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Toxic dilatation in amebic colitis: Successful treatment without colectomy
Toxic Dilatation in Amebic Colitis: Successful Treatment Without Colectomy
Adrian J. Greenstein, MD, New York, New York Robert J. Greenstein, MD, New York, New York David B. Sachar, MD, New York, New York
Toxic dilatation of the colon is a potentially lethal complication of inflammatory bowel disease. It was originally described in ulcerative colitis [1] but has been reported in Crohn’s colitis as well [2-41. Although colonic perforation occurs frequently in amebic colitis, toxic dilatation is seldom recognized in this disease and consequently case reports are few [5-91. We describe herein a patient with amebic dilatation of the colon successfully treated with diverting ileostomy and decompressing blow-hole colostomy. The colon was preserved and intestinal continuity ultimately restored. Case Report The patient (no. 1058877), a 36 year old man, was transferred to The Mount Sinai Hospital because of abdominal distention, pain, tenderness and colonic dilatation. He had been admitted with diarrhea to another hospital, where he was initially thought to have Crohn’s colitis and was therefore treated with intravenous steroids. Shortly before his transfer to Mount Sinai, the possibility of amebic colitis was raised by the finding of a “possible amebic cyst” in the stool. On his admission to Mount Sinai, an amebic antibody titer of 1:33,000 was demonstrated by indirect hemagglutination. The patient was given nothing by mouth except metronidazole, and a long tube was passed. He was treated with emetine, 60 mg intramuscularly daily, metronidazole, 750 mg orally three times daily, and ampicillin, 2 g intraFrom the Departments of Surgery and Medicine, Mount Sinai School of Medicine of the City University of New York, and The Mount Sinai Hospital, New York, New York. Reprint requests should be addressed to Adrian J. Greenstein, MD, Department of Surgery, The Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, New York 10029.
456
venously every 4 hours. Steroid therapy was continued with intravenous hydrocortisone, 75 mg every 8 hours. The patient remained ill and x-ray films revealed progressive colonic dilatation (Figure 1). He therefore underwent laparotomy 2 days after admission. At operation the colon was dilated and somewhat inflamed. A sealed perforation was present approximately 12 cm proximal to the splenic flexure. In addition, there were numerous amebic abscesses in the liver; one, a 3 cm abscess in the left lobe of the liver, had ruptured downward into the supracolic compartment anterior to the stomach and greater omentum. A large amount of yellow, purulent fluid was aspirated from the area of the liver and colon. Another 2 cm abscess in the right lobe of the liver was also aspirated. A Turnbull-type loop ileostomy was constructed in the right lower abdominal quadrant, and a blow-hole colostomy was created in the left upper quadrant at the site of the colonic perforation. The postoperative course was characterized by persistent mild fever, but the patient subsequently recovered after I5 days of continued treatment with metronidazole and emetine (Figure 2). He was discharged approximately 3 weeks after surgery. Four months later he was readmitted for elective reestablishment of bowel continuity. Endoscopy at this time revealed minimal evidence of mucosal inflammation and no contact bleeding. Both the blow-hole colostomy and the loop ileostomy were closed. The patient’s postoperative course was uncomplicated. He regained a total of 40 pounds and attained his preoperative weight of 192 pounds, which he has maintained during the 4 years since his last operation. Recent colonoscopy has revealed minimal residual mucosal inflammation.
