Retroperitoneal gas gangrene after colonoscopic polypectomy without bowel perforation in an otherwise healthy individual: report of a case

A case report of iatrogenic gas gangrene post colonoscopy successfully treated with conservative management- is surgery always necessary?

Background

Colonoscopy is a routine procedure in diagnosis and treatment of colonic disease. While generally regarded as a safe procedure, potentially fatal complications can occur. Gas gangrene is one such complication, with very high mortality. There are few cases of gas gangrene occurring after colonoscopy, making it one of the rarer complications of this procedure. There have been no previously reported cases of a patient surviving such an infection and the optimal treatment strategy is contentious. This report describes a case of intramural gas gangrene of the colon, treated conservatively with antibiotic therapy in which the patient survived with full recovery.

Case presentation

A 71-year-old, previously healthy male presented 6 h post apparently uncomplicated colonoscopic polypectomy with rigors, nausea, vomiting and right upper quadrant pain. At presentation he was febrile at 40.1 °C but hemodynamically stable. Abdominal computed tomography revealed substantial colonic thickening and several focal intramural gas bubbles (pneumatosis intestinalis) surrounding the polypectomy site. Within 24 h post procedure he became hypotensive and was admitted to ICU in frank septic shock requiring inotropes, and with demonstrable septic myocardial depression. Bloods showed multi-organ derangement with leukocytosis, lactic acidosis, haemolytic anaemia and hyperbilirubinemia. A diagnosis of presumed Clostridial gas gangrene was made, and treatment was initiated with benzylpenicillin, clindamycin, metronidazole and vancomycin. After 4 days in ICU he was stepped down, and discharged after a further 10 days with no surgical or endoscopic interventions. At three-month review he reported being back to full health.

Conclusions

This case demonstrates that gas gangrene infection is a possible complication of colonoscopic polypectomy. This is a cause of rapid deterioration in post-colonoscopy patients and has been misdiagnosed as colonic perforation in previously reported cases of retroperitoneal gas gangrene. Such misdiagnosis delays antibiotic therapy, which likely plays a role in the high mortality of this condition. Early diagnosis and initiation of antibiotic therapy with benzylpenicillin and clindamycin as seen in this case is essential for patient survival. While surgery is typically performed, non-operative management of pneumatosis intestinalis, and potentially gas gangrene is becoming more common and was utilized effectively in this patient.

Epidemiological Characteristics of Postoperative Sepsis

BACKGROUND

Postoperative sepsis is a major type of sepsis. Sociodemographic characteristics, incidence trends, surgical procedures, comorbidities, and organ system dysfunctions related to the disease burden of postoperative sepsis episodes are unclear.

METHODS

We analyzed epidemiological characteristics of postoperative sepsis based on the ICD-9-CM codes for the years 2002 to 2013 using the Longitudinal Health Insurance Databases of Taiwan's National Health Insurance Research Database.

RESULTS

We identified 5,221 patients with postoperative sepsis and 338,279 patients without postoperative sepsis. The incidence of postoperative sepsis increased annually with a crude mean of 0.06% for patients aged 45-64 and 0.34% over 65 years. Patients with postoperative sepsis indicated a high risk associated with the characteristics, male sex (OR:1.375), aged 45-64 or ≥ 65 years (OR:2.639 and 5.862), low income (OR:1.390), aged township (OR:1.269), agricultural town (OR:1.266), and remote township (OR:1.205). Splenic surgery (OR:7.723), Chronic renal disease (OR:1.733), cardiovascular dysfunction (OR:2.441), and organ system dysfunctions had the highest risk of postoperative sepsis.

CONCLUSION

Risk of postoperative sepsis was highest among men, older, and low income. Patients with splenic surgery, chronic renal comorbidity, and cardiovascular system dysfunction exhibited the highest risk for postoperative sepsis. The evaluation of high-risk factors assists in reducing the disease burden.

Clostridium difficile Infection and Colorectal Surgery: Is There Any Risk?

Background and objectives: Clostridium difficile infection (CDI) is an important healthcare-associated infection, with important consequences both from a medical and financial point of view, but its correlation with anastomotic leaks after colorectal surgeries is scarcely reported in the literature. Materials and Methods: We conducted a retrospective study looking for patients who underwent open or laparoscopic surgery for colorectal cancers between January 2012 and December 2017, excluding emergency surgeries for complicated colorectal tumors. We also examined patient history for risk factors for CDI such as age, sex, comorbidities, and clinical findings at admission or during hospital stay as well as tumor characteristics. Results: A total of 360 patients were included in the study, out of which 320 underwent surgeries that included anastomoses. There were 19 cases of anastomotic leaks, out of which 13 patients were diagnosed with CDI, with a statistic significance for association between CDI and anastomotic leakage (p < 0.0001). Most patients who developed both CDI and anastomotic leaks had left-sided resections or a type of rectal resection, while none of the patients with right-sided resections had this association, but with no statistical significance possibly due to the limited number of cases. Conclusions: CDI is a relevant risk factor and should be taken into consideration when trying to prevent anastomotic leaks in patients undergoing gastrointestinal surgery for colon or rectal cancer. Thorough assessment of risk factors at admission should be mandatory in order to adequately prepare the patient and plan an optimal course of treatment. Further studies are needed to confirm our findings and a multidisciplinary approach, with a team which should always include the surgeon, is mandatory when it comes to CDI prevention.

