Colonic perforation

Severe disease is defined as the presence of complications of colitis, such as sepsis, volume depletion, electrolyte imbalance, hypotension, paralytic ileus, and toxic megacolon. Patients with signs of severe disease should receive oral vancomycin as initial therapy. Surgical intervention may be indicated and lifesaving, particularly in cases complicated by toxic megacolon or colonic perforation. 

Antibiotics alter the normal colonic flora, leading to loss of colonization resistance, which is the ability of the normal flora to protect against overgrowth of pathogens, especially when the anaerobic flora are depleted [15], In CDAD, the altered colonization resistance can allow for the overgrowth of C. difficile in the colon. The bacteria produces two toxins which cause disease (toxin A, an enterotoxin, and toxin B, a cytotoxin). The toxins of C. difficile inactivate Rho proteins, which results in the loss of cytoskeletal integrity in enterocytes. Cellular damage results in fluid loss, exudation and diarrhea. The most severe form of C. difficile diarrhea is pseudomembranous colitis, which can cause severe colitis, toxic colon and rarely colon perforation and death. 

For ulcerative colitis, colectomy may be performed when the patient has disease uncontrolled by maximum medical therapy or when there are complications of the disease such as colonic perforation, toxic dilatation (megacolon), uncontrolled colonic hemorrhage, or colonic strictures. 

Minford E, Hand T, Jones MC. Constipation and colonic perforation complicating calcinm resoninm. Postgrad MedJ 1992 68(798) 302-6. 

Pediatric Fleets enema or biscodyl suppository Nightly for first 3 days Per rectum Child may experience sense of intrusion colonic perforation possible (rare)... 

Sharma R, Gupta KL, Ammon RH, Gambert SR. Atypical presentation of colon perforation related to corticosteroid use. Geriatrics 1997 52(5) 88-90. 

Freudenreich O, Goff DC. Colon perforation and peritonitis associated with clozapine. J Clin Psychiatry 2000 61(12) 950-1. 

Cocaine exposure in utero can affect various fetal organs. Gastrointestinal disorders, including ten cases of necrotizing enterocolitis (291), one of intestinal atresia, and one of spontaneous colonic perforation, have been reported (292). 

Aluminium hydroxide can cause constipation, or even intestinal obstruction. Severe bowel dysfunction developed in 25 of 945 patients receiving long-term hemodialysis during 10 years (47). There was colonic perforation in 12 patients, six of whom died with peritonitis. In 10 other patients there was prolonged, severe, adynamic ileus that progressed to colonic pseudo-obstruction in eight. All had regularly taken aluminium hydroxide gel and had had chronic constipation before presentation. 

In air-contrast examinations, colonic perforation can actually precede the administration of the barium enema itself. In such cases it is due to the preparatory insufflation of air if this is conducted with excessive enthusiasm in a high-risk patient (for example an elderly patient with a hitherto unrecognized epigastric hernia) (10). 

A possible risk of glucocorticoid treatment of ulcerative colitis is the development of toxic megacolon or colonic perforation. A change from ulcerative colitis to Crohn s disease may have been induced by prolonged treatment with glucocorticoids (SEDA-19, 376) (130). This case provides further evidence for the view that ulcerative colitis and Crohn s disease may represent a continuous spectrum of inflammatory bowel disease and raises the possibility that reduced polymorphonuclear leukocyte function caused by glucocorticoids may have provoked the development of granulomata. 

A case of colonic perforation was described in 1990, but the patient concerned was suffering from the distal intestinal syndrome of cystic fibrosis and may have been at particular risk (SEDA-16, 428). 

Colonic perforation has been attributed to calcium polystyrene sulfonate in a premature infant (26). 

Overdose (stated at as little as 1.0 g per day for several days) can cause colonic perforation and bleeding diarrhea, as well as kidney damage, and, according to one... 

CTC is considered the safest procedure for imaging of the whole colon. Despite this, a few cases of colonic perforation have been described in the literature. The initial two cases have been reported in patients with ulcerative colitis and an obstructive lesion of the recto-sigmoid junction (Coady-Fariborzian et al. 2004 Kamar et al. 2004) recently, perforation following CTC has been reported in a subject without known colonic disease (Young et al. 2006). 

In conclusion, CTC is a very safe procedure, but colonic perforation may occur, especially in symptomatic and elderly patients, particularly if they carry a risk condition known to hinder the free passage of air towards the proximal colon segments. 

Kamar M, Portnoy O, Bar-Dayan A et al (2004) Actual colonic perforation in virtual colonoscopy report of a case. Dis Colon Rectum 47 1490-1491... 

Sosna J, Blachar A, Amitai M et al (2006) Colonic perforation at CT colonography assessment of risk in a multicenter large cohort. Radiology 239 457-463... 

At the time of writing, the authors are aware of only one commercially available device specifically designed for colonic insufflation (Fig. 5.5, Protocol colon insufflation system, E-Z-EM Inc, Westbury, NY, USA). This system electronically controls the flow rate of carbon dioxide increasing over time in a step wise fashion from 1 to 3 L/min to prevent spasm (1 L/min for the first 0.5 L, 2 L/min from 0.5 to 1.0 L, and then 3.0 L/min thereafter). The total volume of gas administered is displayed continuously and, if intracolonic pressure (measured at the rectal catheter tip) increases beyond the limit set by the user (up to a maximum of 25 mm Hg), the system automatically shuts down to prevent further insufflation and so reduces the risk of colonic perforation. In the latest version, insufflation automatically ceases when a total of 4 L of gas have been administered and then for every 2 L administered beyond this. To recommence insufflation, the operator needs to manually override this additional safety feature by pressing the start button. 

Gastrointestinal Ischemic colitis [56 ], colonic necrosis 58, 59 ], colonic perforation [60 ], and deal perforation [61 ] have again been reported in patients taking sodium polystyrene sulfonate. 

Takeuchi N, Nomura Y, Meda T, lida M, Ohtsuka A, Naba K. Development of colonic perforation during calcium polystyrene sulfonate administration a case report. Case Rep Med 2013 2013 102614. 

In a retrospective study of 26 pyoderma gangrenosum patients treated with MMF, 1 patient died after a sigmoid colon perforation [34 ]. 

Further cases demonstrating the delaying effect of corticosteroids on diagnosis and treatment of colonic perforation have been reported (140 , 132). 

Sterioff, S., Orringer, M. B. and Cameron, J. L. (1974) Colon perforations associated with steroid therapy. Surgery, 75, 56. 

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