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LETTERS: Mark Battle, Lara Teare, Sue Law, Jamie Fulton, John Beckly, Stephen Lewis, A L D'Souza, C Rajkumar, J Cooke, and C J Bulpitt Probiotics and antibiotic associated diarrhoea BMJ 2002; 325: 901b [Full text]

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Gut mucosal ischaemia: the precipitating event?

Richard G Fiddian-Green   (20 October 2002)

Gut mucosal ischaemia: the precipitating event? 20 October 2002
Richard G Fiddian-Green, None None Send response to journal: Re: Gut mucosal ischaemia: the precipitating event?	Although I have had a busy surgical practice confined to the management of gastrointestinal diseases in tertiary referral centers in the US I have yet to see a case of “C difficile colitis”. The same applies to the "irritable bowel syndrome" (1). As most of my cases were referred to me by gastroenterologists this experience might have been the product of my seeing a skewed distribution of cases. I think not. There was said to have been a rash of C difficile colitides in the community hospitals, when for a brief period I was chief of surgery at the Brooklyn VA, one of which precipitated had a emergency colectomy. Upon assuming my position I inherited responsibility for management of this patient, who was still intubated and not doing well. I was able to document radiographically that he had an ischaemic stricture with “thumb printing” of the mucosa in the terminal 25 cms of bowel that had been brought out as a diverting ostomy. I had to re-operate to remove the ischaemic segment. It occurred to me then that gut mucosal ischaemia might be a prerequisite for developing any pathological consequences from the anaerobic organism C difficile and thus the cause of “C difficile colitis” (2-11). The superficial surface of the gut mucosa is relatively hypoxic because of the counter current exchange of oxygen in the mucosal blood vessels. It is the first part of the body to be compromised in hypovolaemia and cardiac failure. The passage of liquid stool is its first and most common clinical manifestation. The development of haemorrhagic mucosa and the passage of blood stained stool is the product of reperfusion injury and a later manifestation. I would presume that mucosa rendered ischaemic by these means might be more susceptible to damage by the toxins of some anaerobic organisms, notably C difficle, than others. Lipopolysaccharide, which is present in many gram negative organisms in the gut notably E coli, might compound the problem by releasing cytokines which appear to uncouple oxidative phosphorylation. As Beckly and Lewis observe “only 10-25% of antibiotic associated diarrhoea is caused by infection with C difficile, and infections are most commonly seen in elderly people”. Occlusive mesenteric vascular disease, which may increase the susceptibility of gut mucosa to hypovolaemia or cardiac failure, is especially common in the elderly. Dehydration is the most likely precipitating event in the development of ischaemic mucosa in the elderly, chronic mesenteric vascular insufficiency and gut organisms being secondary pathogenetic mechanisms. The primary therapeutic implications of this pathogenetic scenario is to avoid hypovolaemia from dehydration and possibly to consider gut lavage, rather than probiotics, to cleanse the bowel and limit the possibility of endotoxin translocation and a systemic impairment of oxygen uptake and utilisation (10,11). Diverting loop ileostomy and colonic lavage has reduced the mortality from fulminant amoebic colitis from some 60% top 89% to 5% (12).The beneficial effect appears to be exclusively due to its effect upon translocation for the nectroic gut remains in situ and is resected as a fibrotic remnant after recovery from the acute illness. 1. Fiddian-Green RG. Organic causes of the "irritable bowel syndrome". bmj.com/cgi/eletters/325/7364/555#25610, 18 Sep 2002 2. Fiddian-Green RG, Stanley JC, Nostrant T, Phillips D. Chronic gastric ischemia. A cause of abdominal pain or bleeding identified from the presence of gastric mucosal acidosis. J Cardiovasc Surg (Torino). 1989 Sep-Oct;30(5):852-9 3. Fiddian-Green RG. Provocative test for chronic mesenteric ischemia. Am J Gastroenterol. 1992 Apr;87(4):543. 4. Fiddian-Green RG, Amelin PM, Herrmann JB, Arous E, Cutler BS, Schiedler M, Wheeler HB, Baker S. Prediction of the development of sigmoid ischemia on the day of aortic operations. Indirect measurements of intramural pH in the colon. Arch Surg. 1986 Jun;121(6):654-60. 5. Schiedler MG, Cutler BS, Fiddian-Green RG. Sigmoid intramural pH for prediction of ischemic colitis during aortic surgery. A comparison with risk factors and inferior mesenteric artery stump pressures. Arch Surg. 1987 Aug;122(8):881-6. 6. Fiddian-Green RG, Gantz NM. Transient episodes of sigmoid ischemia and their relation to infection from intestinal organisms after abdominal aortic operations. Crit Care Med. 1987 Sep;15(9):835-9. 7. Faries PL, Narula A, Veith FJ, Pomposelli FB Jr, Marsan BU, LoGerfo FW. The use of gastric tonometry in the assessment of celiac artery compression syndrome. Ann Vasc Surg. 2000 Jan;14(1):20-3. 8. Kolkman JJ, Groeneveld AB, van der Berg FG, Rauwerda JA, Meuwissen SG. Increased gastric PCO2 during exercise is indicative of gastric ischaemia: a tonometric study. Gut. 1999 Feb;44(2):163-7 9. Fiddian-Green RG. Functional abdominal pain: a mesenteric vascular disorder? bmj.com/cgi/eletters/325/7366/701#25838, 27 Sep 2002 10. Fiddian-Green RG. Colonic lavage for severe haemorrhagic shock? bmj.com/cgi/eletters/325/7366/674/b#25839, 27 Sep 2002 11. Fiddian-Green RG Gastric lavage for major operations? bmj.com/cgi/eletters/325/7366/674/b#25849, 27 Sep 2002 12. Singh B, Moodley J, Ramdial PK. Fulminant amoebic colitis: a favorable outcome. Int Surg. 2001 Apr-Jun;86(2):77-81.