Phlegmonous colitis: another source of sepsis in cirrhotic patients?

Abstract

BackgroundThe clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with portal hypertensive colopathy (PHC).Case presentationWe report three cirrhotic patients who were admitted with abdominal sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient underwent emergency colectomy for PC, and subsequently died from multiple organ failure. Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration of submucosal blood vessels.ConclusionsThese data suggest that cirrhotic patients with PHC may progress towards PC, which, in turn, may be the cause for life-threatening sepsis.

Post-endoscopic submucosal dissection phlegmonous enteritis: A case report and literature review

“…The etiology and pathogenesis of phlegmonous enteritis remain uncertain in academic literature. While the association between phlegmonous enteritis and different liver diseases is infrequently documented, it is sufficiently substantiated by several studies [ 8 , 9 , [11] , [12] , [13] , [14] , 17 , 18 ]. Additional uncommon predisposing factors include autoimmune disease (AID) [ 19 ], colon carcinoma [ 10 , 20 ], congestive heart failure (CHF) [ 20 ], and diabetes mellitus [ 9 , 13 ], among others.…”

“…Gastrointestinal phlegmon is an infrequent yet potentially fatal ailment that typically presents with acute abdominal pain and elevated body temperature [ [9] , [10] , [11] ]. The pathological characteristics encompass widespread purulent inflammation, primarily affecting the submucosal layer [ 8 , [11] , [12] , [13] , [14] ].…”

Lethal phlegmonous colitis

“…6 The incidence in patients with cirrhosis at autopsy is around 2.43-2.5%. 1,7 Clinically, it may be difficult to diagnose, with differential diagnoses including pseudomembranous colitis. 8 Phlegmonous inflammation of the stomach is associated with immunosuppression, lower socio-economic status, alcoholism, increased age, chronic gastritis and protein-energy malnutrition.…”

“…5,9 The features are: (a) preferential involvement of the caecum (76.9%), (b) submucosal phlegmonous changes (100%), (c) bacterial infection (100%), (d) no histologically detectable mucosal injuries (92.3%) and (e) acute peritonitis (15.4%). 1,7 Macroscopically, there is either diffuse or segmental thickening of the colon, which on opening reveals a pale, intact mucosa with obliteration of mucosal folds, and occasional small ecchymoses. The underlying submucosa is boggy from oedema fluid.…”

“…The vascular changes are not sufficient to cause an increased risk of mucosal haemorrhage, but may contribute to increased intestinal permeability to bacteria such as E. coli, Enterococcus fecalis, Pseudomonas aeruginosa and Proteus mirabilis. 7,9 Cirrhosis is also associated with impaired complement function, opsonic activity and neutrophil chemotaxis, in addition to altered reticuloendothelial phagocytic activity. 11 The reported case demonstrates a very rare cause of rapid clinical deterioration and death associated with liver disease.…”