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Acute Granulomatous Peritonitis Due to Starch Glove Powder*
Vol. 63, :'-!o. 6 GASTROENTEROLOGY
Printed in U.S.A.
Copyright © 1972 by The Williams & Wilkins Co.
ACUTE GRANULOMATOUS PERITONITIS DUE TO STARCH GLOVE POWDER R. HUMPHREYS, M.D., G. HARRISON, JR., M.D.
STEPHEN EDGAR
ALAN J. CAMERON, M .B.B.CH., AND
Mayo Clinic and Mayo Foundation, Rochester, Minnesota
A 34-year-old woman with acute granulomatous peritonitis due to cornstarch powder used for surgical glove lubrication is described. The patient experienced severe abdominal pain 2 V2 weeks after hysterectomy. Examination revealed ileus and unusual induration of the operative incision. At reexploration, there was ascites and extensive inflammation of the omentum, which histologically showed a foreign body granulomatous reaction with starch granules. Spontaneous recovery was complete. Acute abdominal symptoms due to starch surgical glove powder are rare. In 1970, Taft et al. 1 found less than 20 previously reported cases but added 10 of their own. We wish to report another case to reemphasize the clinical manifestations of this disorder. Report of a Case A 34-year-old white woman was hypertensive in May 1970 during the time she was taking anovular medication, which was then stopped. She took antihypertensive medication for the next 2 months only. On March 5, 1971, total abdominal hysterectomy and incidental appendectomy were performed at another institution for menometrorrhagia. A standard brand of latex surgical gloves lubricated with cornstarch (United States Pharmacopeia) was used by the surgeon. General abdominal exploration was negative. The uterine specimen revealed no serious disease. The patient felt well when dismissed from the hospital 7 days after surgery. She remained well until March 23, 1971, when she experienced crampy lower abdominal pain, vomiting, failure to pass bowel movements or flatus, and fever, with temperatures as high as 100.7 F. Examination revealed generalized abdominal rebound tenderness but no Received April 21, 1972. Accepted July 18, 1972. Address requests for reprints to: Section of Publications, Mayo Clinic, Rochester, Minnesota 55901. The authors wish to thank Dr. C. S. King for the clinical information and Dr. F. E. Ciccarelli for the loan of histologic material.
guarding. The hemoglobin level was 11.8 g per 100 ml, and the leukocyte count was 12,750 per cu mm, with 83% neutrophils, 11% lymphocytes, 4% monocytes, 1% basophils, and 1% eosinophils. The values for serum amylase, lipase, blood urea nitrogen, bilirubin, serum glutamic oxaloacetic transaminase, alkaline phosphatase, sugar, and calcium were normal. A roentgenogram of the abdomen showed distended loops of small bowel. The patient was given cephaloridine on March 25 and 26 and then cephalothin until March 28. She underwent exploration on March 27, 1971. At operation, the previous surgical incision was indurated. There was 750 ml of clear amber fluid in the peritoneal cavity. The omentum was 2 to 3 em thick and markedly indurated; a biopsy specimen was taken. The pancreas was firm but not inflamed. Other intraabdominal structures including the small bowel appeared normal. The omental biopsy showed lobules of adipose tissue with bands of inflammatory fibrosis and many foreign body granulomas composed of histiocytes, lymphocytes, scattered plasma cells, and eosinophils (fig. 1A). Many histiocytic, multinuclear, giant cells of foreign body type contained rounded particles consistent with starch granules. Some of the particles also were found in histiocytes and were surrounded by inflammatory cells in fibrous tissue. The particles stained light blue with hematoxylin and eosin, deep bluish red with the Gram stain, and bright red with the periodic acid-Schiff stain. They had an ovoid or angular central zone from which several radiating lines were occa-
1062
December 1972
1063
CASE REPORTS
