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Treatment of acute postoperative pseudomembranous enterocolitis
TREATMENT OF ACUTE POSTOPERATIVE PSEUDOMEMBRANOUS ENTEROCOLITIS JOHN R. HILSABECK, M.D. AND FelIow in Surgery, Mayo Foundation
CLAUDE
F. DIXON,
M.D.
Division of Surgery, Mayo CIinic
Rochester, Minnesota
B
ECAUSE
few have survived the dreaded compIication of acute pseudomembranous enterocoIitis it is indeed fortunate that its incidence foIlowing surgica1 treatment is minimaI. ContrariIy, by Iimiting experience, uncommonness has undoubtedIy accounted to a Iarge degree for the extremeIy high mortaIity rate. Pseudomembranous enterocoIitis has been the subject of severa studies but the basic etioIogic and pathogenetic factors remain unknown and definitive treatment has been on an empirica basis. Heartened by two survivaIs, Dixon and Weismann in 1948 reviewed and presented the findings in twenty-three cases encountered at the Mayo CIinic foIIowing intestina1 operations during a period of seven and a haIf years. AIthough they were unabIe to estabIish a cause, their clinicopathoIogic observations Ied them to beIieve that the prime cause of death in pseudomembranous enterocoIitis was the marked circulatory coIIapse. Since both survivaIs received vigorous antishock therapy, these authors were of the opinion that, provided shock was combated promptIy and heroicaIIy, this form of enteritis need not aIways have a fata outcome. The conditions which they beIieved must be fuIfiIIed for therapy to be successfu1 are (I) cognizance ’ of pseudomembranous enterocoIitis as a possibIe postoperative complication, (2) prompt recognition of suggestive symptoms and (3) and immediate repIacement of aggressive ffuids with bIood or bIood substitutes whiIe attempting to make a tentative or working diagnosis. Because the diagnosis was of necessity presumptive in the two cases in which recovery occurred, the rationaIe of treatment advanced by Dixon and Weismann was hypothetic. Recently a case was encountered on the service of one of us (Dixon) in which an opportunity presented itself to test this treatment. The case is doubly interesting and constructive because, 114
shortIy after the patient had recovered from presumed acute pseudomembranous enterocolitis, death occurred from another cause and, at necropsy, Iesions compatibIe with pseudomembranous enterocoIitis were aIso found in the coIon. CASE
REPORT
A seventy-six year old multiparous widow was admitted to the cIinic November 2, 1949, with the chief compIaint of passing three or four partiaIIy formed stooIs daiIy during the previous two to three months. The stooIs contained much mucus but no bIood. About the same time a non-radiating, duI1, aching sensation, which seemed to originate in the Ieft Iower quadrant, apneared. On admission her genera1 condition was satisfactory aIthough a Ioss of IO pounds had been sustained despite a good appetite. PhysicaI examination reveaIed an obese, stocky, white woman, weighing Igo pounds, who presented no significant physica findings. A partiaIIy obstructing, sIightIy fixed, annuIar Iesion was visualized 20 cm. from the dentate margin on proctoscopic examination. Biopsy discIosed an adenocarcinoma. Roentgenographic examination of the colon was not attempted in view of the partial obstruction. With the exception of an eIevated sedimentation rate of 32 mm. in one hour (Westergren method), the resuIts of pertinent Iaboratory studies were within norma Iimits. FoIIowing routine preparation of the coIon with suIfasuxidine (succinyIsuIfathiazoIe), a non-paIIiative, open type, Iow anterior resection, with end-to-end anastomosis, was executed November 14, 1949, for a Iarge grade 2 adenocarcinoma of the rectosigmoid (type B, Dukes) and a proxima1 Ioop type transverse coIonic stoma was estabIished. Before cIosure of the wound 2.5 gm. each of suIfathiazoIe and SuIfaniIamide and 5,000 units of peniciIIin were pIaced in the abdomen.
