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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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– Vancomycin 4 x 125–250 mg PO (expensive).
– Rifaximin 3 x 200 mg PO.
Inpatient with Significant Comorbidities/ICU Patient
Discontinuation of offending antibiotics (if possible)
Correction of underlying disease process
Perianal skin care: barrier ointments.
Combined antibiotic treatment (dual coverage) for at least 10 days with:
– Metronidazole 3
x 500 mg PO or IV (cheap).
– Vancomycin 4 x 125–250 mg PO or via NGT (expensive).
– Rifaximin 3 x 200 mg PO.
Refractory/recurrent colitis: combination of vancomycin and rifaximin for 10 days, pulse dose thereafter.
Alternatives
Binding agents: cholestyramine 3–4 x 4 g PO (will also bind oral antibiotics!), colestipol
Other antibiotics: Bacitracin.
Antidiarrheal agents: to be used with caution, contraindicated as long as infectious component uncontrolled.
Steroids?
Probiotics: eg, Saccharomyces boulardii (nonpathogenic yeast, except risk in ICU patients with central lines),
Lactobacillus GG (generally nonpathogenic, but can cause bacteremia/liver abscess).
Fecal enemas or colonoscopic stool transfer from healthy donor (eg, spouse): effective reconstitution of colonic flora.
Operative Treatment
INDICATIONS
Fulminant disease.
Toxic megacolon.
Colonic perforation.
Failure of medical therapy with refractory or worsening disease: warning signs among others include secondary organ
dysfunction (respiratory, renal, neurologic, hemodynamic), vasopressor use, steroid use, WBC > 20,000.
OPERATIVE APPROACH
Total abdominal colectomy with end-ileostomy for all patients (no exceptions).
Outcome
Symptomatic improvement in > 95% of patients after 10 days of combined conservative efforts. Persistent C difficile in stool:
3.5% of "cured" patients, 20% of patients whose colitis recurs. Risk of first relapse: 20–35%, risk of subsequent relapse 45–
65% repeat antibiotics, no single effective treatment.
Overall 30-day attributable mortality: 6–7%.
Emergency colectomy: mortality 10–40% (mostly related to delayed decision to intervene).
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Follow-Up
Emergency surgery: planning of subsequent surgery, ie, elective restoration of intestinal continuity, after complete
physical/nutritional recovery.
Cross-Reference
Diarrhea (Ch. 1)
Megacolon (Ch. 1)
Colonoscopy (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Ischemic colitis (557.X) (Ch. 4)
Infectious enterocolitis (002-009.X) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
Colonic pseudoobstruction (Ogilvie syndrome, 560.89) (Ch. 4)
Total abdominal colectomy with end-ileostomy (open) (Ch. 5)
INFECTIOUS ENTEROCOLITIS (002-009.X)
Overview
Infectious colitis is a group of acute and chronic inflammatory diseases of the colon that have an identifiable cause and
represent an important differential diagnosis to idiopathic IBD. The clinical picture shows variations and may range from
acute self-limiting diarrhea to fulminant toxic and potentially fatal presentation.
Pathogenesis: enterotoxic organisms preserve mucosal integrity but cause secretory diarrhea; enteroinvasive organisms
cause mucosal injury with combined secretory, ulcerative symptoms. Immunosuppression (eg, HIV infection) may predispose
to specific pathogens (Table 4–6).
Table 4–6. Pathogens of Infectious Enterocolitis.
Type Pathogen Diarrhea Colitis Acute Chronic Immuno-suppression
Bacterial Bacillus cereus + +
Bacteroides fragilis + +
Campylobacter + + + +
Clostridium difficile + + + +
Clostridium perfringens + +
Enterohemorrhagic E coli + + +
Salmonella enteritidis + + +
Salmonella typhimurium + + + +
Shigella + +
Staphylococcus aureus + + +
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Vibrio cholerae + +
Yersinia enterocolitica + + +
Yersinia paratuberculosis + +
Myobacterial Mycobacterium avium complex (MAC) + + + +
M tuberculosis + + +
Parasitic Cryptosporidium + + +
Cyclospora cayetanensis + + + +
Entamoeba histolytica + + + +
Giardia + + +
Isospora + + + +
Microsporidium + +
Viral Adenovirus + + +
Astrovirus + + +
Cytomegalovirus + + + +
Norovirus + +
Rotavirus + +
+, positive.
Epidemiology
Exact incidence unknown as patients with many minor forms do not seek medical care. Sporadic local epidemics achieving
attention in news media.
Symptoms
Universal enterocolitis symptoms (acute/chronic: see Table 4–6): diarrhea, passage of mucus, urgency, tenesmus,
incontinence; bleeding per rectum associated with certain pathogens.
Possible systemic effects: anorexia, dehydration, mental status change, abdominal pain, fever.
