Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

Effect of Arrabideae chica (crajiru) extract in a model of induced experimental colitis in rats

Objective: This study aimed to investigate the effect of A. chica extract on the evolution of experimental rectocolitis in rats, and the expression of the pro-inflammatory cytokines TNF-a, IL-1β and IL-6 in colonic tissue. Methods: Wistar rats weighing 275±23g were distributed into 4 groups of 6 animals each. Rectocolitis was induced in rats by rectal administration of trinitrobenzene sulfonic acid (TNBS). Seventy-two hours after TNBS injection, animals were treated daily for 6 days. Groups: 1. Normal control group without induction of rectocolitis. Received 0.9% saline injection v.o. by gavage during treatment. 2. TNBS rectocolitis group, treated with normal saline (SN) by gavage (TNBS+SN); 3. TNBS rectocolitis group treated with A. chica extract (ACE), receiving a daily dose of 300 mg of A. chica extract by gavage (TNBS+ACE);4. TNBS rectocolitis group treated with mesalazine, receiving a daily dose of 100 mg/kg of mesalazine orally (TNBS+MEZ). Macroscopic examination of the colon and dosing of TNF-α, IL-1β and IL-6 in colon tissue were performed. Results: There was a reduction in weight in animals treated only with TNBS+NS. No difference in weight was observed comparing the animals treated with ACE and MEZ. In the control group no mucosal ulcers or edema of the colon wall were observed. Several mucosal ulcers, edema and hyperemia occurred in the colon of rats in the TNBS+SN group. In two of the animals in this group there was colon perforation, tamponated by omentum. A reduction of mucosal ulcers number in the TNBS+ACE (crajiru) group was seen, compared to the TNBS+SN and TNBS+MEZ group. There was a significant reduction of TNF-α, IL-1β and IL-6 in the colon tissue of animals treated with crajiru extract, TCBS+ACE group, when compared to the control group (p<0.001), TNBS+SN group, and TNBS+MEZ groups (p<0.001). Conclusion: This is the first study to show that A. chica extract positively influences the treatment of TNBS/induced rectocolitis through its antiinflamatory activity. More comprehensive studies are needed to understand the underlying mechanisms.

Successful endoscopic closure with an over-the-scope clip for sigmoid colon perforation due to bile duct stent migration

An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future.

Lupus enteritis as a flare up of systemic lupus erythematosus- a case report and review

Systemic lupus erythematosus (SLE) generally affects young to middle-aged women, commonly presenting as a triad of fever, rash, and joint pain. Abdominal pain is a common symptom in patients with SLE. The leading causes of abdominal pain in SLE are lupus enteritis, pancreatitis, pseudo-obstruction, acalculous cholecystitis, mesenteric thrombosis, hepatic thrombosis, medications like (NSAIDS, MMF, steroids, HCQ), colon perforation. The incidence of abdominal pain in patients with SLE ranges from 8-40%, and the commonest cause is lupus enteritis. The following case describes a young woman presenting with lupus enteritis as a manifestation of SLE, the importance of early disease recognition, utilities of abdominal computed tomography (CT) in diagnosis, and current treatment protocols for lupus enteritis.

Radiology guided antegrade GASTROSTOMY deployment of mushroom (pull type) catheters with classical and modified methods in patients with oropharyngeal, laryngeal carcinoma, and anesthesia risk

Objective: The aim of study is to evaluate the results of deployment of Percutaneous Radiological Gastrostomy (PRG), which is a good alternative to Surgical Gastrostomy (SG), with transoral approach in cases where Percutaneous Endoscopic Gastrostomy (PEG) is contraindicated, difficult or unsuccessful, in patients with high risk of American Society of Anesthesiologists with four scores. In addition, we aimed to demonstrate the advantages of mushroom pull type catheters over push type gastrostomy catheters. Methods: This retrospective study included a total of 40 patients (18 females and 22 males) aged 21–92 years who underwent PRG with the antegrade transoral approach. PRG was performed by retrograde passing through the esophagus or snaring the guidewire from the stomach and taking out of the anterior abdominal wall. Patients’ demographic data, indications for PRG, procedural outcomes and complications were screened and recorded. Results: PRG was performed in 39 of 40 patients included in the study. Technical success rate was 97.5%. Procedure-dependent major complications such as death, aspiration, colon perforation, and deep abscess were not observed. Aspiration occurred in the first patient during the first feeding on the day after the procedure. Major complication rate was 2.5%. The total minor complication rate was 17.5% in 7 patients; parastomal leakage in 2 patients (5%), skin rash and infection in 3 (7.5%) patients, minor bleeding in 2 (5%) patients with oropharynx cancer, minimal bleeding from the gastrostomy catheter 1 week after the procedure in 1 (2.5%) patient. None of the cases had buried buffer. Tube functionality was preserved in all patients without any damage. Conclusion: Mushroom tip (pull type) gastrostomy catheter is a safe treatment method for patients requiring prolonged feeding because of wide diameter, endurance, long staying opening duration, less excessive dilatation and parastomal leakage, and no need for gastropexy. Lower cost and easier access are advantageous for mushroom tip pull type catheters compared to push type gastrostomy catheters in our country. The less invasive PRG is an alternative option in patients who are difficult to administer PEG, are at high anesthesia risk and cannot be sedated. Advances in knowledge: This article is valuable in terms of its contribution to develop an alternative radiological method for the deployment of gastrostomy tubes in medical difficult patients. This method has shortened the duration of the procedure and increased the success rate in patients with difficulty in transition from the stomach to the esophagus or with difficulty in the upper gastrointestinal tract. Mushroom tip catheters can be placed successfully by radiological methods.

Colon perforation as a complication of COVID-19: a case report

Background Coagulopathy induced by COVID-19 has received much attention. Arterial and venous thrombosis of multiple organs due to COVID-19-related coagulopathy is associated with a poor outcome. Case presentation A 67-year-female was transferred to our hospital in need of intensive care for severe COVID-19 pneumonia. On day 7 after admission, despite the treatments, her respiratory and hemodynamic status deteriorated. Computed tomography revealed massive ascites and free air as well as wall defects of the transverse colon. An emergency laparotomy was undertaken in the intensive-care unit, and 17 cm of the transverse colon was resected. Histopathological findings revealed two perforation sites of 25 and 7 mm in diameter, necrosis of the intestinal mucosa around the perforation sites, and the microcirculatory thrombosis in the mesentery vessels which was suspected of having been induced by COVID-19-related coagulopathy. Conclusions The case highlights the risk of intestinal ischemia and perforation induced by COVID-19 coagulopathy. Physicians treating COVID-19 should recognize the risk and evaluate patients carefully.

Colonic perforation in patients with COVID-19 pneumonia – case reports

Introduction: Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. Case report: We present two cases of SARS-CoV-2 positive patients treated in our department for colon perforation. One patient was operated for a diastasic right colon perforation due to acute over distension of the bowel. The perforation in the second case was associated with chronic diverticulitis. Conclusion: These cases highlight the fact that besides typical respiratory symptoms and signs of COVID-19, digestive symptoms also occur. These can caused by intestinal perforation, be it directly or due to changing homeostasis of the internal environment.