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 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.
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PMID:Restorative proctocolectomy in children and adolescents. 898 80

In the North of Scotland, 40 out of 196 patients who had surgery for colitis between 1986 and 1992 underwent restorative proctocolectomy. The problems of the development of experience in a new technique were reduced by cooperation between two consultant surgeons from centres 100 miles apart who performed the first 30 operations together. Over 7 years, the standard operative technique evolved from perimuscular dissection of the rectum with formation of an S pouch and hand sutured endo-anal anastomosis to perimesenteric rectal dissection with a stapled J pouch and double stapled anastomosis. There was no mortality and no pelvic sepsis requiring urgent re-operation. One pouch has been removed subsequently because of Crohn's disease. One patient required revisional surgery for severe stricture of the ileo-anal anastomosis. At 1 year post-operatively, 35 out of 40 patients were highly satisfied with the result of surgery. The proportion of patients undergoing restorative proctocolectomy rather than panproctocolectomy for ulcerative colitis has risen from 15 to 52%. The number of total colectomies performed as initial procedures for colitis has increased. The age of patients who have restorative proctocolectomy has widened to include teenagers as well as a few patients over 50 years of age.
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PMID:The impact of the development of restorative proctocolectomy on the management of inflammatory bowel disease in the north of Scotland. 904 35

Clostridium difficile is a spore-forming anaerobe that resides in the colon and is capable of producing gastrointestinal disease in humans. Factors such as previous exposure to antibacterials and some antineoplastic agents have been reported to promote the overgrowth of C. difficile, with subsequent liberation of potent exotoxins that induce inflammation in the colonic mucosa. Colonisation rates vary, and are higher during infancy and hospitalisation, compared with healthy adults. Although many antibacterials have been reported to induce disease, those agents that achieve high concentrations in the intestinal lumen and are active against bowel flora are more likely to promote overgrowth of C. difficile. Agents with a high potential to induce C. difficile-associated disease (CDAD) include aminopenicillins, cephalosporins and clindamycin. These antibacterials are capable of reducing normal colonisation resistance within the colon. The exact incidence of CDAD is unknown. Some reports suggest an incidence of 1 to 3 infections per 100,000 courses of outpatient oral therapy. The spectrum of illness of CDAD can range from mild diarrhoeal disease to severe colitis, toxic megacolon and sepsis. Fatalities have occurred in some cases. Discontinuation of the offending antibacterial in patients with mild disease is often sufficient to alleviate symptoms. For those with moderate to severe illness, metronidazole and vancomycin are reported to be equally efficacious. Increasing resistance of enterococci to vancomycin limits its use to patients with severe life-threatening infections. Patients with recurrent disease usually respond well to the same course of therapy as was used to treat the initial infection. CDAD is potentially preventable when appropriate antibacterial selection and infection control measures are implemented.
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PMID:Drug-induced Clostridium difficile-associated disease. 925 29

This review illustrates the changing paradigms in the understanding of the pathogenesis of pneumatosis intestinalis. Although many theories have been evoked, pragmatically there appear to be four major clinical and diagnostic imaging considerations. The most common and most emergent life-threatening cause of intramural bowel gas is the result of bowel necrosis due to bowel ischemia, infarction, necrotizing enterocolitis, neutropenic colitis, volvulus, and sepsis. In the stomach, intramural gas can be caused by emphysematous gastritis or ingestion of caustic agents. These situations represent surgical emergencies. Pneumatosis is found secondary to mucosal disruption presumably due to over-distention from peptic ulcer, pyloric stenosis, annular pancreas, and even to more distal obstruction. Disruption can also be caused by ulceration, erosions, or trauma, including the trauma of child abuse. Disruption can also be iatrogenic from intracatheter jejunal feeding tubes, stent perforation, sclerotherapy, or surgical or endoscopic trauma. In these cases, the gas may be focal or linear. Treatment depends on the extent of the disruption and the underlying cause. A more subtle form of mucosal disruption may occur due to mucosal erosions and also to defects in intestinal crypts secondary to acute and subclinical enteritides that allow intraluminal bacterial gas under pressure to percolate into the bowel wall layers, particularly the submucosa (29). Pneumatosis, often linear or cystic in appearance, is seen with increased frequency in patients who are immunocompromised because of steroids, chemotherapy, radiation therapy, or AIDS. In these cases, the pneumatosis may result from intraluminal bacterial gas entering the bowel wall due to increased mucosal permeability caused by defects in bowel wall lymphoid tissue. Clinical and imaging findings are important in the differentiation of this transient pneumatosis from fulminant life-threatening causes in this subset of patients. A pulmonary cause must still be considered in cases of chronic obstructive pulmonary disease, asthma, and cystic fibrosis. It can occur with barotrauma and after chest tube placement. It may relate to increased intrathoracic pressure associated with retching and vomiting. The possibility remains that occasionally the origin of pneumatosis intestinalis will remain cryptogenic--caused but unexplained.
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PMID:Pneumatosis intestinalis: a review. 953 Feb 94