Comments The combination of amebic colitis and liver abscess is frequently fatal. Lin and Schwartz [IO] recently
The American Journal of Surgery
Amebic Toxic Dilatation
reported three cases of both colitis and liver abscess. Delay in diagnosis resulted in death in two of the patients. Kean et al 1111 reported on 148 fatal cases of amebiasis from the Armed Forces Instit.ute of P.&hology. Two associated findings in these autopsy reports were rupture of an amebic hepatic abscess in
We carried out nonresectional surgery of the type recommended by Turnbull et al [12] for severe ulcerative colitis, as our patient’s colon did not manifest the extreme “tissue paper” friability frequently encountered in amebic disease [IS]. Moreover, the sealed perforation in the left transverse colon was in an ideal site for exteriorization of the bowel. The use of a defunctioning ileostomy, with or without resection of perforated bowel when present, has been described previously in children with amebic colitis. Spitz [ 71 in South Africa and Vargas and Pena [B] in Mexico City described the successful use of such an ileostomy with 5 of 5 and 10 of 14 survivors, respectively. In the former series intract,able postamebic colitis with ulceration and strictures necessitated subsequent colectomy with ileo-sigmoid or -rectal anastomoses in four patients whereas in the latter at least three patients required colectomy. Wilmot [14] noted that chronic colitis developed in 20 of 33 patients with amebic colitis, with ultimate scarring and Our patient, stricture formation in 11 patients. however, had almost complete healing of the colonic mucosa. The outcome in this case emphasizes the critical importance of considering the possibility of amebiasis in every case of acute fulminant colitis.
3:’ of the 56 cases with hepatic amebiasis, and colonic perforation in 30 percent of the 148 cases.
Summary
A patient with acute amebic dilatation of the colon and multiple intrahepatic abscesses was successfully treated by a combination of medical and surgical therapy. Creation of a loop ileostomy and blow-hole colostomy facilitated complete healing of the colon.
Figure 1. X-ray film showing marked colonic dilatation.
PM
36~0
d
EMETINE (65mga m qd)
;1
METAONIDIAZOLE (750mgpot1dl AMPICILLIN l2qmtvq6h) TETRACYCLINE (250mqpaq6h)
Figure 2. Course and treatment of patient wfth amebic toxic dilatation.
Volume
139,
March
1980
C
j j
I
t
DAYS
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OF HOSPITALIZATION
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Greenstein
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Intestinal continuity was restored 6 months later with an excellent long-term result. Achnowledgment: We thank Jean DiCarlo for her excellent secretarial assistance in the preparation of this manuscript. References 1. Marshak RH, Lester LJ, Friedman Al. Megacolon, a complication of ulcerative colitis. Gastroenterology 1960; 16:768-72. 2. Javett S, Brooke BN. Acute dilatation of colon in Crohn’s disease. Lancet 1970; 2:126-8. 3. Greenstein AJ, Kark AE, Dreiling DA. Crohn’s disease of the colon. Ill. Toxic dilatation of the colon in Crohn’s colitis. Am J Gastroenterol 1975; 62: 117-28. 4. Buzzard AJ, Baker WNW, Needham PRG, Warren RE. Acute toxic dilatation of the colon in Crohn’s colitis. Gut 1974; 15:416-20. 5. Wruble LD, Duckworth JK, Duke DD, Rothschild JA. Toxic dilatation of the colon in a case of amebiasis. N Engl J Med
458
1966; 285926-8. 6. Faegenburg D, Chiat H, Mandel PR, Ross ST. Toxic megacolon in amebic colitis. Report of a case. Am J Roentgen01 1967; 99:74-6. 7. Spitz L. The surgical management of amebiasis in children. Br J Surg 1973; 60:623-5. 8. Vargas M, Pena A. Toxic amebic colitis and amebic colon perforation in children. An improved prognosis. J Pediatr Surg 1976; 11:223-5. 9. Giacchino JL, Pickleman J, Bartizal JF, Banich FE. The therapeutic dilemma of acute amebic and ulcerative colitis. Surg Gynecol Obstet 1978; 146:599-602. 10. Lin CS, Schwartz IS. Invasive amebiasis in New York City. NY J Med 1976; 761574-8. 11. Kean BH, Gilmore HR Jr, Van Stone WW. Fatal amoebiasis: report of 148 fatal cases from the Armed Forces Institute of Pathology. Ann Intern Med 1956; 44:831-43. 12. Turnbull RB, Jr, Hawk WA, Weakley F. Surgical treatment of toxic megacolon; ileostomy and colostomy to prepare patients for colectomy. Am J Surg 1971; 122:325-31. 13. Gupta S. Massive necrosis and perforation of the colon in amebiasis. Am Surg 1975; 41:429-31. 14. Wilmot AJ. Clinical amoebiasis. Oxford. Blackwell, 1962.
