Phlegmonous colitis: another source of sepsis in cirrhotic patients?

A 43 year-old alcoholic male presented at the Emergency Department with diffuse abdominal pain. The patient had been previously diagnosed with Child C cirrhosis, and suffered one prior episode of upper GI bleeding. On admission, the patient was hemodynamically stable, with a distended and diffusely painful abdomen, but no signs of peritonitis. Blood tests showed a mild inflammatory syndrome. CT scan revealed a liver with cirrhotic aspect, as well as all classical signs of portal hypertension, including ascites, splenomegaly and repermeabilization of the umbilical vein. There was a marked thickening of the large bowel, predominantly on the ascending and transverse colon (Figure 1). Hemocultures were positive for Enterococcus faecalis, and the initial antibiotic regimen, consisting of ceftriaxone and metronidazole IV, was replaced by ertapenem 1 × 1 G/day IV. The patient did well and was discharged home ten days after his admission.

A 70 year-old male presented at the Emergency Department with acute abdominal pain and hypotension. Medical history was positive for Child B cirrhosis, hepatitis C, oesophageal varices, and diabetes; he previously suffered one episode of right colitis of unknown origin that responded well to a treatment of ceftriaxone and metronidazole. On admission, the patient was acutely ill, with a severe inflammatory syndrome, and was transferred to the Intensive Care Unit for resuscitation. CT scan showed a cirrhotic liver, ascites in low quantity, and an aspect of pancolitis with a thickened and oedematous wall (Figure 2). Hemocultures were positive for Enterococcus and Streptococcus bovis. The patient was treated with a combination of amoxicilline-clavulanic acid and gentamicine, with rapid improvement in both clinical and biological signs of inflammation. The patient was discharged on day 15 after his admission.

A 69-year-old alcoholic male was admitted for abdominal pain, associated with diarrhoea and hematochezia. The patient was also known for cirrhosis and type II diabetes. On admission, the patient was in poor condition and presented with peritonitis associated with hypotension, acute renal failure and sepsis. The patient was transferred to the intensive care unit for resuscitation and IV antibiotics (ceftriaxone and metronidazole) were administered. CT scan of the abdomen showed, in addition to cirrhotic liver, a marked thickening of the whole colon with infiltration of the peri-colic fat, and ascites in low quantity. 24 hours after admission, the patient developed increased abdominal pain associated with a septic shock and was taken to the operating room. At surgery, the colon was thick, indurated and congestive; lesions predominated within the ascending colon (Figure 3). A total colectomy with terminal ileostomy and a hepatic biopsy were performed. Histopathology examination of the surgical specimen revealed: 1) disseminated erosions/ulcerations of the colonic mucosa (Figure 4); 2) multiple micro-abscesses located in the sub-mucosa in association with polynuclear infiltration, and 3) a vasculopathy characterized by venous ectasias and numerous venous thrombi (Figure 5). The hepatic biopsy showed an important cirrhotic alteration of the parenchyma with fresh thrombosis of the branches of the portal vein. One week after surgery, the patient developed multiple organ failure and died. Preoperative culture of ascites came back positive for Pepto-streptococcus.