The interleukin-1 receptor antagonist (IL-1Ra) is a member of the IL-1 family that binds to IL-1 receptors but does not induce any intracellular response. Two structural variants of IL-1Ra have previously been described: a 17-kDa form that is secreted from monocytes, macrophages, neutrophils, and other cells (sIL-1Ra) and an 18-kDa form that remains in the cytoplasm of keratinocytes and other epithelial cells, monocytes, and fibroblasts (icIL-1Ra). An additional 16-kDa intracellular isoform of IL-1Ra has recently been described in neutrophils, monocytes, and hepatic cells. Both of the major isoforms of IL-1Ra are transcribed from the same gene through the use of alternative first exons. The two promoters regulating transcription of the secreted and intracellular forms have been cloned, and some of the functional cis-acting DNA regions have been characterized. The production of IL-1Ra is stimulated by many substances including adherent IgG, other cytokines, and bacterial or viral components. The tissue distribution of IL-1Ra in mice indicates that sIL-1Ra is found predominantly in peripheral blood cells, lungs, spleen, and liver, while icIL-1Ra is found in large amounts in skin. Studies in transgenic and knockout mice indicate that IL-1Ra is important in host defense against endotoxin-induced injury. IL-1Ra is produced by hepatic cells with the characteristics of an acute phase protein. Endogenous IL-1Ra is produced in numerous experimental animal models of disease as well as in human autoimmune and chronic inflammatory diseases. The use of neutralizing anti-IL-1Ra antibodies has demonstrated that endogenous IL-1Ra is an important natural antiinflammatory protein in arthritis, colitis, and granulomatous pulmonary disease. Treatment of human diseases with recombinant human IL-1Ra showed an absence of benefit in sepsis syndrome. However, patients with rheumatoid arthritis treated with IL-1Ra for six months exhibited improvements in clinical parameters and in radiographic evidence of joint damage.
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PMID:Interleukin-1 receptor antagonist: role in biology. 959 23

Most patients with Crohn's disease have to be operated on. Necessity to loose some amount of the intestine and time-point of the surgical intervention may be derived from the irreversible cascade of the inflammatory process and the limitations of the conservative treatment. In ileocecal disease indications for surgery are represented by stenotic and/or penetrating complications of the inflamed bowel, whereas in Crohn's colitis acute or terminal medical refractority is predominating. Standard-procedures result from constantly definable patterns of the disease manifestation: ileocecal resection and colectomy/-proctocolectomy. In segmental colitis sometimes "resections within Crohn's" may be adequate in a first attempt to avoid anticipating the natural course by surgical means. In these cases the further prognosis depends on the treatment possibilities of the remaining colon. In contrast, true recurrence is a new inflammation of the neoterminal ileum and may indicate repeated resections. The frequence decreases with the number of resections. Nevertheless nutritional status is restored even by multiple resections, whereas specific functional sequelae of the resection--distal resection- and dehydration syndromes--are well treatable mostly. In the case of appropriate timing of the operation and the reoperation operative morbidity and mortality are remarkable low today resulting in an almost normal life expectancy. Most important as negative prognostic factor remains sepsis resulting from pre-existing or postoperative infectious complications. Keeping this in mind experimental pharmaco-therapy to delay the operation and not profoundly substantiated tendencies to minimize surgery are to be considered only with critical scepticism. At the moment, future research is thought to be more successful in focussing prophylaxis of ileal recurrence than avoiding surgery.
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PMID:[Surgical concepts in Crohn disease of the terminal ileum and colon]. 962 90