American
Journal of Surgery
Hilsabeck,
Dixon-Pseudomembranous
Postoperative response was satisfactory and uneventfu1 for two days. Duracillin at a rate of I cc. (300,000 units per cc.) a day and dihydrostreptomycin at a rate of 0.5 gm. four times a day were started by intramuscuIar injection the day of operation. The colonic stoma was opened with the cautery early on the morning after operation. The foIIowing day Aatus was expeIIed through the stoma, oraI administration of clear Iiquids was begun and these were we11 toIerated. Later in the day ambuIation was instituted. On the morning of the third day after operation, excessive, watery movements from the coIonic stoma began and by midnight the patient had had eight such movements. At noon the temperature was 102.5’~., the pulse rate 130 and the respirations 30 per minute. Because of the pronounced Ioss of fluid, 1,000 cc. of 5 per cent soIution of gIucose was started intravenousIy, Iater in the afternoon, in addition to 1,000 cc. of 5 per cent soIution of glucose aIone and 1,000 cc. of 5 per cent SOIUtion of gIucose in isotonic saIine which had aIready been taken oraIIy. Paregoric, as we11 as aspirin, was prescribed to slow movements at the coIonic stoma but onIy partia1 success was obtained. In the evening (8 P.M.) the temperature was IOI’F., the puIse rate I IO and respirations 30. There were occasiona cardiac extrasystoIes, the Iungs were cIear and the abdomen was soft aIthough sIightIy tender. A portabIe roentgenogram of the chest reveaIed only minima1 Iinear ateIectasis in the right midIung fieId. However, in view of the marked dyspnea and advanced age, the patient was placed in an oxygen tent. For the twenty-fourhour period ending at midnight of the third day the urinary output was 1,050 cc. During this day a minimal residue diet had been instituted and during the morning a routine determination of the hemogIobin concentration in the blood was reported as being 79 per cent. At 3 A.M. on the fourth day after operation the patient went into profound shock following the passage of severa profuse watery movements from the coIonic stoma. The blood pressure immediateIy dropped to 80 mm. of mercury systolic and o diastoIic and rapidly became unobtainabIe. The temperature was IO~‘F., the puIse rate 140 and the pulse thready, and decided hyperpnea was present. Since midnight onIy 20 cc. of urine had been passed. On insertion of a recta1 tube in the coIonic
July, 1952
stoma over
EnterocoIitis
115
1,500 cc. of watery excreta was expeIIed in a matter of five minutes. Apprehension was marked. It was thought that this probabIy represented an acute pseudomembranous enterocoIitis and intravenous repracement therapy was instituted at once via three different portaIs using ~&gauge needIes. AIso 4 minims (0.25 cc.) of I: 1,000 soIution of epinephrine was given subcutaneou$y.. The response to the intravenousIy admmrstered fluids was remarkabIe. Within a matter of minutes the patient received 500 cc. of whole bIood, 1,000 cc. of 5 per cent soIution of gIucose in isotonic saline soIution with 735 gr. (0.5 gm.) of aminophyIIine added to stimuIate renaI function, and 380 cc. of dextran. This was folIowed with 1,000 cc. of IO per cent soIution of gIucose with 30 cc. of adrena cortical extract added. By 4~30 A.M. the profuse diarrhea had abated, 2,200 cc. of watery brown stoo1 having been passed in the period of one and a haIf hours. The patient was excreting urine (200 cc. since 3 A.M.), the bIood pressure was I I o systoIic and 60 diastoIic, and the puIse rate was IOO. Five hundred miIIigrams of aureomycin was given oraIIy and the dose was repeated every six hours for eight doses; the use of dihydrostreptomycin was discontinued. At 7 A.M. a digitaIis gIucoside was given intravenousIy for probabIe auricuIar fibrilIation. By 9:30 A.M. the bIood pressure was being maintained and 800 cc. of urine had been passed since midnight. The puIse rate was IOO to 108 but frequent premature contractions were present. Another portabIe roentgenogram of the chest did not discIose anything of significance. There was no tenderness of the caIves of the Iegs and Homan’s sign was absent. Another dose of digitalis gIucoside was given intravenousIy at IO A.M. An emergency electrocardiogram confirmed the suspicion of auricuIar fibriIIation. The rate was 135. At 2:30 P.M. the status was stiI1 improving. The bIood pressure was staying we11 above IOO systoIic. Around 4 P.M. the digitaIis preparation was again given intravenousIy because the pulse was more irreguIar and rapid. The Mood pressure remained around 120 systolic. The urinary output for the twenty-four-hour period ending at midnight of the fourth day was 1,400 cc. The foIlowing day the temperature and bIood pressure were normal, the p&e rate was 90 and the rate of respiration 25. An oral intake of 1,500 cc. was suppjemented with the intra-
116
HiIsabeck,
Dixon-Pseudomembranous
venous administration of I ,000 cc. of 5 per cent solution of gfucose containing added vitamins and 1,000 cc. of IO per cent sofution of gfucose. The digitafis gfucoside was prescribed daily for awhife in view of the fibriffation. The pertinent faboratory data obtained during the
The pertinent necropsy findings are as foffows: Grossly, the esophagus, stomach and duodenum were not remarkable, but proximaf to the site of cofostomy were patches of granular hemorrhagic mucosa mingfed with areas of white, smooth, thickened mucosa.
