BRI EF COMMUN ICATION Severe bleeding from 'diversion pouchitis' Cl IRIST OPI IHl H EUt,I IAN, M R, RCI II R, FRCS( ', J •\Mb R,\RRl1W~l t\N, M R, r, I D, mer e, WII LI AM G Pt)LLJ Tr, MD, FRCSC ABSTRACT: A patie nt suffered seve re bleeding from a <l cf un ctione<l il ea l p ouch. Although chi has not been descrih e<l before, it may become more r rcva lenr ,ts more pau enc:. h ave ilea! po uches co preserv e anal f un c tio n. Th e p oss ible causes and a possible way of avo iding this cata strop he in the fULur c are J,sc us,ed. C an J Gastroe nterol l 990; 4(8):495-496 Key Words: Bleedmg, Il ea! po11ch Hemorragie grave provenant d'une 'pouchite de de tourneme nt ' RESUME: Un pat ie nt a souffe rc d' un e hcmorrngie grave res ul ta nt d' un rc:.ervo ir ilea! "dcsa ff cc te". Bien qu e le ph enomcne n'a il pas encore cte dcc ril , ii SC peut qu'il se pmJuise plus souvent avec le nombre gran<lissant Je patienb ayant Jes r esc rvmrs il caux af in J e conserver la fonction an ale. Le prese nt art ic le exa min e b causes possibles J e ce tte catas trophe et un e fo ~on de l' ev iter a l' ave nir. A 3 5-Y EA R-Ol l) M AN WITI I PROVEN ulcerati ve col ni s unJ crwenc a ,u htocal colec tomy anJ ilem tomy fo r ,1 tox ic mcgacol on in August 1987. In November 19 88, he underwent mucosa! pmct ec wm y wnh constru c- uon of an ilea! ' S' pouch and a Lem- porary l oop ilern,tom y. Recovery was un compli ca ted apart from d f eve r and so me drainage per rec tum which set tle<l on anuhioti cs. T h e ra t ie nt was reaJ - m1 tteJ and h is deo tomy closed in June 1989. He was read mmed 10 J a ys la te r hccm,se of severe diarr hea. This se ul ed He alth Sc ien ces C.? nr re, SrJohn·.,, N< ·wf,1 wull und C orresponde nce a nd re/ 1rint 1: /Jr C hn 1wp/1er HeuRlum, /Jc/1a rr ml'nr of Sur,c:cn, I ll'alrh S.lt'Tlces Centrt!, Sr John \. Newfmmdlnnd A 1H lV6 Tdt!/ihone (7tN) 737 6'i'i8 R ecewed for publ1ca11011 Jullt' 13. 1990. Acn:/>recl J une 25. /990 C\\ J GASTROENTERt)L VOL 4 No 8 NOVl: ~lllER/ Dn I MBl,R l 990 rap idly on lo peram1de (l mo dium; Jan sse n Ph ,irm ace uti L, t) and an ult rasound showed no evi den ce of pel- v ic absc ess. T hree month , l at er, in Se ptember 1989, he was ,1ga 111 adm ,ued hcca u,e of we igh t loss, di, irrh ca a nd poor an al u >n - tro l. On thi s oc rn ,io n, exa mina uon revealed a ,tnu urc at the site of I he dco,inal anas tomosis togeth er with an area of disrupt 10n of the anastom(hb. A n a no r l,tsty 11•a , performed hut rhe diar rh ea, m co n1 men cc and a na l ex- c11 ria1 io n c o n t in ued des pit e met ro- n1d amle and a nt1d1arrh eal ,tge nt,. Accordmg ly , a terminal ileosromy was performed in O c tober 1989. T he proximal e nJ of rhe pouch was closeJ , mJ left 111 th e abdo men wn h a view to re -establishing th e il ea l pouch a ft er the ana stomos is had healed. T he rau e nr recovered unev emfully and wa, d1 sch mged ho me in Oc wber 1 989 I le remain ed we ll 1111111 Janua ry 1990 whL ·n he was re admitted w 1t h sev er e ble eding pe r an um requmng seven un ib of frL ·, h wh 11 le blood 111 the u m1mun1t y ho, pn al where the fam il y 495
Transcript
BRIEF COMMUNICATION
Severe bleeding from 'diversion pouchitis'
Cl IRISTOPI IHl H EUt,I IAN, M R, RCI IIR, FRCS( ', J •\Mb R,\RRl1W~l t\N, M R, r, ID, mere, WII LIAM G Pt)LLJ Tr, MD, FRCSC
ABSTRACT: A patient suffe red severe bleed ing from a <lcfunctione<l ileal pouch. Although ch i has not been descrihe<l before, it may become more r rcvalenr ,ts more pau enc:. have ilea! pouc hes co preserve ana l function . The possible causes and a possible way of avoiding this catastrophe in the fULurc are J,scus,ed. Can J G astroenterol l 990;4(8):495-496
Key Words: Bleedmg, Ilea! po11ch
Hemorragie grave provenant d'une 'pouchite de detournement'
RESUME: Un pat ient a soufferc d 'une hcmorrngie grave resultant d 'un rc:.ervoir ilea! "dcsaffccte". Bien que le phenomc ne n'a il pas encore cte dccril , ii SC peut qu'il se pmJuise plus souvent avec le nombre gran<l issant J e pat ie nb ayant Jes rescrvmrs ilcaux afin J e conserver la fonc t ion anale. Le present art ic le examine b causes possibles J e cette catastrophe et une fo~on de l'eviter a l'avenir.