sionally seen. In partially polarized light, the particles exhibited typical "Maltese cross" patterns (fig. 1B) . After the operation, she received 80 mg of methylprednisolone intramuscularly for 2 days, but she did not improve. She was transferred to the Mayo Clinic on March 29, 1971. Vomiting, abdominal pain and distention, and absolute constipation had per- · sisted. At that time she appeared well nourished but was diaphoretic and in severe abdom' ina! pain, with an oral temperature of 100 F; her pulse was regular, rate was 130 per min, and her blood pressure was 170/110 mm Hg. The optic fundi showed moderate arteriolar constriction and sclerosis. The abdomen was distended, with four quadrant Penrose drains in place, and there was unusual induration and swelling of the subcutaneous tissue immediately to the left of a recent surgical incision. There was marked generalized rebound tenderness with some guarding. ·Bowel sounds were infrequent. The rectum was empty. Investigation revealed the following: hemo"
globin 14.5 g per 100 ml ; leukocytes 29,800 per cu mm, with 92 % neutrophils, 1% lymphocytes, and 7% monocytes; serum albumin 2.0 g per 100 ml; total protein 5.25 g per 100 ml; sedimentation rate (Westergren) 92 mm in 1 hr; serum calcium 8.8 mg per 100 ml; sodium 131 mEq per liter; and potassium 3.1 mEq per liter. The serum and urine amylase values and the serum lipase, creatinine, glutamic oxaloacetic transaminase, alkaline phosphatase, bilirubin, and blood sugar were normal. Results of tests for lupus erythematosus clot , antinuclear antibodies, and Venera! Disease Research Laboratories were negative. Two blood cultures were negative. The urine contained a moderate amount of protein and a few erythrocytes and leukocytes and was sterile on culture. There were no urine porphyrins, and metanephrines were normal. A roentgenogram of the abdomen showed multiple loops of distended small and large bowel. She was treated conservatively with MillerAbbott tube suction and intravenous fluids. Additional steroid and antibiotic treatment was
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B FIG. 1. A, foreign body type gra nuloma with abundant histiocytic type multinucleated giant cells which contain starch granules (hematoxylin and eosin, x 130.) B, "Maltese cross" appea ra nce of polarized granules seen in giant cells and in chronic infla mmatory reaction (hemat oxylin and eosin, polarized light; x 305).
1064
CASE REPORTS
Vol. 63, No.6
scrotum. 1 Miliary peritoneal nodules can grossly resemble metastatic tumor 6 • 7 or tuberculosis. Cecal induration and deformity due to the granulomatous reaction have led to bowel resection because of suspected carcinoma. 8 Intestinal dilation is usually due to adynamic ileus, but mechanical bowel obstruction secondary to adhesions also occurs. 2 • 9 Starch granulomatous peritonitis probably is often unrecognized in patients with symptoms that occur at a similar time after surgery but are of insufficient severity to lead to reexploration. Recovery is usually spontaneous, and the long term prognosis is good. In 1965, Bates 3 obtained late follow-up information on 12 of the 15 cases reported up to that Discussion time. Ten patients had remained sympAcute granulomatous peritonitis due to tom-free; 1 had mild abdominal symptoms starch glove powder was first reported by of uncertain cause, and 1 had required adMcAdams 2 in 1956 and was reviewed by ditional surgery 6 years after the original Bates 3 in 1965 and Taft et al. 1 in 1970. Af- illness for ileal obstruction due to fibrous ter abdominal operation, recovery is nor- adhesions which were not histologically mal until the onset of severe abdominal proved to contain starch particles. pain, usually 2 to 4 weeks later. Pain may Corticosteroid therapy has sometimes be localized or generalized, and steady or produced dramatic improvement in the cramping, sometimes with vomiting and acute phase, 1 but other patients like ours abdominal distention. Fever may occur, have shown no response. It appears justibut the leukocyte count is frequently nor- fiable to try steroid therapy once the diagmal. Abdominal roentgenograms often nosis is established, if spontaneous recovshow evidence of ileus. Suspicion of an ery is slow. acute infection or obstruction may lead to The pathogenesis is not fully underreexploration, when ascites, miliary nod- stood. Starch powder acts as a slowly abules, adhesions, and tissue induration sorbed foreign body in the