TABLE LABORATORY
DATA AFTER
THE
ONSET
Enterocolitis
OF
I PSEUDOMEMBRANOUS
ENTEROCOLITIS
Postoperative jN ormal
Blood
Third :4 P.M.)
1 O-40
. 25-29 4-5 40-48 6-8
Fifth (A.M.)
Fourth
( 10 A.M. ____
Urea, mg./roo cc... Chlorides, mEq./L Carbon dioxide, mEq./L Potassium, mEq./L.. Cell voiume percentage., Total proteins, pm./ 100 cc.
Day
30 96 19.6
38 102.5 20.9 2.5 32
Sixth (A.M.)
Seventh (A.M.)
Eighth (A.M.)
___.__~__ I
28 99 25
95 30
35
45
.
Leukocyte count on the fourth postoperative day: tota 3,100 per cu. mm. of blood; lymphocytes monocytes 8 per cent; neutrophils 47 per cent (filaments I per cent and non-filaments 46 per cent).
45 per cent;
Urinary findings on the fifth and eighth postoperative days, respectively: specific gravity I .o I 5 and I .o I 7; reaction: acid, acid; albuminuria grade 2, grade I ; glycosuria grade I, grade I ; erythruria grade 2, grade 3; pus cells none, occasiona1; and granuIar casts few, none.
period from the third through the ninth days after operation are fisted in Table I. Waterchforide bafance studies4 were carried out on the fifth, sixth and seventh postoperative days but were discontinued after it was obvious that satisfactory balances were being maintained. While getting out of bed on the eighth postoperative day, the patient became dyspneic, cold and clammy, the pufse became weak, and she complained of retrosternaf pressure. The attack subsided shortly. The patient was recovering and beginning to ambufate again when death occurred suddenfy on the evening of the tenth postoperative day. At 8 P.M., on getting back into bed after voidshe became very apprehensive and ing, dyspneic but shortly feft better. The pulse rate was I 12 and blood pressure IOO systolic and 70 diastofic. At I I :20 P.M. the patient went into irreversibfe shock and the pulse became very rapid, thready and graduaIIy imperceptible, the patient a11 the while compIaining of pronounced dyspnea and retrosternaf pressure. Despite al1 efforts at one’s command death occurred within a few minutes.
