Enteritis necroticans – megacolon with massive portal venous gas embolization in a patient after malabsorptive bariatric surgery

Dear Editor,
A 70-year old male patient with a history of bariatric surgery performed at age 40 was admitted to our intensive care unit (ICU) in septic shock, with multiple organ failure and advanced abdominal compartment syndrome. Contrast-enhanced abdominal computed tomography demonstrated megacolon with extensive gas embolization in the portal venous system (Figure 1). Emergency laparotomy was performed with resection of the necrotic small intestine and colon (Figure 2). Intraoperative transection of small mesenteric veins showed massive gas leakage (video provided in supplement). Microbiological samples revealed Clostridium perfringens (CP) infection. This severe CP manifestation is referred to as enteritis necroticans (EN), in which CP exotoxins cause extensive intestinal and vascular necrosis, submucosal hemorrhage, as well as edema and bleeding in the muscularis propria [1]. Importantly, trypsin typically cleaves CP exotoxins into inactive products. Enteritis necroticans is mostly observed in protein-deprived populations in Papua New Guinea, in which trypsin inhibition is caused by extensive consumption of sweet potatoes with EN induced after ingestion of uncooked pork meat at ceremonial festivals (known as “pigbel disease”) [2]. In our ICU patient, potential trypsin deficiency due to malabsorptive bariatric surgery (distal common channel 25 cm) [3] and a reported particularly high protein diet may have promoted development of this life-threatening clinical finding [4].

ACKNOWLEDGEMENTS

1. Conflict of interest: none.
2. Source of funding: none.

REFERENCES

1. Miclard J, van Baarlen J, Wyder M, Grabscheid B, Posthaus H. Clostridium perfringens beta-toxin binding to vascular endothelial cells in a human case of enteritis necroticans. J Med Microbiol 2009; 58 (Pt 6): 826-828. doi: 10.1099/jmm.0.008060-0.
2. Murrell TG, Walker PD. The pigbel story of Papua New Guinea. Trans R Soc Trop Med Hyg 1991; 85: 119-122. doi: 10.1016/0035-9203(91)90183-y.
3. Jüllig M, Yip S, Xu A, et al. Lower fetuin-A, retinol binding protein 4 and several metabolites after gastric bypass compared to sleeve gastrectomy in patients with type 2 diabetes. PLoS One 2014; 9: e96489. doi: 10.1371/journal.pone.0096489.
4. Millar JS, Smellie S, Coldman AJ. Meat consumption as a risk factor in enteritis necroticans. Int J Epidemiol 1985; 14: 318-321. doi: 10.1093/ije/14.2.318.


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