The American Journal of Surgery
Adrian J. Greenstein, MD, New York, New York Robert J. Greenstein, MD, New York, New York David B. Sachar, MD, New York, New York
Toxic dilatation of the colon is a potentially lethal complication of inflammatory bowel disease. It was originally described in ulcerative colitis [1] but has been reported in Crohn’s colitis as well [2-41. Although colonic perforation occurs frequently in amebic colitis, toxic dilatation is seldom recognized in this disease and consequently case reports are few [5-91. We describe herein a patient with amebic dilatation of the colon successfully treated with diverting ileostomy and decompressing blow-hole colostomy. The colon was preserved and intestinal continuity ultimately restored. Case Report The patient (no. 1058877), a 36 year old man, was transferred to The Mount Sinai Hospital because of abdominal distention, pain, tenderness and colonic dilatation. He had been admitted with diarrhea to another hospital, where he was initially thought to have Crohn’s colitis and was therefore treated with intravenous steroids. Shortly before his transfer to Mount Sinai, the possibility of amebic colitis was raised by the finding of a “possible amebic cyst” in the stool. On his admission to Mount Sinai, an amebic antibody titer of 1:33,000 was demonstrated by indirect hemagglutination. The patient was given nothing by mouth except metronidazole, and a long tube was passed. He was treated with emetine, 60 mg intramuscularly daily, metronidazole, 750 mg orally three times daily, and ampicillin, 2 g intraFrom the Departments of Surgery and Medicine, Mount Sinai School of Medicine of the City University of New York, and The Mount Sinai Hospital, New York, New York. Reprint requests should be addressed to Adrian J. Greenstein, MD, Department of Surgery, The Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, New York 10029.
456
venously every 4 hours. Steroid therapy was continued with intravenous hydrocortisone, 75 mg every 8 hours. The patient remained ill and x-ray films revealed progressive colonic dilatation (Figure 1). He therefore underwent laparotomy 2 days after admission. At operation the colon was dilated and somewhat inflamed. A sealed perforation was present approximately 12 cm proximal to the splenic flexure. In addition, there were numerous amebic abscesses in the liver; one, a 3 cm abscess in the left lobe of the liver, had ruptured downward into the supracolic compartment anterior to the stomach and greater omentum. A large amount of yellow, purulent fluid was aspirated from the area of the liver and colon. Another 2 cm abscess in the right lobe of the liver was also aspirated. A Turnbull-type loop ileostomy was constructed in the right lower abdominal quadrant, and a blow-hole colostomy was created in the left upper quadrant at the site of the colonic perforation. The postoperative course was characterized by persistent mild fever, but the patient subsequently recovered after I5 days of continued treatment with metronidazole and emetine (Figure 2). He was discharged approximately 3 weeks after surgery. Four months later he was readmitted for elective reestablishment of bowel continuity. Endoscopy at this time revealed minimal evidence of mucosal inflammation and no contact bleeding. Both the blow-hole colostomy and the loop ileostomy were closed. The patient’s postoperative course was uncomplicated. He regained a total of 40 pounds and attained his preoperative weight of 192 pounds, which he has maintained during the 4 years since his last operation. Recent colonoscopy has revealed minimal residual mucosal inflammation.
Comments The combination of amebic colitis and liver abscess is frequently fatal. Lin and Schwartz [IO] recently
The American Journal of Surgery
Amebic Toxic Dilatation
reported three cases of both colitis and liver abscess. Delay in diagnosis resulted in death in two of the patients. Kean et al 1111 reported on 148 fatal cases of amebiasis from the Armed Forces Instit.ute of P.&hology. Two associated findings in these autopsy reports were rupture of an amebic hepatic abscess in
We carried out nonresectional surgery of the type recommended by Turnbull et al [12] for severe ulcerative colitis, as our patient’s colon did not manifest the extreme “tissue paper” friability frequently encountered in amebic disease [IS]. Moreover, the sealed perforation in the left transverse colon was in an ideal site for exteriorization of the bowel. The use of a defunctioning ileostomy, with or without resection of perforated bowel when present, has been described previously in children with amebic colitis. Spitz [ 71 in South Africa and Vargas and Pena [B] in Mexico City described the successful use of such an ileostomy with 5 of 5 and 10 of 14 survivors, respectively. In the former series intract,able postamebic colitis with ulceration and strictures necessitated subsequent colectomy with ileo-sigmoid or -rectal anastomoses in four patients whereas in the latter at least three patients required colectomy. Wilmot [14] noted that chronic colitis developed in 20 of 33 patients with amebic colitis, with ultimate scarring and Our patient, stricture formation in 11 patients. however, had almost complete healing of the colonic mucosa. The outcome in this case emphasizes the critical importance of considering the possibility of amebiasis in every case of acute fulminant colitis.