This was believed to represent evidence of heafing of a pseudomembranous ulcerative cofitis. Microscopically, in the cofon distal to the site of the colostomy was some superficiaf denudation of the epitheIium. The number of round ceffs and eosinophifs in the famina propria was increased. There were areas of fat necrosis in the pericofic adipose tissue. In the ifeum there was focaf denudation of the surface epithefium, and a few pofymorphonucfear ceffs were present in the famina propria. Some areas showed increased fibrous tissue in the submucosa. A few dilated glands with atypicaf epithelium were seen. No actuaf pseudomembrane was observed. There were simifar changes in the ascending and transverse cofon. The anatomic diagnosis was (I) biIatera1 fata and recurrent pufmonary emboIism, with residual thrombosis of the right internaf and common ifiac veins, and (2) heafing pseudomembranous ifeocofitis. COMMENT
It is branous necropsy
not often that acute pseudomementerocofitis is suspected prior to because onIy about 30 per cent of
American
Journal
of Surgeq,
Hilsabeck,
Dixon-Pseudomembranous
the cases are associated with a voluminous, sustained diarrhea. In the remainder there is an outpouring of fluid into the Iumen of the bowel but diarrhea is absent and the clinical picture is one of profound, unexplained shock. Why the diarrhea ceased in the case reported herein we do not know. Furthermore, we possess no evidence to state dogmaticahy that the diarrhea will uItimateIy abate and the patient live in those cases in which fluid Ioss is repIaced promptIy and adequateIy. However, we feel justified in continuing to advocate the empIoyment of an aggressive program of fluid and electrolyte replacement for that 30 per cent of the cases in which the presence of acute pseudomembranous enterocoIitis may be suspected by the surgeon and for this reason have cited this case. It is our belief that in this manner Iife may be maintained long enough in a few cases for the body to mobiIize whatever forces are necessary to overcome the excessive loss of fluid and eIectroIyte. To date, a number of investigations have failed to find an expIanation for acute pseudomembranous enterocolitis, aIthough it is known that similar Iesions are seen in a number of other conditions such as uremia, certain toxic infections and poisoning from arsenic and mercury. BacterioIogic examinations of the feca1 discharges performed in a number of cases have not discIosed the usual agents which produce primary enteritis. It is also noteworthy that the disease does not seem to be related to the preoperative use of suIfonamides or antibiotics since the Iesions were found at necropsy prior to the advent of suIfonamides and antibiotics. Our case adds IittIe to the meager knowIedge of the etioIogic and pathologic aspects of this complication. As in the previous cases reported from the clinic, shock appeared in this case after the onset of diarrhea. This is in contrast to the observations of Penner and Bernheim, who, because shock was present in their cases in the postoperative period prior to the onset of enterocoIitis, expressed the beIief that the major factors in the pathogenesis of the Iesions were vasomotor disturbances incident to postoperative or traumatic circuIatory deficiencies. In the case reported herein the Iaboratory and fluid baIance data present onIy the usual changes one wouId expect in deaIing with any diarrhea of simiIar proportion. On the basis of present knowIedge chemo-
July, ‘9fi2
EnterocoIitis
117
therapy or the use of antibiotics is not mandatory in the management of pseudomembranous enteritis but wouId definitely be of value in controlling secondary infection. Treatment with aureomycin was instituted oraIIy shortI> after restoration of the circulatory status in the case just reported. In view of the work of Dearing and HeiIman this wouId seem to be the agent of choice. In the presence of vomiting or gastric suction with an indweIIing tube, the intramuscuIar use of peniciIIin and dihydrostreptomycin shouId be as satisfactory as the intravenous use of aureomycin especiaIIy since the survivals of Dixon and Weismann, occurring before the advent of aureomycin, received onIy these drugs. SUMMARY
AND
CONCLUSIONS
OnIy those cases of acute postoperative pseudomembranous enterocolitis which present severe diarrhea foIIowed with shock suggest to the attending physician that he is dealing with this complication. In such instances, it has been contended that if vigorous antishock measures are instituted promptIy and fluid and eIectroIyte balance restored, some of these patients wiI1 survive. In the case just which was encountered foIIowing reported, an anterior resection of the coIon, the presence of this form of enteritis was suspected and it was successfuhy treated according to these principles. A few days Iater the patient died of a massive puImonary emboIus, and at necTopsy, heaIing Iesions consistent with the diagnosis of pseudomembranous enterocolitis were aIso found in the coIon. Thus this was a case of proved pseudomembranous enterocoIitis treated successfuIIy. REFERENCES I. DEARING, W. H. and HEILMAN, F. R. The effect of aureomycin on the bacteria1 Aora of the intestinal
to preoperative tract of man: a contribution preparation. Proc. Staf Meet., Mayo Clin., q: 87-102, 1950. 2. DIXON, C. F. and WEISMANN, R. E. Acute pseudomembranous enteritis or enterocolitis: a complication following intestinal surgery. S. Clin. North America, 28: 999-1023, 1948. 3. PENNER, A. and BERNHEIM, A. I. Acute postoperative enterocolitis. A study on the pathologic nature of shock. Arch. Patb.. 27: 46638% IQ~Q. 4. SCRIBNER, B. H. Bedside determination’ofchide: a method for pIasma, urine and other Auids and its application to fluid balance problems. Proc. Stczff Meet., Mayo Clin., 25: 209-218, 1950.