A 35-YEAR-Oll) MAN WITI I PROVEN
ulcerative co lnis unJcrwe nc a ,uhtocal colectomy anJ ilem tomy for ,1 toxic mcgacolon in A ugust 1987.
In November 1988, he unde rwent mucosa! pmctecwmy wnh construcuon of an ilea! 'S' pouch and a Le m-
porary loop ilern,tomy. Recovery was uncomplicated apart from d fever and some drainage pe r rectum which settle<l on anuhiotics. T he ra t ient was reaJm1tteJ and h is deo tomy closed in June 1989. He was read mmed 10 J ays later hccm,se of se vere diarrhea . This se uled
Health Sciences C.?nrre, Sr John·.,, N<·wf,1wullund Correspondence and re/1rint1: /Jr Chn1wp/1er HeuRlum, /Jc/1arrml'nr of Sur,c:cn, I ll'alrh
S.lt'Tlces Centrt!, Sr John \. Newfmmdlnnd A 1H lV6 Tdt!/ihone (7tN) 737 6'i'i8 Recewed for publ1ca11011 Jullt' 13. 1990. Acn:/>recl June 25. /990
C\\ J GASTROENTERt)L VOL 4 No 8 NOVl:~lllER/Dn I MBl,R l 990
rap idly on lo peram1de (l modium; J a n sse n Ph,irm ace ut iL,t) and a n ultrasound showed no evidence of pelvic abscess.
T hree month, later, in September 1989, he was ,1ga111 adm ,u ed hccau,e of we igh t loss, di ,irrhca and poor anal u >nt ro l. O n this ocrn,ion, examinau on revealed a , tn u urc at the site of I he dco,inal anastomosis toge ther with an area of d isrupt 10n of the anastom(hb. A n anor l,tsty 11•a , perfo rmed hut rhe d iarrhea , mcon1 mencc a nd anal exc11 ria1 io n co nt inued despite me tron1damle and a nt1d1arrheal ,tgent,.
Accordmgly, a terminal ileosromy was performed in O ctober 1989. T he proximal enJ of rhe pouch was closeJ ,mJ left 111 the abdomen wnh a view to
re-establishing the ileal pouch aft er the anastomosis had hea led.
T he rauenr recovered unevemfull y and wa, d1schmged home in Ocwber 1989 I le remained we ll 1111111 January 1990 whL·n he was readmitted w 1t h severe bleeding per anum requmng seven unib of frL·,h wh11 le blood 111 the u m1mun1t y ho, pna l where the fam il y
495
I IEUGI-I/\N er a/
physician haJ a lso applied pneumm ic
ant ishock t rousers and placed a Fnlcy
catheter in his rectum to try, without
success, to tampo nade the bleeding.
Aft er transfer, his pubc was l 00
beat~/min , hkxx.l pre&>ure 100/60 mmHg,
and hemoglobin 108 g/J L. There wn~ a
tender mass in the lower abdomen . A steady flow ofblooJ was coming around
the catheter in the a nal cana l.
A rigid s igmoidoscopy was ,it
tempted but the v iew was obscured hy a
mass of blood clot in the ilea! pouch.
T h e anal stric ture would not permit passage of the instrument.
The patient underwent a laparo
tomy when a mass of clot in the pelvis
was evacuated. The serosal surface of
the ilea! pouch appe.ired granular and
wa, bleeding. The pouc h was excised
per abdomen leaving the anus inrnct. His ileostomy, which had receded, wa~
rev ised.
The patient receiveJ a total of 13
units of packed red cells, rwn units of
fresh frozen plasnrn anJ large volumes of
c rysra llo iJ during the pe riopernt ive
perioJ . He maJe an uncomplicat ed
recovery ,and wa, di~charged home o n
t he 10th poswpcrative day.