peritoneal cavmay be found. The ascitic fluid is bacteri- ity, and, in animal experiments, regularly ologically sterile. The diagnosis is con- causes adhesions that histologically show firmed microscopically by the finding of starch granules and an inflammatory reacforeign body granulomas that contain tion.10 In the study by Lee et al., 10 there starch particles; the latter are best seen were more adhesions 2 days after the introwith polarized light as Maltese cross pat- duction of starch than 3 weeks later, howterns. ever, and these authors did not note any The usual source of starch powder con- acute illness in their dogs after a period of tamination is surgical glove powder, but a improvement. MacQuiddy and Tollman 11 similar condition has been found in a implanted 200-mg pellets of cornstarch woman who had not undergone surgery but subcutaneously in rabbits, but saw no sewhose husband used condoms packed in vere reaction during a 56-day observation starch powder; the powder presumably period. entered the peritoneal cavity via the falloThe rarity of the type of reaction seen pian tubes. 4 Inflammatory masses of simi- in our patient, despite the almost univerlar etiology have been reported at other sal use of starch glove powder, suggests operation sites such as the loin 5 and the a hypersensitivy reaction rather than a not given . Improvement was slow. A study with contrast medium (Gastrografin) showed no evidence of mechanical obstruction. Ileus persisted until the lOth postoperative day, and she had a fever up to the 11th day. Subsequent excretory urogram was normal. She went home on April 8, 1971. On April 20, after failing to have a bowel movement for 3 days, she again noted abdominal colic which cleared with enemas. On examination on May 4, 1971, she looked well and her blood pressure was 135/ 95 mm Hg (without medication) ; the induration to the left of the surgical scar had partly resolved . In November, 1971, she reported that for several months after her last visit, large meals had caused abdominal pain but that she was now entirely symptomfree.
December 1972
CASE REPORTS
dose-related response. MacQuiddy and Tollman 11 could not demonstrate skin sensitivity to starch in normal persons or in subjects with allergic histories, but none of these had a history of starch peritonitis. Bates 3 did demonstrate sensitivity in 1 patient. After recovery from acute starch peritonitis, an intradermal. , injection of cornstarch caused a local, cutaneous inflammatory reaction associated with further recurrence of abdominal symptoms. Taft et a!. 1 collected, within 6 months, 10 cases of peritonitis, apparently due to the use of rice starch powder, which was subsequently discontinued. The importance of the thorough removal of powder from the donned gloves must be reemphasized. Harder and Christ 12 showed that washing, followed by wiping with a wet cloth, was much more effective in removing powder from the gloves than washing alone. REFERENCES 1. Taft DA, Lasersohn JT, Hill LD : Glove starch granulomatous peritonitis. Am J Surg 120:231235, 1970
1065
2. McAdams GB: Granulomata caused by absorbable starch glove powder. Surgery 39:329-336, 1956 3. Bates B: Granulomatous peritonitis secondary to cornstarch. Ann Intern Med 62: 335-347, 1965 4. Saxen L, Kassinen A, Saxen E : Peritoneal foreign-body reaction caused by condom emulsion. Lancet 1:1295-1296, 1963 5. Sneierson H, Woo ZP : Starch powder granuloma: a 'report of two cases. Ann Surg 142:1045-1050, 1955 6. Cox KR: Starch granuloma (pseudo-malignant seedlings). Br J Surg 57:650- 653, 1970 7. Neely J, Davies JD : Starch granulomatosis of the peritoneum. Br Med J 3:625-629, 1971 8. Hyden WH, McClellan JT: Glove powder granuloma in peritoneal cavity. JAMA 170:1048-1050, 1959 9. Melody GF: Intestinal obstructions following · gynecological operations. J Int Coil Surg 35:283295, 1961 10. Lee CM Jr, Collins WT, Largen TL: A reappraisal of absorbable glove powder. Surg Gynecol Obstet 95 :725- 737, 1952 11. MacQuiddy EL, Tollma n JP: Observations on an absorbab le powder to replace talc. Surgery 23: 786- 793, 1948 12, Harder HI, Christ NM : The peril of glove powder. Am J N urs 66:761 - 764, 1966
Printed in U.S.A.