CLAUDE
F. DIXON,
M.D.
Division of Surgery, Mayo CIinic
Rochester, Minnesota
B
ECAUSE
few have survived the dreaded compIication of acute pseudomembranous enterocoIitis it is indeed fortunate that its incidence foIlowing surgica1 treatment is minimaI. ContrariIy, by Iimiting experience, uncommonness has undoubtedIy accounted to a Iarge degree for the extremeIy high mortaIity rate. Pseudomembranous enterocoIitis has been the subject of severa studies but the basic etioIogic and pathogenetic factors remain unknown and definitive treatment has been on an empirica basis. Heartened by two survivaIs, Dixon and Weismann in 1948 reviewed and presented the findings in twenty-three cases encountered at the Mayo CIinic foIIowing intestina1 operations during a period of seven and a haIf years. AIthough they were unabIe to estabIish a cause, their clinicopathoIogic observations Ied them to beIieve that the prime cause of death in pseudomembranous enterocoIitis was the marked circulatory coIIapse. Since both survivaIs received vigorous antishock therapy, these authors were of the opinion that, provided shock was combated promptIy and heroicaIIy, this form of enteritis need not aIways have a fata outcome. The conditions which they beIieved must be fuIfiIIed for therapy to be successfu1 are (I) cognizance ’ of pseudomembranous enterocoIitis as a possibIe postoperative complication, (2) prompt recognition of suggestive symptoms and (3) and immediate repIacement of aggressive ffuids with bIood or bIood substitutes whiIe attempting to make a tentative or working diagnosis. Because the diagnosis was of necessity presumptive in the two cases in which recovery occurred, the rationaIe of treatment advanced by Dixon and Weismann was hypothetic. Recently a case was encountered on the service of one of us (Dixon) in which an opportunity presented itself to test this treatment. The case is doubly interesting and constructive because, 114
shortIy after the patient had recovered from presumed acute pseudomembranous enterocolitis, death occurred from another cause and, at necropsy, Iesions compatibIe with pseudomembranous enterocoIitis were aIso found in the coIon. CASE
REPORT
A seventy-six year old multiparous widow was admitted to the cIinic November 2, 1949, with the chief compIaint of passing three or four partiaIIy formed stooIs daiIy during the previous two to three months. The stooIs contained much mucus but no bIood. About the same time a non-radiating, duI1, aching sensation, which seemed to originate in the Ieft Iower quadrant, apneared. On admission her genera1 condition was satisfactory aIthough a Ioss of IO pounds had been sustained despite a good appetite. PhysicaI examination reveaIed an obese, stocky, white woman, weighing Igo pounds, who presented no significant physica findings. A partiaIIy obstructing, sIightIy fixed, annuIar Iesion was visualized 20 cm. from the dentate margin on proctoscopic examination. Biopsy discIosed an adenocarcinoma. Roentgenographic examination of the colon was not attempted in view of the partial obstruction. With the exception of an eIevated sedimentation rate of 32 mm. in one hour (Westergren method), the resuIts of pertinent Iaboratory studies were within norma Iimits. FoIIowing routine preparation of the coIon with suIfasuxidine (succinyIsuIfathiazoIe), a non-paIIiative, open type, Iow anterior resection, with end-to-end anastomosis, was executed November 14, 1949, for a Iarge grade 2 adenocarcinoma of the rectosigmoid (type B, Dukes) and a proxima1 Ioop type transverse coIonic stoma was estabIished. Before cIosure of the wound 2.5 gm. each of suIfathiazoIe and SuIfaniIamide and 5,000 units of peniciIIin were pIaced in the abdomen.
