 and 2020 in a tertiary referral centre. Results Sixty-six patients underwent subtotal colectomy (median age, 40years; M:F, 1.3:1). Subtotal colectomy was performed for failure of medical therapy during an acute episode of severe colitis (56%), for fulminant colitis (40%), or for colonic strictures (4%). In 98% percent of patients the rectal stump was closed at the level of the recto-sigmoid junction and in 2% a mucous fistula was formed. 73% of patients opted for no further surgery, but 27% underwent a completion proctectomy, most commonly performed because of rectal stump bleeding. The median follow-up was 6.25years, during which 17% of those with a completion proctectomy underwent an ileo-pouch anal anastomosis (IPAA). Conclusions Subtotal colectomy with closed rectal intra-peritoneal stump and end ileostomy is the procedure of choice in severe acute colitis refractory to maximal medical therapy or fulminant colitis. Given the patient dissatisfaction and morbidity associated with mucous fistula, this procedure should be abandoned. Pelvic dissection should not be performed at the time of the emergency subtotal colectomy given the risk of morbidity.

Campylobactercolitis leads to toxic megacolon and multiple organ failure

A 58-year-old woman presented to the emergency department in a district general hospital with severe abdominal pain and diarrhoea, after collapsing at home. She was admitted to the intensive care unit (ICU) in septic shock, and with acute kidney injury. An initial CT scan was suggestive of colitis. She was treated for suspected gastroenteritis and her microbiology results showed Campylobacter coli as the causative organism. She failed to respond to antibiotics, and underwent serial contrast CTs which showed no progression of colitis. Colonoscopy performed on day 10 of her admission, however, revealed fulminant colitis. After a multidisciplinary meeting among gastroenterologists, general surgeons and intensivists, the patient underwent total colectomy with ileostomy. She made a slow but steady recovery in ICU, and subsequently in the ward, and was discharged to a local community hospital for further rehabilitation.

Predictors of Clostridioides difficile Infection-Related Complications and Treatment Patterns among Nucleic Acid Amplification Test-Positive/Toxin Enzyme Immunoassay-Negative Patients

ABSTRACT The addition of toxin enzyme immunoassay (EIA) to nucleic acid amplification tests, including PCR, creates challenges in the diagnosis and management of Clostridioides difficile infection (CDI). There are limited data in large cohorts, with discordant results, that is, PCR-positive/EIA-negative (PCR+/EIA−) results. We conducted a retrospective cohort study on all PCR+/EIA− adult inpatients and assessed CDI-related complications and clinical failure. We identified 240 individuals. Twenty-three (9.6%) patients experienced a CDI-related complication, including 2 cases of megacolon, 1 colectomy, and 22 intensive care unit (ICU) admissions. In multivariable logistic regression analyses, baseline severe disease by Infectious Diseases Society of America (IDSA) criteria (odds ratio [OR], 5.84; 95% confidence interval [CI], 1.88 to 18.1; P = 0.002), baseline fulminant colitis (OR, 84.7; 95% CI, 14.3 to 500; P < 0.001), fever of >38.5°C (OR, 4.61; 95% CI, 1.42 to 15.0; P = 0.011), and proton pump inhibitor (PPI) use (OR, 3.50; 95% CI, 1.19 to 10.3; P = 0.023) were associated with increased odds of CDI-related complications. For 67 PCR+/EIA− patients who did not receive complete treatment, clinical failure was observed in 10 (15%) patients. A comparison of PCR+/EIA− patients who received complete treatment to all 112 PCR+/EIA+ patients showed no differences in CDI-related complications (11% and 13% for PCR+/EIA− and PCR+/EIA+ patients, respectively), 60-day all-cause mortality (17% and 18% for PCR+/EIA− and PCR+/EIA+ patients, respectively), or recurrent CDI (7% and 9% for PCR+/EIA− and PCR+/EIA+ patients, respectively). Predictors of CDI-attributable complications among PCR+/EIA− patients include baseline severe disease by IDSA criteria, baseline fulminant colitis, and fever of >38.5°C. Identifying the subgroup of PCR+/EIA− patients who could have true disease, and therefore allowing them to be targeted for treatment, is critical.

Fulminant amoebic colitis in the era of computed tomography scan: A case report and review of the literature

Amoebic colitis, caused by ingestion of water or food contaminated with the protozoan Entamoeba histolytica, can progress to a fulminant colitis. Computed tomography (CT) findings reported in the literature on this type of colitis are sparse. We present a 59-year-old male patient with a one-week history of progressive abdominal pain, abdominal distension and associated watery and bloody diarrhoea. A CT scan revealed deep ulcerations with submucosal and intramural tracking of contrast. Colonoscopy and biopsy confirmed a diagnosis of Amoebic colitis. The patient required a laparotomy and demised. Deep ulcerations with submucosal and intramural tracking of contrast on CT are diagnostic of fulminant amoebic colitis. Although not demonstrated at CT in this case, discontinuous bowel necrosis, omental wrapping (seen at laparotomy in our case) and neovascularisation of the bowel wall may be other features to look out for.