Rhabdomyolysis Following Colonoscopy: A Case Report

We experienced a case of 1 patient who died from rhabdomyolysis-related complications after colonoscopy. A 60-year-old man had undergone an ‘uncomplicated’ colonoscopic polypectomy. Approximately 10 hours following this procedure, the patient complained of increasing left abdominal pain. His computed tomography image showed free gas, but his operative findings revealed no macroscopic perforation or abscess formation. Eight hours after the operation, the patient presented with myoglobulinuria, and we diagnosed the condition to be rhabdomyolysis. Based on this case, we recommend that rhabdomyolysis be added to the list of complications following a colonoscopic procedure. Moreover, for prevention and early treatment, endoscopists should be attentive to the risk factors and signs/symptoms of rhabdomyolysis.

Fatal Clostridium perfringens Septicemia After Colonoscopic Polypectomy, Without Bowel Perforation

Since its introduction, colonoscopy has played an important role as a diagnostic, therapeutic, and screening tool. In general, colonoscopy is regarded as a safe procedure, but complications may occur. The most dreaded of these complications is colonic perforation. Bacteremia postprocedure may occur, and although it is not uncommon, it rarely results in clinically significant complications. Patients with IBD (inflammatory bowel disease) are a high-risk population for bacteremia, which may leads to bowel wall overstepping by the bacteria. With regard to that, we report a fatal case of gas gangrene complicating colonoscopy polypectomy without bowel perforation in a healthy adult. To the best of our knowledge, only two other cases of retroperitoneal gas gangrene associated with colonoscopy polypectomy without bowel perforation have been described in international literature, but none of which was completed by a molecular biology analysis.

Case of Clostridium perfringens bacteremia after routine colonoscopy and polypectomy

Bacteremia is an uncommon complication after polypectomy and colonoscopy. We report one of the first cases of Clostridium perfringens bacteremia after polypectomy. Our patient was a four years old boy with congenital polyposis, who underwent colonoscopy and polypectomy without complication. Approximately 12h later he developed a fever and tachycardia with no other clinical symptoms. His blood cultures grew out penicillin susceptible C. perfringens and Enterococcus faecalis. He responded to antibiotic therapy and remained clinically asymptomatic for the duration of his course. There are a few reports of bacteremia after routine polypectomy, but no reported cases of C. perfringens bacteremia in the pediatric population. Clostridial sp. bacteremia can be fatal with devastating consequences if appropriate antibiotics and/or surgical debridement are delayed. Polymicrobial infection, as illustrated in our patient, is also common and can be a poor prognostic risk factor. Therefore, for patients with a history of polypectomy and new onset fever, anaerobic infections should be considered and empiric antibiotic therapy should include coverage for these organisms.

Diagnosis and misdiagnosis of necrotizing soft tissue infections: three case reports

BACKGROUND

Today, gas gangrene is rare, but still many of the patients die, despite having received timely treatment.

CASE PRESENTATION

This report highlights the cases of three different patients, who were transferred to our surgical department in 2006. The first patient (Patient_A), with the suspected diagnosis "femoral hematoma", a second patient (Patient_B) because of an "acute abdomen" and the third patient (Patient_C) with suspected gas gangrene of the right leg.

CONCLUSION

The first two cases demonstrate gas gangrene should always be kept in mind, especially in high-risk-patients. Though, the third case shows that severe consequences because of a precipitate diagnosis can be avoided by careful evaluation.

Infection and musculoskeletal conditions: Infectious myositis

Infectious myositis, an infection of the skeletal muscle(s), is uncommon. This clinical entity may be caused by viral, bacterial, fungal, and parasitic pathogens. Viral etiologies typically cause diffuse myalgias and/or myositis, whereas bacteria and fungi usually lead to a local myositis which may be associated with sites compromised by trauma or surgery and are more common among immunocompromised patients. Localized collections within the muscles are referred to as pyomyositis. Other pyogenic causes of myositis include gas gangrene, group A streptococcal myonecrosis, and other types of non-clostridial myonecrosis. Early recognition and treatment of these conditions are necessary as they may rapidly become life-threatening.