Necrotizing amebic colitis: a frequently fatal complication.

Acute necrotizing amebic colitis is an uncommon but life threatening development with a high mortality rate, even when properly diagnosed and treated. We report six cases of acute necrotizing amebic colitis, none of which were diagnosed preoperatively. At operation, five of the six patients had friable, necrotic, and gangrenous colon. A right hemicolectomy with ileostomy was performed in two patients and a subtotal colectomy with ileostomy was performed in four patients. Five of the six patients died within 4 weeks of operation. The sole survivor was the patient who had received metronidazole preoperatively. Only after histologic examination of the surgical specimen was the diagnosis made in all cases. If the diagnosis can be made preoperatively and antiamebic therapy instituted, surgical resection may decrease the high mortality rate of this disease.

Hernia of Morgagni in a trauma patient.

A case is presented of a patient with a congenital hernia of Morgagni that was diagnosed after a motorcycle accident. These may be confused with a traumatic diaphragmatic hernia. The lateral chest film is helpful in the differential diagnosis. The barium enema is usually diagnostic.

Angiodysplasia of the colon. A review of 17 cases.

From October 1977 through December 1982, 24 patients with lower gastrointestinal tract hemorrhage were diagnosed by visceral angiography as having angiodysplasia of the colon. Seventeen of them underwent surgery for definitive treatment of their hemorrhage. Five patients had lesions on both sides of the colon, and five had coagulation disorders. Three of the 17 patients with lesions isolated to the cecum underwent right hemicolectomy. The rest underwent subtotal colectomy with ileoproctostomy. No patient had recurrent or persistent bleeding. There were three deaths in the subtotal colectomy group (21%); coagulation disorders contributed to two of them. Subtotal colectomy was universally successful in controlling bleeding but had a significant mortality in these elderly patients. Coagulopathy, especially platelet disorders, was a significant risk factor with this diagnosis. A coagulation panel, including platelet function, should be part of the preoperative assessment.

Severe liver trauma in the face of coagulopathy. A case for temporary packing and early reexploration.

Most liver injuries lend themselves to satisfactory hemostasis and drainage, with or without resectional debridement. A small number of injuries will necessitate massive blood transfusion with clinically significant coagulopathy developing in about half of these patients despite prophylactic infusion of fresh frozen plasma and platelet concentrates. In our experience, after major, discrete arterial and venous vessels are individually ligated, the diffuse ooze from the raw surfaces can be effectively controlled by temporary packing of the liver. Packing provides time for coagulopathy and hypothermia to be corrected and for urgent diagnostic maneuvers to be completed safely. Packs should be removed early (within 24 to 48 hours postoperatively), and surgery performed as indicated by the injury. No intraabdominal abscesses have been encountered among our 12 patients who underwent temporary packing of their liver injuries.

Compartment syndrome after anti-shock trouser use without lower-extremity trauma.

The use of anti-shock trousers is widely advocated for the treatment of hypovolemic shock. Despite its frequent use, few complications have been reported in the medical literature. Although speculation exists that anti-shock trouser application may result in ischemic injury to the lower extremities, this complication has only recently been reported. Our report describes a patient with no lower extremity trauma who developed bilateral anterior and lateral compartment syndromes after the application of anti-shock trousers.

Trauma of the colon: early drop-back of exteriorized repair.

Exteriorized repair of selected colonic injuries has been reported to be successful. Eighty-two colonic injuries were reviewed to determine the indications for primary repair, exteriorized repair, or colostomy and to assess the feasibility of early drop-back of the exteriorized repaired colon. Injuries were graded into three stages: stage 1, good risk; stage 2, moderate risk; and stage 3, bad risk. Sixty-seven percent of patients with stage 1 injuries underwent primary repair, 61% of patients with stage 2 injuries underwent exteriorized repair, and 61% of patients with stage 3 injuries received a colostomy. Of 38 patients who had exteriorized repair, 29 (76%) had their colon successfully dropped back on an average of five days postoperatively. Nine patients had their exteriorized colon converted to a colostomy on an average of 5.5 days postoperatively. The overall mortality was 2.4%; however, the mortality of the patients with exteriorized repair was 0%. Exteriorized repair with early drop-back is safe and economical for most patients with stage 2 injuries and selected patients with stage 3 injuries.