Overview.
Cholera-like syndrome, now more commonly referred to as pseudomembranous enteritis, is an acute necrotizing inflammation of the mucosa with pseudomembrane coating that occurs primarily in the colon. It is a common complication following antibiotic therapy and is therefore a medical complication. It has been shown to be caused by toxins from Clostridium difficile and can be fatal in severe cases.
Etiology
The syndrome is thought to be caused by Clostridium difficile infection, and can be triggered by trauma, surgery, stress, and the use of broad-spectrum antibiotics in some seriously ill patients. The exotoxin produced by Clostridium difficile can cause intravascular coagulation, thrombosis, necrosis and even perforation of the intestinal wall; and the toxin stimulates the cAMP system in the epithelial cells of the mucous membranes, causing cholera-like symptoms.
Symptoms
Fever, nausea, abdominal pain, abdominal distension, massive diarrhea, green seawater-like or yellow egg-like loose stools, shedding of pseudomembranes; after diarrhea, abdominal distension is reduced, pulse rate increases, blood pressure decreases, shortness of breath, signs of dehydration, confusion, abdominal pressure, abdominal muscle tension, intestinal distension and intestinal sounds are weakened.
The onset of this disease is mostly in the age group of 50 to 59 years old, women slightly more than men, the onset of most of the acute, light cases only mild diarrhea, heavy cases can be violent, rapid progression of the disease.
1. Diarrhea
Diarrhea is the most important symptom, which occurs within 4 to 10 days after the application of antibiotics, 1 to 2 weeks after the discontinuation of antibiotics, or 5 to 20 days after surgery. The degree and frequency of diarrhea varies, light cases, stools 2-3 times a day, can be self-cured after stopping antibiotics; heavy cases have a large amount of diarrhea, stools can be more than 30 times a day, and sometimes diarrhea can last for 4-5 weeks, a small number of cases can be discharged plaque pseudomembrane, bloody feces is rare.
2. Abdominal pain
Abdominal pain is a common symptom, sometimes very severe, accompanied by abdominal distension, nausea, vomiting, which can be misdiagnosed as acute abdomen, surgical anastomosis leakage.
3. Toxemia
The symptoms of toxemia include tachycardia, fever, delirium, and disorientation. In severe cases, hypotension, shock, severe dehydration, electrolyte imbalance, metabolic acidosis, oliguria and even acute renal insufficiency may occur.
Examination
1. Laboratory examination
The peripheral white blood cell count is increased, with neutrophils predominating. There is hypoalbuminemia, electrolyte imbalance or acid-base imbalance. Fecal bacteria are cultured under special conditions, and Clostridium difficile growth is found in most cases. Fecal cytotoxicity test has a diagnostic value, the filtrate of the patient’s feces is diluted in different multiples and placed in tissue culture to observe the cytotoxic effect, and 1:100 or more has a diagnostic significance. Clostridium perfringens sludge antitoxin neutralization test is often positive.
2. Endoscopy
Timely endoscopy can not only make a clear diagnosis at an early stage, but also understand the scope and extent of the lesion. In mild cases, the mucosa can be seen to be congested and edematous, and the vascular texture is not clear: in slightly severe cases, the mucosa can be seen to be scattered superficial erosion, pseudomembrane speckled distribution, and the periphery is congested; in severe cases, the pseudomembrane can be seen to be patchy or map-like.
3. X-ray examination
Abdominal plain film, barium enema examination.
Diagnosis
This disease should be thought of when there is a sudden appearance of mucus diarrhea without red blood cells during the use of antibiotics or within a short period of time after stopping antibiotics, especially after the application of lincomycin and clindamycin; or when the condition worsens instead after abdominal surgery and diarrhea occurs. Diagnosis can be obtained rapidly by sigmoidoscopy, seeing pseudomembranes and positive cytotoxicity determination in feces. The diagnosis can be confirmed on the basis of history, clinical symptoms and laboratory tests.
Differential diagnosis
Acute necrotizing enterocolitis, inflammatory bowel disease, ischemic bowel disease and cholera should be differentiated.
Complications
Toxic megacolon, paralytic intestinal obstruction, intestinal perforation.
Treatment
1. Immediate discontinuation of all antibacterial drugs
2. Supportive therapy and anti-shock, such as plasma, albumin or whole blood, and timely intravenous replenishment of fluids and potassium salts. The amount of rehydration fluid is decided according to the degree of water loss, or oral glucose saline to compensate for the loss of sodium chloride, to correct electrolyte imbalance and metabolic acidosis. If there is hypotension, vasoactive drugs can be used on the basis of blood volume supplementation.
3.Mirex Mirex is the preferred therapeutic drug for this disease, the general use is 3 to 4 times a day, oral 7 to 10 days, the vast majority of patients with a good response to treatment, fever and diarrhea can be relieved in 2 days after the use of the drug, diarrhea usually disappears within a week, the feces can not be detected in the treatment of toxin B in the first 72 hours. frequent vomiting in severe cases can be used to intravenous drip method of administration of the drug, but the effectiveness of treatment is significantly lower than that of oral method of delivery of the drug. Alcohol should be abstained from during administration.
4. Vancomycin Vancomycin used to be the mainstay of the disease, but vancomycin has a similar efficacy and relapse rate as methotrexate. Vancomycin is expensive and is no longer used as a first-line drug for this disease. Vancomycin is not absorbed orally, has no damage to the kidneys, and can reach high concentrations in the intestines, and low concentrations in the intestines for intravenous use are not suitable. In mirex after side effects or recurrence of patients, available vancomycin treatment, the general use of oral 4 times a day, a total of 7 to 10 days.
5. Mycopeptide Mycopeptide has antimicrobial effect on gram-positive bacteria, can be used for this disease, 4 times a day orally for 7-10 days, symptomatic relief is the same as vancomycin, in the elimination of fecal pathogens is not as good as vancomycin. The incidence of nephrotoxicity and ototoxicity of bacillus peptide is high should not be injected with the drug, but the oral method has not been found side effects.
6. Other treatments Cholestyramine 3 to 4 times a day, a total of 7 to 10 days. This drug can combine with the toxin, reduce the absorption of toxin, promote the absorption of bile salts at the end of the ileum to improve the symptoms of diarrhea. The application of specific antitoxin treatment has been reported abroad. To restore normal intestinal flora, mild cases are allowed to recover on their own after discontinuing antibiotics. In severe cases, oral lactobacillus preparations (such as lactasexan), vitamin C, as well as lactose, honey, maltose, etc. to support the cultivation of E. coli; oral folic acid, vitamin B complex, glutamic acid and vitamin B12 to support the cultivation of enterococci.
If the case is an outbreak, the internal medicine treatment is ineffective, and the lesion is mainly in the colon, or there is significant intestinal obstruction, toxic megacolon, and intestinal perforation, colon resection or diversionary ileostomy can be considered, which is effective.