American
Journal of Surgery
Hilsabeck,
Dixon-Pseudomembranous
Postoperative response was satisfactory and uneventfu1 for two days. Duracillin at a rate of I cc. (300,000 units per cc.) a day and dihydrostreptomycin at a rate of 0.5 gm. four times a day were started by intramuscuIar injection the day of operation. The colonic stoma was opened with the cautery early on the morning after operation. The foIIowing day Aatus was expeIIed through the stoma, oraI administration of clear Iiquids was begun and these were we11 toIerated. Later in the day ambuIation was instituted. On the morning of the third day after operation, excessive, watery movements from the coIonic stoma began and by midnight the patient had had eight such movements. At noon the temperature was 102.5’~., the pulse rate 130 and the respirations 30 per minute. Because of the pronounced Ioss of fluid, 1,000 cc. of 5 per cent soIution of gIucose was started intravenousIy, Iater in the afternoon, in addition to 1,000 cc. of 5 per cent soIution of glucose aIone and 1,000 cc. of 5 per cent SOIUtion of gIucose in isotonic saIine which had aIready been taken oraIIy. Paregoric, as we11 as aspirin, was prescribed to slow movements at the coIonic stoma but onIy partia1 success was obtained. In the evening (8 P.M.) the temperature was IOI’F., the puIse rate I IO and respirations 30. There were occasiona cardiac extrasystoIes, the Iungs were cIear and the abdomen was soft aIthough sIightIy tender. A portabIe roentgenogram of the chest reveaIed only minima1 Iinear ateIectasis in the right midIung fieId. However, in view of the marked dyspnea and advanced age, the patient was placed in an oxygen tent. For the twenty-fourhour period ending at midnight of the third day the urinary output was 1,050 cc. During this day a minimal residue diet had been instituted and during the morning a routine determination of the hemogIobin concentration in the blood was reported as being 79 per cent. At 3 A.M. on the fourth day after operation the patient went into profound shock following the passage of severa profuse watery movements from the coIonic stoma. The blood pressure immediateIy dropped to 80 mm. of mercury systolic and o diastoIic and rapidly became unobtainabIe. The temperature was IO~‘F., the puIse rate 140 and the pulse thready, and decided hyperpnea was present. Since midnight onIy 20 cc. of urine had been passed. On insertion of a recta1 tube in the coIonic
July, 1952
stoma over
EnterocoIitis
115
1,500 cc. of watery excreta was expeIIed in a matter of five minutes. Apprehension was marked. It was thought that this probabIy represented an acute pseudomembranous enterocoIitis and intravenous repracement therapy was instituted at once via three different portaIs using ~&gauge needIes. AIso 4 minims (0.25 cc.) of I: 1,000 soIution of epinephrine was given subcutaneou$y.. The response to the intravenousIy admmrstered fluids was remarkabIe. Within a matter of minutes the patient received 500 cc. of whole bIood, 1,000 cc. of 5 per cent soIution of gIucose in isotonic saline soIution with 735 gr. (0.5 gm.) of aminophyIIine added to stimuIate renaI function, and 380 cc. of dextran. This was folIowed with 1,000 cc. of IO per cent soIution of gIucose with 30 cc. of adrena cortical extract added. By 4~30 A.M. the profuse diarrhea had abated, 2,200 cc. of watery brown stoo1 having been passed in the period of one and a haIf hours. The patient was excreting urine (200 cc. since 3 A.M.), the bIood pressure was I I o systoIic and 60 diastoIic, and the puIse rate was IOO. Five hundred miIIigrams of aureomycin was given oraIIy and the dose was repeated every six hours for eight doses; the use of dihydrostreptomycin was discontinued. At 7 A.M. a digitaIis gIucoside was given intravenousIy for probabIe auricuIar fibrilIation. By 9:30 A.M. the bIood pressure was being maintained and 800 cc. of urine had been passed since midnight. The puIse rate was IOO to 108 but frequent premature contractions were present. Another portabIe roentgenogram of the chest did not discIose anything of significance. There was no tenderness of the caIves of the Iegs and Homan’s sign was absent. Another dose of digitalis gIucoside was given intravenousIy at IO A.M. An emergency electrocardiogram confirmed the suspicion of auricuIar fibriIIation. The rate was 135. At 2:30 P.M. the status was stiI1 improving. The bIood pressure was staying we11 above IOO systoIic. Around 4 P.M. the digitaIis preparation was again given intravenousIy because the pulse was more irreguIar and rapid. The Mood pressure remained around 120 systolic. The urinary output for the twenty-four-hour period ending at midnight of the fourth day was 1,400 cc. The foIlowing day the temperature and bIood pressure were normal, the p&e rate was 90 and the rate of respiration 25. An oral intake of 1,500 cc. was suppjemented with the intra-
116
HiIsabeck,
Dixon-Pseudomembranous
venous administration of I ,000 cc. of 5 per cent solution of gfucose containing added vitamins and 1,000 cc. of IO per cent sofution of gfucose. The digitafis gfucoside was prescribed daily for awhife in view of the fibriffation. The pertinent faboratory data obtained during the
The pertinent necropsy findings are as foffows: Grossly, the esophagus, stomach and duodenum were not remarkable, but proximaf to the site of cofostomy were patches of granular hemorrhagic mucosa mingfed with areas of white, smooth, thickened mucosa.