Omission of a temporary ileostomy in patients undergoing restorative proctocolectomy is controversial. Although fewer operations may be required and some complications avoided, the risks of anastomotic dehiscence and pelvic sepsis may be greater. Patients undergoing restorative proctocolectomy with no ileostomy (Group NI, n = 72) were compared retrospectively with patients given a conventional loop ileostomy (Group I, n = 30). Criteria for avoiding faecal diversion included: absence of severe acute colitis, good nutritional status and favourable surgery with creation of a sound, tension-free anastomosis. Steroid intake was not a contraindication to single-stage surgery. Delayed stomas were necessary in 8% of Group NI. For Groups NI and I, the rates of anastomotic leak (3% vs 3%), pelvic sepsis without demonstrable leak (3% vs 0%), pouch fistula (3% vs 10%) and intestinal obstruction (8% vs 3%) were similar. Closure of the temporary ileostomy in Group I was associated with a 10% complication rate. Cumulative post-operative hospital stay was significantly less in Group NI (median 11 vs 16 days). Functional results at 1 year were similar. A temporary loop ileostomy can be safely avoided in carefully selected patients undergoing restorative proctocolectomy.
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PMID:Selective omission of loop ileostomy in restorative proctocolectomy. 968 61

We report the case of a 21-year-old man who had been developing acute renal failure with Methicillin-resistant Staphylococcus aureus (MRSA) colitis and sepsis. He was admitted for consciousness disturbance, nausea, vomiting, and diarrhea. Oliguria was also observed and his serum creatinine level was elevated to 10 mg/dl. Urinary protein was positive and an abundance of hyaline cast were seen in urinary sedimentation. Diarrhea and pyrexia were prolonged and serum C-reactive proteins were elevated, but lymphocyte and leukocyte counts temporarily decreased from the 3rd to the 6th hospital day and remained low until normalizing after the 14th day. His clinical symptoms improved with hemodialysis (HD) and effective antibiotic therapies. An MRSA strain producing toxic shock syndrome toxin-1 (TSST-1), a super antigen which specifically stimulates human V beta 2-positive T cells, was separated from his feces and blood. To ascertain the cause of his renal dysfunction, a renal biopsy was performed on the 8th day. His renal histology revealed acute interstitial nephritis with severe inflammatory cell infiltration around the medullary areas without glomerular changes. Most of the infiltrated cells were small monocytes, and lymphoid cells were rich in the interstitium. With immunohistochemical staining, over 70% of T-cells were V beta 2-positive. TSST-1-producing MRSA was detected in his blood specimen. Furthermore, V beta 2-positive T cells were accumulated in the renal intersititium, and transient lymphocytopenia was observed. These data suggested the following possible pathogenesis for interstitial nephritis: TSST-1 acts as a super antigen in the renal interstitium where major histocompatibility complex (MHC) is class-2-positive, thereby resulting in interstitial nephritis with T cell migration.
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PMID:[A case of interstitial nephritis induced by a super antigen produced by methicillin-resistant Staphylococcus aureus (MRSA) presenting as acute renal failure]. 1036 25

From fiscal years 1992 through 1996, 14 African hedgehog (Atelerix albiventris) cases were submitted to the Animal Disease Diagnostic Laboratory at Purdue University. The most common diagnoses were splenic extramedullary hematopoiesis (91%), hepatic lipidosis (50%), renal disease (50%), and neoplastic disease (29%). Other less frequent necropsy findings were myocarditis (21%), colitis (14%), bacterial septicemia (14%), and pneumonia (14%). The data indicate that splenic extramedullary hematopoiesis, hepatic lipidosis, renal disease, and neoplasms are frequent postmortem findings in hedgehogs.
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PMID:Necropsy and histopathologic findings in 14 African hedgehogs (Atelerix albiventris): a retrospective study. 1048 45

Two cases of unexpected childhood death due to hemolytic uremic syndrome are reported. A 21-month-old girl who was discovered dead in bed following a short illness was found at autopsy to have overwhelming sepsis resulting from transmural colitis. Escherichia coli serotype 0157A was isolated from the intestine, and renal changes of hemolytic uremic syndrome were found. A 4-year-old girl died suddenly in hospital from intracranial hemorrhage while being treated for hemolytic uremic syndrome-related renal failure. Culture of urine and feces grew verocytotoxin producing E. coli. These cases demonstrate that hemolytic uremic syndrome may be a rare cause of unexpected childhood death and that the diagnosis may not be established prior to autopsy. Postmortem culture of tissues and fluids in cases of suspected sepsis in children may be essential in establishing this diagnosis, because histologic evaluation may be compromised by profound sepsis and tissue putrefaction. Accuracy in diagnosis may have significant public health and medicolegal consequences.
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PMID:Unexpected childhood death due to hemolytic uremic syndrome. 1073 36


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