Copyright © 1972 by The Williams & Wilkins Co.
ACUTE GRANULOMATOUS PERITONITIS DUE TO STARCH GLOVE POWDER R. HUMPHREYS, M.D., G. HARRISON, JR., M.D.
STEPHEN EDGAR
ALAN J. CAMERON, M .B.B.CH., AND
Mayo Clinic and Mayo Foundation, Rochester, Minnesota
A 34-year-old woman with acute granulomatous peritonitis due to cornstarch powder used for surgical glove lubrication is described. The patient experienced severe abdominal pain 2 V2 weeks after hysterectomy. Examination revealed ileus and unusual induration of the operative incision. At reexploration, there was ascites and extensive inflammation of the omentum, which histologically showed a foreign body granulomatous reaction with starch granules. Spontaneous recovery was complete. Acute abdominal symptoms due to starch surgical glove powder are rare. In 1970, Taft et al. 1 found less than 20 previously reported cases but added 10 of their own. We wish to report another case to reemphasize the clinical manifestations of this disorder. Report of a Case A 34-year-old white woman was hypertensive in May 1970 during the time she was taking anovular medication, which was then stopped. She took antihypertensive medication for the next 2 months only. On March 5, 1971, total abdominal hysterectomy and incidental appendectomy were performed at another institution for menometrorrhagia. A standard brand of latex surgical gloves lubricated with cornstarch (United States Pharmacopeia) was used by the surgeon. General abdominal exploration was negative. The uterine specimen revealed no serious disease. The patient felt well when dismissed from the hospital 7 days after surgery. She remained well until March 23, 1971, when she experienced crampy lower abdominal pain, vomiting, failure to pass bowel movements or flatus, and fever, with temperatures as high as 100.7 F. Examination revealed generalized abdominal rebound tenderness but no Received April 21, 1972. Accepted July 18, 1972. Address requests for reprints to: Section of Publications, Mayo Clinic, Rochester, Minnesota 55901. The authors wish to thank Dr. C. S. King for the clinical information and Dr. F. E. Ciccarelli for the loan of histologic material.
guarding. The hemoglobin level was 11.8 g per 100 ml, and the leukocyte count was 12,750 per cu mm, with 83% neutrophils, 11% lymphocytes, 4% monocytes, 1% basophils, and 1% eosinophils. The values for serum amylase, lipase, blood urea nitrogen, bilirubin, serum glutamic oxaloacetic transaminase, alkaline phosphatase, sugar, and calcium were normal. A roentgenogram of the abdomen showed distended loops of small bowel. The patient was given cephaloridine on March 25 and 26 and then cephalothin until March 28. She underwent exploration on March 27, 1971. At operation, the previous surgical incision was indurated. There was 750 ml of clear amber fluid in the peritoneal cavity. The omentum was 2 to 3 em thick and markedly indurated; a biopsy specimen was taken. The pancreas was firm but not inflamed. Other intraabdominal structures including the small bowel appeared normal. The omental biopsy showed lobules of adipose tissue with bands of inflammatory fibrosis and many foreign body granulomas composed of histiocytes, lymphocytes, scattered plasma cells, and eosinophils (fig. 1A). Many histiocytic, multinuclear, giant cells of foreign body type contained rounded particles consistent with starch granules. Some of the particles also were found in histiocytes and were surrounded by inflammatory cells in fibrous tissue. The particles stained light blue with hematoxylin and eosin, deep bluish red with the Gram stain, and bright red with the periodic acid-Schiff stain. They had an ovoid or angular central zone from which several radiating lines were occa-
1062
December 1972
1063
CASE REPORTS