Complications: abdominal distention, toxic megacolon, perforation.
Differential Diagnosis
Idiopathic IBD (ulcerative colitis, Crohn colitis), microscopic colitis, collagenous colitis, IBS, radiation enterocolitis/proctitis,
ischemic colitis, diversion colitis, eosinophilic colitis, diverticulitis, STD proctitis (eg, lymphogranuloma venereum, gonorrhea),
noninfectious causes (drugs, food allergies, celiac disease).
Pathology
Inflammatory process with or without microscopically identifiable organisms.
Pathogens (see Table 4–6):
Acute: Salmonella, Campylobacter, Shigella, Cryptosporidium, E coli O157:H7, Campylobacter jejuni, C difficile,
norovirus, Staphylococcus aureus, Yersinia enterocolitica, Listeria, Vibrio cholerae, etc.
Chronic: Entamoeba histolytica, Cryptosporidium, Microsporidium, MAC/tuberculosis, CMV, Cyclospora, Giardia,
Isospora.
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Bloody diarrhea: E coli O157:H7, Shigella, Campylobacter, Salmonella species, C difficile, amebic colitis.
Evaluation
REQUIRED MINIMAL STANDARD
History: symptom characterization, endemic area, risk factors, recent travel, underlying HIV infection or immunosuppression,
simultaneously affected family members, bowel function prior to onset, etc.
Clinical examination: general appearance, vital signs, dehydration, abdominal distention, focal tenderness, peritoneal signs,
bowel sounds.
Rigid/flexible sigmoidoscopy or colonoscopy: evaluation of extent/severity of morphologic changes
biopsy.
Stool cultures, O&P, C difficile toxins: rule out specific, infectious etiology:
20% positive.
Emergency presentation: plain abdominal x-rays—rule out perforation or colonic dilation > 6 cm (1
1
/
2
vertebrae) in
transverse colon or > 12 cm for cecum.
ADDITIONAL TESTS (OPTIONAL)
Stool WBCs: positive if epithelial injury.
Classification
Acute vs chronic presentation.
Specific vs idiopathic colitis.
Segmental colitis vs pancolitis.
Enteroinvasive vs enterotoxic colitis.
Nontoxic colitis vs toxic colitis.
Nonoperative Treatment
Unspecific/symptomatic treatment: rehydration, antidiarrheals, empirical antibiotics (quinolone, metronidazole).
Pathogen-specific treatment: targeted antibiotic treatment.
Identification of source of infection?
Operative Treatment
INDICATIONS
Life-threatening complications: fulminant colitis, toxic megacolon, colonic perforation, massive bleeding.
Lack of response or deterioration within 3–5 days of conservative treatment.
OPERATIVE APPROACH
Total abdominal colectomy with end-ileostomy (ie, sparing rectum and pelvic dissection).
Outcome
Fulminant/toxic colitis rare significant morbidity/mortality. Nontoxic colitis complete recovery expected.
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Follow-Up
Upon resolution of infection: no specific follow-up needed.
Carrier status (eg, Salmonella), eg, in gallbladder
need for cholecystectomy?
Cross-Reference
Diarrhea (Ch. 1)
Megacolon (Ch. 1)
Radiation proctitis/enteritis (558.1) (Ch. 4)
Ischemic colitis (557.X) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
Colonic pseudoobstruction (Ogilvie syndrome, 560.89) (Ch. 4)
Diversion colitis (V44.2) (Ch. 4)
Total abdominal colectomy with end-ileostomy (open) (Ch. 5)
IBD—ULCERATIVE COLITIS (556.9)
Overview
Ulcerative colitis (UC), a subentity of idiopathic inflammatory bowel diseases, is a complex chronic autoimmune disease of
unknown etiology characterized by relapsing and remitting course of an acute ulcerating inflammation of the colorectal
mucosa. Lacking a specific cause, treatment remains unspecific. Surgery is largely curative, but does not completely
normalize the functional aspects. Approximately 30–40% of UC patients will at some point require an operative treatment.
Epidemiology
Annual incidence in Western countries: 5–16 new cases per 100,000. Age at onset most commonly but not exclusively
between 15 and 45 years. Prevalence: 50–220 cases per 100,000 with familial, geographic, ethnic, and cultural variations.
Nicotine use may exert favorable effect in UC (in contrast to Crohn disease). At any time, 50% of patients are relatively
asymptomatic, 30% with mild symptoms, 20% with moderate to severe symptoms. Despite periods of complete remission,
cumulative probability of remaining relapse-free only around 20% after 2 years, < 5% after 10 years.
Cancer risk: 5% after 10 years, increase of 1–2% per year, about 15–25% after 20 years. Average risk of established cancer
in presence of dysplasia 20%, in presence of severe dysplasia or DALM 40–50%.