TABLE LABORATORY
DATA AFTER
THE
ONSET
Enterocolitis
OF
I PSEUDOMEMBRANOUS
ENTEROCOLITIS
Postoperative jN ormal
Blood
Third :4 P.M.)
1 O-40
. 25-29 4-5 40-48 6-8
Fifth (A.M.)
Fourth
( 10 A.M. ____
Urea, mg./roo cc... Chlorides, mEq./L Carbon dioxide, mEq./L Potassium, mEq./L.. Cell voiume percentage., Total proteins, pm./ 100 cc.
Day
30 96 19.6
38 102.5 20.9 2.5 32
Sixth (A.M.)
Seventh (A.M.)
Eighth (A.M.)
___.__~__ I
28 99 25
95 30
35
45
.
Leukocyte count on the fourth postoperative day: tota 3,100 per cu. mm. of blood; lymphocytes monocytes 8 per cent; neutrophils 47 per cent (filaments I per cent and non-filaments 46 per cent).
45 per cent;
Urinary findings on the fifth and eighth postoperative days, respectively: specific gravity I .o I 5 and I .o I 7; reaction: acid, acid; albuminuria grade 2, grade I ; glycosuria grade I, grade I ; erythruria grade 2, grade 3; pus cells none, occasiona1; and granuIar casts few, none.
period from the third through the ninth days after operation are fisted in Table I. Waterchforide bafance studies4 were carried out on the fifth, sixth and seventh postoperative days but were discontinued after it was obvious that satisfactory balances were being maintained. While getting out of bed on the eighth postoperative day, the patient became dyspneic, cold and clammy, the pufse became weak, and she complained of retrosternaf pressure. The attack subsided shortly. The patient was recovering and beginning to ambufate again when death occurred suddenfy on the evening of the tenth postoperative day. At 8 P.M., on getting back into bed after voidshe became very apprehensive and ing, dyspneic but shortly feft better. The pulse rate was I 12 and blood pressure IOO systolic and 70 diastofic. At I I :20 P.M. the patient went into irreversibfe shock and the pulse became very rapid, thready and graduaIIy imperceptible, the patient a11 the while compIaining of pronounced dyspnea and retrosternaf pressure. Despite al1 efforts at one’s command death occurred within a few minutes.
