Intestinal necrosis and perforation in patients receiving immunosuppressive drugs.

Immunosuppressive agents are frequently used in transplant recipients for prevention of homograft rejection and in patients with leukemia for treatment of their primary disease. From 1973 to 1975, fifty-nine patients undergoing renal transplantation and forty-one patients with leukemia were treated at the University of California (Davis) Medical Center. Intestinal necrosis and perforation developed in four (7 per cent) of those receiving transplants and in four (10 per cent) of the patients with leukemia. One transplant receipient and all four patients with leukemia had extensive necrosis of both the small and large intestines. Two transplant recipients had isolated sigmoid perforations, and one had splenic flexure colonic perforation. All died from septicemia with septic shock. The etiology of these intestinal complication appears related to immunosuppressive agents, particularly high dosages of steroids. Despite the grave prognosis, early surgical intervention is the only method of dealing with these complications. Early diagnosis as well as properly timed and selected operations are necessary for the successful management of these patients.

Gastric necrosis from blunt abdominal trauma.

Two patients with ischemic necrosis of a portion of the gastric wall resulting from blunt abdominal trauma are reported. This gastric injury results from avulsion of the mesentery from the injured area or from a shearing force. Careful inspection of the stomach during exploration is emphasized and gastrotomy advocated if injury is suspected. Treatment consists of resection of the ischemic portion of the stomach.

Antiperistaltic bowel segment for prevention of ileoproctostomy diarrhea.

Persistent diarrhea accompanied by water, electrolyte, and nutritional depletion and skin excoriation can occur following subtotal colectomy with ileoproctostomy. Attempting to improve the course of these patients, an experimental study using dogs was undertaken to evaluate the use of antiperistaltic ileal segment in the management of ileoproctostomy diarrhea. Subtotal colectomy with ileoproctostomy was performed in dogs. One animal died from weight loss and massive diarrhea with water and electrolyte depletion. The surviving dogs had water and electrolyte imbalance and lost an average of 30.6% of their body weight. A second group of animals was treated identically except that an antiperistaltic ileal segment was placed one foot proximal to ileorectal anastomosis. These dogs maintained their weight and electrolyte and water balance. The stools of these animals became solid, as opposed to the watery diarrhea of the animals with ileoproctostomy only. Ileoproctostomy diarrhea can be successfully controlled by the use of antiperistaltic ileal segment.