Cancer screening: 2% of patients with regular colonoscopies end up with cancer; 25% of UC patients with colorectal
carcinoma show no dysplasia except in immediate proximity to the cancer; 18% of patients with colorectal cancer in UC are
less than 8 years post onset of the disease.
Symptoms
Variations in severity of the disease, alternating exacerbations and remissions: diarrhea, passage of mucus and blood per
rectum, urgency/incontinence, tenesmus. Systemic effects associated with longstanding or fulminant course of the disease:
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anemia, anorexia, malnutrition/weight loss, retardation of growth, general debility, abdominal pain, fever.
Extraintestinal manifestations (15–25% of patients): paralleling colonic disease activity: peripheral arthritis (15–20%), skin
lesions (pyoderma gangrenosum, erythema nodosum), ocular (episcleritis), hypercoagulability. Independent of colonic
disease activity: ankylosing spondylitis and sacroiliitis (1–6%), hepatobiliary disease (pericholangitis, primary sclerosing
cholangitis; 3–5%), ocular (anterior uveitis, iritis), cardiac complications (pericarditis), hypercoagulability.
Complications: massive bleeding, toxic megacolon (5%), perforation (may be masked by steroids), malignant transformation.
Differential Diagnosis
Crohn disease, indeterminate colitis (7–15%), ischemic colitis, diverticulitis, infectious colitis (including pseudomembranous C
difficile colitis), STD proctitis (eg, lymphogranuloma venereum, gonorrhea), radiation proctitis, IBS.
Pathology
MACROSCOPIC
Confluent inflammation starting at dentate line and extending proximally, sharp demarcation between distal involved
colon and more proximal uninvolved colon (Figure 4–13A), or pancolitis (Figure 4–13B).
Ulcerations in distal ileum in 10% of patients with pancolitis (backwash ileitis).
Edematous, hyperemic and very friable mucosa, large mucosal erosions and ulcerations, margins may protrude into
the lumen and form pseudopolyps.
Chronically involved colon segments lose haustral folds, become foreshortened, flat, and rigid pipelike ("burned-out
colitis").
Cancer developing in UC often does not form a mass!
Figure 4–13A.
Ulcerative colitis: extended colitis with sharp demarcation.
Figure 4–13B.
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Ulcerative colitis: pancolitis.
MICROSCOPIC
Superficial acute (neutrophils) and chronic (lymphocytes) inflammation limited to mucosa and submucosa (except in
toxic megacolon).
Crypt abscesses, vascular congestion, hemorrhage (acute episodes), distortion of the crypt architecture (gland
branching, shortening, loss of parallel arrangement), Paneth cell metaplasia, infiltration of lamina propria with
mononuclear cells (chronic disease).
Caveats: overlap of morphologic picture with Crohn disease in 7–15% of patients (indeterminate colitis). Relative rectal
sparing: "burned-out proctitis," treatment effect (steroid enemas).
Evaluation
REQUIRED MINIMAL STANDARD
Rigid or flexible sigmoidoscopy: sufficient to establish diagnosis, always needed prior to elective surgery to rule out cancer in
rectum (as that would change the management).
Colonoscopy: gold standard to evaluate the extent and activity of the disease, but increased risk of perforation in acute
disease. (Bi-)annual surveillance starting no later than 7 years post onset.
Stool cultures, O&P, C difficile toxins:
rule out specific, infectious etiology.
Emergency presentation: plain abdominal x-rays
rule out perforation or colonic dilation > 6 cm (1
1
/
2
vertebrae) in
transverse colon or > 12 cm for cecum.
Caveat: extent of the colonic diameter does not accurately predict risk of perforation.
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ADDITIONAL TESTS (OPTIONAL)
Contrast studies (barium or Gastrografin enema): mucosal pattern as well as foreshortening and stricturing of the colon;
procedures are contraindicated in patients with acute disease (may precipitate deterioration with toxic dilation).
Virtual colonoscopy: role not defined, risk of perforation.
MRI, PET, PET-CT: role not yet defined, may be useful for detection of fistulae or skip lesions, for assessment of the disease
activity, and for differentiation between Crohn disease and UC.
Capsule endoscopy: not indicated.
Markers: pANCA-positive (60–80% positive in UC), ASCA-negative (60% positive in Crohn disease): definitive role remains
controversial.
Classification
Proctitis or proctosigmoiditis (45–60%), left-sided colitis (distal to the splenic flexure), extensive colitis (involving the
transverse colon), pancolitis (20%).
Minor forms of UC (?): microscopic colitis, collagenous colitis.
Nonoperative Treatment
Principle: control symptoms, suppress disease activity, maintain remission.
Antidiarrheals/antispasmodics (contraindicated in acute exacerbation: may precipitate toxic dilation).
Enemas containing corticosteroids or 5-ASA (mesalamine, olsalazine, sulfasalazine) for limited disease (proctitis, left-
sided colitis) or chronic pouchitis.
