Segmental enteritis - Forum

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Surrgeon

Segmental enteritis - Ärzteforum

Post#1 »

Dear all, help much appreciated concerning a 5 yr. old African male who presented nearly 4 weeks ago malnourished, pyrexial, bile vomiting, distended abdomen, tender. One of my Registrars took him to OT but found nothing, took a lymph node Bx - reactive changes only on histo.
Post op no change except temp settled. Commenced NG feeds with semi elemental formula, but still vomited, started TPN and tolerated some NG feeds, vomiting occasionally. Contrast follow through - some hold up in stomach, abnormal proximal ileum, long partial stricture, ulcerative mucosal pattern, bowel distal normal with good eventual transit distally. Sat and waited but failed to improve, back to OT today for a relap. Belly clean, organs normal, but from pylorus to end of first 30cm of jejunum serosa a bit red, muscularis grossly thickened and on wedge biopsy mucosa appeared completely absent and replaced by granulation tissue. Lumen Patent but only about 5mm diam. A few fleshy nodes, but unremarkable.
It seems some agent has badly damaged a segment of this child's proximal small bowel. No oesophageal or gastric damage to suggest a caustic agent, therefore presumably infective. I have seen 2 similar cases in the past year but both these affected the mid jejunum or prox ileum, one presenting with a perforation. One died, the other recovered after a protracted illness and prolonged diarrhoea (not a feature of this present case).
1) I am unfamiliar with this pathology. Can anyone shed any light on possible causative agents
2) The lesion here, involving as it does the duodenum, is unresectable, I put in a feeding jejunostomy, but presumably if the child survives it will stricture.
Any suggestions as to further surgical management


Gaster

Re: Segmental enteritis - Ärzteforum

Post#2 »

Are you sure this isn't Crohn's disease? It can occur anywhere in the GI tract.

Hans

Re: Segmental enteritis - Ärzteforum

Post#3 »

what do you mean about necrotic enteritis ?, bacteriological investigations
-Clostridium perfringens ?.
But when he has long partial stricture I think it is Crohn too.

User avatar
الجراح

Re: Segmental enteritis - Ärzteforum

Post#4 »

He looks have Crohn's disease. Why didn't you do a gastrojejunal by-pass? Obstruction may be partial now but it looks the reason of the vomiting.

Noro

Re: Segmental enteritis - Ärzteforum

Post#5 »

Intersting case, I have seen three patients with this obscure type of
enteritis in the last 5 years.The spectrum of the gross pathology is
variable and can be extremeley severe ,ending with gangrene of the
bowel.histologically it is a non specific acute inflammation with
necrosis of the mucosa and occasional air producing bacteria
(clostridial). It has been described in Papua New Guinea and other
tropical areas. probably food borne , canned meat products opened and
left unrefrigirated have been incriminated. treatment is essentially
Tazocillin, flagyl, Close follow up of the abdomen with no hesitation of
reexploration if gangrenous or perforated boxel suspected. Rapid CT scans
helpful to diagnose the latter.

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Surgeon

Re: Segmental enteritis - Ärzteforum

Post#6 »

I quite agree about the diagnosis, as a matter of
fact this type of enteritis is well documented. Enterocolitis
necroticans or pigbel is a rare condition characteristically affecting
chronically malnourished people who abruptly increase their intake of
protein. The classic presentation of the disease as seen in the highlands of
Papua New Guinea is that of a necrotising enterocolitis after the ritual
ingestion of contaminated pork.

Pig Bel is a form of acute, segmental, necrotising enteritis
presenting as a common and life-threatening disease among the people
(particularly the children) of the Highlands of Papua New Guinea. It relates
to the consumption of pig meat and is thought to be caused by Clostridium
welchii type C (an organism not usually present in the human intestine), the
organism being transmitted to man by means of contaminated pig meat. Pig Bel
resembles the diseases called "Darmbrand" which occurred in Northern Germany
in the years that immediately followed World War II. Darmbrand was associated
with a Clostridium welchii infection, possibly precipitated by malnutrition.
It disappeared within a few years of its recognition. Conditions that closely
resemble the clinical and pathological features of Pig Bel have been reported
from Uganda and Thailand. In these countries, only a few cases have been
encountered and they have not been associated with the eating of pig meat or
with a clostridial infection. in communities where protein deprivation, poor
food hygiene, epochal meat feasting and staple diets containing trypsin
inhibitors co-exist. Such human habitats occur in Africa, Central and South
America, western Pacific, Asian and south-east Asian cultures. Isolated
outbreaks of necrotising enteritis have been reported from, Malaysia and
Indonesia . Enteritis necroticans is preventable by vaccination,

Necrotising Enteritis (NE) is a two-stage process. In stage 1, a
necrotic focus is established in the intestinal mucosa-submucosa by
'initiating' factors of vascular (functional or organic) or microbial
(exotoxic, endotoxic, or Shwartzman) origin. Functional circulatory
insufficiency in the intestine is of particular relevance to NE in neonates
and in adults with traumatic shock or cardiac insufficiency. The jejunal
and--to a lesser extent--the ileal microcirculation appear to be particularly
vulnerable to microcirculatory insufficiency. Ninety-seven per cent of NE
occur in the small intestine, of which 76% involve the jejunum alone or as a
part of a jejunoileitis. These 'initiating' factors act either singly or
synergistically with 'promoting' factors (changes in the volume, composition,
or pH of the diet, intestinal stasis, or bacterial factors) in the
establishment of necrotic foci in the intestine. Stage 2 results from the
colonisation of the necrotic foci by intestinal clostridia, the toxigenic
capacity of which will determine the progress of the intestinal lesion.
Clinically established NE is essentially gas gangrene of the intestinal wall.
Bacteriological findings (microscopic, cultural, and serological) support a
pathogenetic role of Cl. welchii in the established stages of necrotising
enteritis.

Acute non-obstructive necrotising enterocolitis in adults is
characterized by pathological features: it is an intestinal necrosis
beginning in the mucosa, without obstruction of the mesenteric vessels. .
Management is medical and/or surgical; it includes alleviation of the
symptoms in intensive care unit, attempts at producing local vasodilatation
whenever possible and resection of the intestinal segment affected. In many
cases the diagnosis is made at exploratory laparotomy.

The indications for surgery include perforation, peritonitis and
persistent intestinal obstruction. It is doubtful whether laparotomy is
indicated in those children with rapid deterioration and simple peritoneal
drainage in very sick infants as described. The mortality rate of operated
children is around 40%, which is in accord with published literature. The
possibility of intestinal stenosis developing and producing intestinal
obstruction is stressed.

User avatar
Lady Surgeon

Re: Segmental enteritis - Ärzteforum

Post#7 »

Your suggestion represents no the state of the art by Crohn.
First perhaps it is not Crohn and second the gastrointestinal by-pass is today
obsolete.(By way of exception duodenal obstruction by M.Crohn and advanced ca).

Surrgeon

Re: Segmental enteritis - Ärzteforum

Post#8 »

Crohn's disease in black South Africans? rare as hen's teeth - this is not
Crohn's, (I've also never seen Crohn's that look like this either).
I didn't use the word necrotic, as no dead tissue . Unfortunately bug
cultures showed nothing (from blood - there has been nothing else to
culture - stool? - very little of it and our lab always seems to lose it if
we send any - sorry but this is Africa).
Any other thoughts - I can tell you what it isn't but I don't know what it
is. Anyone seen coxsackie enteritis in AIDS patients - I don't think I have
but I wonder if it might look similar.

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