sionally seen. In partially polarized light, the particles exhibited typical "Maltese cross" patterns (fig. 1B) . After the operation, she received 80 mg of methylprednisolone intramuscularly for 2 days, but she did not improve. She was transferred to the Mayo Clinic on March 29, 1971. Vomiting, abdominal pain and distention, and absolute constipation had per- · sisted. At that time she appeared well nourished but was diaphoretic and in severe abdom' ina! pain, with an oral temperature of 100 F; her pulse was regular, rate was 130 per min, and her blood pressure was 170/110 mm Hg. The optic fundi showed moderate arteriolar constriction and sclerosis. The abdomen was distended, with four quadrant Penrose drains in place, and there was unusual induration and swelling of the subcutaneous tissue immediately to the left of a recent surgical incision. There was marked generalized rebound tenderness with some guarding. ·Bowel sounds were infrequent. The rectum was empty. Investigation revealed the following: hemo"
globin 14.5 g per 100 ml ; leukocytes 29,800 per cu mm, with 92 % neutrophils, 1% lymphocytes, and 7% monocytes; serum albumin 2.0 g per 100 ml; total protein 5.25 g per 100 ml; sedimentation rate (Westergren) 92 mm in 1 hr; serum calcium 8.8 mg per 100 ml; sodium 131 mEq per liter; and potassium 3.1 mEq per liter. The serum and urine amylase values and the serum lipase, creatinine, glutamic oxaloacetic transaminase, alkaline phosphatase, bilirubin, and blood sugar were normal. Results of tests for lupus erythematosus clot , antinuclear antibodies, and Venera! Disease Research Laboratories were negative. Two blood cultures were negative. The urine contained a moderate amount of protein and a few erythrocytes and leukocytes and was sterile on culture. There were no urine porphyrins, and metanephrines were normal. A roentgenogram of the abdomen showed multiple loops of distended small and large bowel. She was treated conservatively with MillerAbbott tube suction and intravenous fluids. Additional steroid and antibiotic treatment was
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B FIG. 1. A, foreign body type gra nuloma with abundant histiocytic type multinucleated giant cells which contain starch granules (hematoxylin and eosin, x 130.) B, "Maltese cross" appea ra nce of polarized granules seen in giant cells and in chronic infla mmatory reaction (hemat oxylin and eosin, polarized light; x 305).
1064
CASE REPORTS
Vol. 63, No.6
scrotum. 1 Miliary peritoneal nodules can grossly resemble metastatic tumor 6 • 7 or tuberculosis. Cecal induration and deformity due to the granulomatous reaction have led to bowel resection because of suspected carcinoma. 8 Intestinal dilation is usually due to adynamic ileus, but mechanical bowel obstruction secondary to adhesions also occurs. 2 • 9 Starch granulomatous peritonitis probably is often unrecognized in patients with symptoms that occur at a similar time after surgery but are of insufficient severity to lead to reexploration. Recovery is usually spontaneous, and the long term prognosis is good. In 1965, Bates 3 obtained late follow-up information on 12 of the 15 cases reported up to that Discussion time. Ten patients had remained sympAcute granulomatous peritonitis due to tom-free; 1 had mild abdominal symptoms starch glove powder was first reported by of uncertain cause, and 1 had required adMcAdams 2 in 1956 and was reviewed by ditional surgery 6 years after the original Bates 3 in 1965 and Taft et al. 1 in 1970. Af- illness for ileal obstruction due to fibrous ter abdominal operation, recovery is nor- adhesions which were not histologically mal until the onset of severe abdominal proved to contain starch particles. pain, usually 2 to 4 weeks later. Pain may Corticosteroid therapy has sometimes be localized or generalized, and steady or produced dramatic improvement in the cramping, sometimes with vomiting and acute phase, 1 but other patients like ours abdominal distention. Fever may occur, have shown no response. It appears justibut the leukocyte count is frequently nor- fiable to try steroid therapy once the diagmal. Abdominal roentgenograms often nosis is established, if spontaneous recovshow evidence of ileus. Suspicion of an ery is slow. acute infection or obstruction may lead to The pathogenesis is not fully underreexploration, when ascites, miliary nod- stood. Starch powder acts as a slowly abules, adhesions, and tissue induration sorbed foreign body in the peritoneal cavmay be found. The ascitic fluid