PATHOLOGY A review of the patho logy of chc
origin a l total colectomy confi rmed
acute inflammat ion confined to the mucnsa and submucosa, consiste nt with
ulcerat ive co lit is. Aerobic and a n
aernhic c ult ures fro m the excised pouch taken during surgery were negat ive.
The excised po uc h showed s uh-
REFERENCES I . Luukkonen P, Valtom:n V, Sivontn A,
Sipponcn P. Jarvinen 11. Fecal bacccriology anJ reservoir ileitis in patient, operated on for ukeranve colitis. Di, Colon Rectum 1988; 11 :864-7.
2. G lntzcr DJ, C lick ME, (JOloman 11. Pmctiti, Hnd colitis fo llowing cliversion of rhe fecal , trcam. Ga,tmentenilogy
496
mucosa I edema and nonspeci fi c infla m
matory ch ange ch rough,)ut the howcl wall a nd congestion and hemorrhage in
the sernsa.
DISCUSSION T h ere is, co th e author~' knowledge,
no previou~ description o( ~eve re hi ced
ing fro m a defunctioned ilea! pouch.
The cause of the blccJing which (lC·
curred both in to the lumen and from
the serosa l surface in this patient is not
c lear.
Examination of the excised pouch
showed inflammation th roughout che th icknessof the ilea! wall. However, the
other featu res were not suggest ive of Crohn 's disease and a rev iew of the
origina l colonic patho logy did no t s ug
ges t anything other than ulcerative
cnl it is.
Pouch iris is a well-recognized entity
but its cause is obscure. Altho ugh there
is a ch tm ge in the !um inal flora fo llow
ing conversio n of ileum to a reservoir
,md a l though pouchiti~ responds to
trea tment with mctronid azole, the re
appear to be no d ifference~ in flora be
t ween pouc hes of patients with t he
clinica l syndrome o f pouchiti~ a nd
chose with out (I). Furthermore, n,1
descriptions could be found in the licc racurc of heavy bleeding caused by
pouchi tis.
Diversio n coli t is h as been described as affect ing defunctioncd recrnl stumps
after Hartmann's o perat ion (2). A l
though the histology is sim ilar to thm
of ulcerative colitis (2-4), it docs not
respond to treatment with steroids (3).
1981;80:438-41. 1. Kl>rclitz Bl, Chcskin LJ, Suhn N,
Sommer, SC. The fate of the rccrnl ~cgmcnt after diversiun uf the foca l stream in C rohn's disease: Its imrlication, for surgical management. J C lin G.1,tmcntcrnl 1985;7:37-45.
4. l lm1s PA, Fox TA. The fote of the forgmten rectal pouch after I lartmann's
The re is no ch an ge in flnr:1 which correlates with the cl inica l comli1ion nf diversio n colitis which may occur after colectomy for tumour, diverticular Jis
easc o r functiona l bowel d iscase ( 2) as well as for in flammatory howel disease.
Gross bleeding may occur from diwr
sion colitis (5). It has been suggested recently I hat
diversion colitis may be Jue to a diwr
sion of nutrients normally present m the feca l stream since the condition 1s
improved by irrigation wirh short cham
fatty acids (6). If thb is so, it would he rcason::ih lc ro speculate that a defuncti,m ed ilea! po uc h may he similarly
prone to acute infec tio n caused by nnrmally h armless organisms (6) wlH:n
deprived of adequa te lum1na l nutrients.
Di version ileiti s has n ot hccn
Jc ·cribed in patients with a pouch who arc await ing routine closure o( their
ilcoscomy. This may he due tn I he rda
ci vcl y short t ime during which the
pouch is not in the fcc;i l stream . Alter·
native ly, it may he that a loop ilcosromy
permits passage of enough material into
the dista l limh to keep the pouch m
reasonable health. A lrhough chis report i~ o( an isolated
case, it seems possible that, if the cur
ren cl y fashionable be l ief that a
functio ning anus is necessary fo r social
and psycho logica l wel l-being persist.,,
more cases of life threa tening hlce<l1ng 1m1y occur. If a pouch is o ur o f che fee;1I
5. Ona FV, Ro~er JN. Rectal hlcedini.: duo.: 10 Jivcr,1011 coliw,. Am J G,1,rrocnterol i 985;80:40- l .
6. 1-larigJM, Soergel Kl I, Krnnorow,ki RA, Wood CM. Trcni menr nf di ver· ,ion colitb with shon-cha111 fony aciJ im gar1on. N Engl J Med I 989;320:23-8.
C/\N J G/\STRtWNTFROL Vt)L 4 Nn 8 NllVtMIIER/Dt:CEMIIER 1990