3:’ of the 56 cases with hepatic amebiasis, and colonic perforation in 30 percent of the 148 cases.
Summary
A patient with acute amebic dilatation of the colon and multiple intrahepatic abscesses was successfully treated by a combination of medical and surgical therapy. Creation of a loop ileostomy and blow-hole colostomy facilitated complete healing of the colon.
Figure 1. X-ray film showing marked colonic dilatation.
PM
36~0
d
EMETINE (65mga m qd)
;1
METAONIDIAZOLE (750mgpot1dl AMPICILLIN l2qmtvq6h) TETRACYCLINE (250mqpaq6h)
Figure 2. Course and treatment of patient wfth amebic toxic dilatation.
Volume
139,
March
1980
C
j j
I
t
DAYS
1
OF HOSPITALIZATION
457
Greenstein
et al
Intestinal continuity was restored 6 months later with an excellent long-term result. Achnowledgment: We thank Jean DiCarlo for her excellent secretarial assistance in the preparation of this manuscript. References 1. Marshak RH, Lester LJ, Friedman Al. Megacolon, a complication of ulcerative colitis. Gastroenterology 1960; 16:768-72. 2. Javett S, Brooke BN. Acute dilatation of colon in Crohn’s disease. Lancet 1970; 2:126-8. 3. Greenstein AJ, Kark AE, Dreiling DA. Crohn’s disease of the colon. Ill. Toxic dilatation of the colon in Crohn’s colitis. Am J Gastroenterol 1975; 62: 117-28. 4. Buzzard AJ, Baker WNW, Needham PRG, Warren RE. Acute toxic dilatation of the colon in Crohn’s colitis. Gut 1974; 15:416-20. 5. Wruble LD, Duckworth JK, Duke DD, Rothschild JA. Toxic dilatation of the colon in a case of amebiasis. N Engl J Med
458
1966; 285926-8. 6. Faegenburg D, Chiat H, Mandel PR, Ross ST. Toxic megacolon in amebic colitis. Report of a case. Am J Roentgen01 1967; 99:74-6. 7. Spitz L. The surgical management of amebiasis in children. Br J Surg 1973; 60:623-5. 8. Vargas M, Pena A. Toxic amebic colitis and amebic colon perforation in children. An improved prognosis. J Pediatr Surg 1976; 11:223-5. 9. Giacchino JL, Pickleman J, Bartizal JF, Banich FE. The therapeutic dilemma of acute amebic and ulcerative colitis. Surg Gynecol Obstet 1978; 146:599-602. 10. Lin CS, Schwartz IS. Invasive amebiasis in New York City. NY J Med 1976; 761574-8. 11. Kean BH, Gilmore HR Jr, Van Stone WW. Fatal amoebiasis: report of 148 fatal cases from the Armed Forces Institute of Pathology. Ann Intern Med 1956; 44:831-43. 12. Turnbull RB, Jr, Hawk WA, Weakley F. Surgical treatment of toxic megacolon; ileostomy and colostomy to prepare patients for colectomy. Am J Surg 1971; 122:325-31. 13. Gupta S. Massive necrosis and perforation of the colon in amebiasis. Am Surg 1975; 41:429-31. 14. Wilmot AJ. Clinical amoebiasis. Oxford. Blackwell, 1962.
The American Journal of Surgery