is bacteri- ity, and, in animal experiments, regularly ologically sterile. The diagnosis is con- causes adhesions that histologically show firmed microscopically by the finding of starch granules and an inflammatory reacforeign body granulomas that contain tion.10 In the study by Lee et al., 10 there starch particles; the latter are best seen were more adhesions 2 days after the introwith polarized light as Maltese cross pat- duction of starch than 3 weeks later, howterns. ever, and these authors did not note any The usual source of starch powder con- acute illness in their dogs after a period of tamination is surgical glove powder, but a improvement. MacQuiddy and Tollman 11 similar condition has been found in a implanted 200-mg pellets of cornstarch woman who had not undergone surgery but subcutaneously in rabbits, but saw no sewhose husband used condoms packed in vere reaction during a 56-day observation starch powder; the powder presumably period. entered the peritoneal cavity via the falloThe rarity of the type of reaction seen pian tubes. 4 Inflammatory masses of simi- in our patient, despite the almost univerlar etiology have been reported at other sal use of starch glove powder, suggests operation sites such as the loin 5 and the a hypersensitivy reaction rather than a not given . Improvement was slow. A study with contrast medium (Gastrografin) showed no evidence of mechanical obstruction. Ileus persisted until the lOth postoperative day, and she had a fever up to the 11th day. Subsequent excretory urogram was normal. She went home on April 8, 1971. On April 20, after failing to have a bowel movement for 3 days, she again noted abdominal colic which cleared with enemas. On examination on May 4, 1971, she looked well and her blood pressure was 135/ 95 mm Hg (without medication) ; the induration to the left of the surgical scar had partly resolved . In November, 1971, she reported that for several months after her last visit, large meals had caused abdominal pain but that she was now entirely symptomfree.
December 1972
CASE REPORTS
dose-related response. MacQuiddy and Tollman 11 could not demonstrate skin sensitivity to starch in normal persons or in subjects with allergic histories, but none of these had a history of starch peritonitis. Bates 3 did demonstrate sensitivity in 1 patient. After recovery from acute starch peritonitis, an intradermal. , injection of cornstarch caused a local, cutaneous inflammatory reaction associated with further recurrence of abdominal symptoms. Taft et a!. 1 collected, within 6 months, 10 cases of peritonitis, apparently due to the use of rice starch powder, which was subsequently discontinued. The importance of the thorough removal of powder from the donned gloves must be reemphasized. Harder and Christ 12 showed that washing, followed by wiping with a wet cloth, was much more effective in removing powder from the gloves than washing alone. REFERENCES 1. Taft DA, Lasersohn JT, Hill LD : Glove starch granulomatous peritonitis. Am J Surg 120:231235, 1970
1065
2. McAdams GB: Granulomata caused by absorbable starch glove powder. Surgery 39:329-336, 1956 3. Bates B: Granulomatous peritonitis secondary to cornstarch. Ann Intern Med 62: 335-347, 1965 4. Saxen L, Kassinen A, Saxen E : Peritoneal foreign-body reaction caused by condom emulsion. Lancet 1:1295-1296, 1963 5. Sneierson H, Woo ZP : Starch powder granuloma: a 'report of two cases. Ann Surg 142:1045-1050, 1955 6. Cox KR: Starch granuloma (pseudo-malignant seedlings). Br J Surg 57:650- 653, 1970 7. Neely J, Davies JD : Starch granulomatosis of the peritoneum. Br Med J 3:625-629, 1971 8. Hyden WH, McClellan JT: Glove powder granuloma in peritoneal cavity. JAMA 170:1048-1050, 1959 9. Melody GF: Intestinal obstructions following · gynecological operations. J Int Coil Surg 35:283295, 1961 10. Lee CM Jr, Collins WT, Largen TL: A reappraisal of absorbable glove powder. Surg Gynecol Obstet 95 :725- 737, 1952 11. MacQuiddy EL, Tollma n JP: Observations on an absorbab le powder to replace talc. Surgery 23: 786- 793, 1948 12, Harder HI, Christ NM : The peril of glove powder. Am J N urs 66:761 - 764, 1966