Oral 5-ASA, prednisone for mild to moderate UC and to maintain remission in 75–80% of patients.
Hospitalization, intravenous steroids (or ACTH), intravenous nutritional support, transfusions for severe forms of the
disease with systemic signs and symptoms
Cyclosporine A, azathioprine, or 6-mercaptopurin induce and maintain remission (3–6 months delay to establish an
effect).
Newer developments: nicotine, thalidomide, or infliximab.
Antibiotics not indicated except for medical management of fulminant/toxic colitis.
Operative Treatment
INDICATIONS
Life-threatening complications: fulminant colitis, toxic megacolon, colonic perforation, massive bleeding. Lack of
response or deterioration within 3–5 days of conservative treatment.
Malignancy: established cancer, any level of dysplasia (low grade, high grade), stricture, cancerophobia. Caveat:
rectal cancer should always be treated with neoadjuvant chemoradiation first to avoid radiating the pouch!
Treatment-refractoriness of the disease: failure of or side effects from conservative treatment, steroid dependency,
unacceptable quality of life.
OPERATIVE APPROACH
Goal: cure from the disease and/or from toxic effects of medications, reconstruction with low morbidity but high quality of
life, minimization of morbidity/mortality.
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Surgical principle: combination of surgical modules (Figure 4–13C): (1) elimination of disease (2) reconstruction (3)
protection (4) completion.
Figure 4–13C.
Ulcerative colitis: surgical treatment algorithm.
Urgent/Emergency
Total abdominal colectomy with end-ileostomy (ie, sparing rectum and pelvic dissection) for all high-risk patients. Complete
excision (ie, proctocolectomy with reconstruction and diversion) acceptable in selected cases. Turnball blowholes: more of
historical than practical interest.
Elective
Most common approach: proctocolectomy, ileal J-pouch anal anastomosis (with/without temporary ileostomy). Mandatory
criteria to consider one-stage operation: perfect tension-free anastomosis, normal nutritional status, no immunosuppressive
medication (steroid, infliximab, etc). Caveat: For patient, the adjustment period is more difficult (bowel frequency, urgency,
control) after one-stage than after two-stage operation.
Less frequent approach: proctocolectomy with end ileostomy or continent ileostomy.
Rarely performed: total abdominal colectomy/ileorectal anastomosis in selected patients (relative rectal sparing, maintained
rectal compliance).
Outcome
Emergency colectomy: mortality dropped from 30% to 1%. Massive hemorrhage: leaving rectum in continued bleeding in
10–12% of the patients.
Elective: Mortality 1%, satisfaction 90–95%, 4–8 bowel movements per day.
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Complications: SBO 15–35%, wound infections 5–6%, bleeding 4%, leak with/without pelvic sepsis 4–10%, abscess
formation, fistula (perirectal, vaginal pouch), ileostomy-related complications: 1 episode of pouchitis 20–50%, ATZ cuffitis
(UC pathology in rectal remnant), ATZ dysplasia. Pouch loss 3–10%. Sexual dysfunction in males 1–3%, dyspareunia 5–25%,
decreased fertility 25–40%.
Follow-Up
Emergency surgery: planning of subsequent surgeries after complete physical/nutritional recovery.
Elective surgery: ileostomy takedown > 6 weeks if clinically and radiologically (pouchogram) no evidence of leak and steroids
tapered off.
Long-term: antidiarrheals and fibers may be needed. (Bi-)Annual routine follow-up with pouchoscopy and biopsy of ATZ, or
as needed. Education about pouchitis symptoms and management.
Cross-Reference
Diarrhea (Ch. 1)
Megacolon (Ch. 1)
Ischemic colitis (557.X) (Ch. 4)
Pseudomembranous/Clostridium difficile colitis (008.45) (Ch. 4)
Infectious enterocolitis (002-009.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
"Pouchology"—the science of pouches (Ch. 4)
Pouchitis—ileoanal dysfunction (569.60) (Ch. 4)
Toxic megacolon (556.9) (Ch. 4)
Colonic pseudoobstruction (Ogilvie syndrome, 560.89) (Ch. 4)
Diversion colitis (V44.2) (Ch. 4)
Total abdominal colectomy with end-ileostomy (open) (Ch. 5)
Proctocolectomy, ileal J-pouch anal anastomies (open) (Ch. 5)
Medical management of ulcerative colitis (Ch. 6)
Medications against tumor or inflammation (App. 1)
IBD—CROHN DISEASE (555.X)
Overview
Crohn disease ("terminal ileitis"), a subentity of idiopathic inflammatory bowel diseases, is a complex chronic autoimmune
disease of unknown etiology characterized by relapsing and remitting inflammation anywhere in the GI tract between mouth
and perianal area.