This was believed to represent evidence of heafing of a pseudomembranous ulcerative cofitis. Microscopically, in the cofon distal to the site of the colostomy was some superficiaf denudation of the epitheIium. The number of round ceffs and eosinophifs in the famina propria was increased. There were areas of fat necrosis in the pericofic adipose tissue. In the ifeum there was focaf denudation of the surface epithefium, and a few pofymorphonucfear ceffs were present in the famina propria. Some areas showed increased fibrous tissue in the submucosa. A few dilated glands with atypicaf epithelium were seen. No actuaf pseudomembrane was observed. There were simifar changes in the ascending and transverse cofon. The anatomic diagnosis was (I) biIatera1 fata and recurrent pufmonary emboIism, with residual thrombosis of the right internaf and common ifiac veins, and (2) heafing pseudomembranous ifeocofitis. COMMENT
It is branous necropsy
not often that acute pseudomementerocofitis is suspected prior to because onIy about 30 per cent of
American
Journal
of Surgeq,
Hilsabeck,
Dixon-Pseudomembranous
the cases are associated with a voluminous, sustained diarrhea. In the remainder there is an outpouring of fluid into the Iumen of the bowel but diarrhea is absent and the clinical picture is one of profound, unexplained shock. Why the diarrhea ceased in the case reported herein we do not know. Furthermore, we possess no evidence to state dogmaticahy that the diarrhea will uItimateIy abate and the patient live in those cases in which fluid Ioss is repIaced promptIy and adequateIy. However, we feel justified in continuing to advocate the empIoyment of an aggressive program of fluid and electrolyte replacement for that 30 per cent of the cases in which the presence of acute pseudomembranous enterocoIitis may be suspected by the surgeon and for this reason have cited this case. It is our belief that in this manner Iife may be maintained long enough in a few cases for the body to mobiIize whatever forces are necessary to overcome the excessive loss of fluid and eIectroIyte. To date, a number of investigations have failed to find an expIanation for acute pseudomembranous enterocolitis, aIthough it is known that similar Iesions are seen in a number of other conditions such as uremia, certain toxic infections and poisoning from arsenic and mercury. BacterioIogic examinations of the feca1 discharges performed in a number of cases have not discIosed the usual agents which produce primary enteritis. It is also noteworthy that the disease does not seem to be related to the preoperative use of suIfonamides or antibiotics since the Iesions were found at necropsy prior to the advent of suIfonamides and antibiotics. Our case adds IittIe to the meager knowIedge of the etioIogic and pathologic aspects of this complication. As in the previous cases reported from the clinic, shock appeared in this case after the onset of diarrhea. This is in contrast to the observations of Penner and Bernheim, who, because shock was present in their cases in the postoperative period prior to the onset of enterocoIitis, expressed the beIief that the major factors in the pathogenesis of the Iesions were vasomotor disturbances incident to postoperative or traumatic circuIatory deficiencies. In the case reported herein the Iaboratory and fluid baIance data present onIy the usual changes one wouId expect in deaIing with any diarrhea of simiIar proportion. On the basis of present knowIedge chemo-
July, ‘9fi2
EnterocoIitis
117
therapy or the use of antibiotics is not mandatory in the management of pseudomembranous enteritis but wouId definitely be of value in controlling secondary infection. Treatment with aureomycin was instituted oraIIy shortI> after restoration of the circulatory status in the case just reported. In view of the work of Dearing and HeiIman this wouId seem to be the agent of choice. In the presence of vomiting or gastric suction with an indweIIing tube, the intramuscuIar use of peniciIIin and dihydrostreptomycin shouId be as satisfactory as the intravenous use of aureomycin especiaIIy since the survivals of Dixon and Weismann, occurring before the advent of aureomycin, received onIy these drugs. SUMMARY
AND
CONCLUSIONS
OnIy those cases of acute postoperative pseudomembranous enterocolitis which present severe diarrhea foIIowed with shock suggest to the attending physician that he is dealing with this complication. In such instances, it has been contended that if vigorous antishock measures are instituted promptIy and fluid and eIectroIyte balance restored, some of these patients wiI1 survive. In the case just which was encountered foIIowing reported, an anterior resection of the coIon, the presence of this form of enteritis was suspected and it was successfuhy treated according to these principles. A few days Iater the patient died of a massive puImonary emboIus, and at necTopsy, heaIing Iesions consistent with the diagnosis of pseudomembranous enterocolitis were aIso found in the coIon. Thus this was a case of proved pseudomembranous enterocoIitis treated successfuIIy. REFERENCES I. DEARING, W. H. and HEILMAN, F. R. The effect of aureomycin on the bacteria1 Aora of the intestinal
to preoperative tract of man: a contribution preparation. Proc. Staf Meet., Mayo Clin., q: 87-102, 1950. 2. DIXON, C. F. and WEISMANN, R. E. Acute pseudomembranous enteritis or enterocolitis: a complication following intestinal surgery. S. Clin. North America, 28: 999-1023, 1948. 3. PENNER, A. and BERNHEIM, A. I. Acute postoperative enterocolitis. A study on the pathologic nature of shock. Arch. Patb.. 27: 46638% IQ~Q. 4. SCRIBNER, B. H. Bedside determination’ofchide: a method for pIasma, urine and other Auids and its application to fluid balance problems. Proc. Stczff Meet., Mayo Clin., 25: 209-218, 1950.