VCOM Louisiana Research Day Program Book 2024

Case Studies

45 PERFORATION OF TERMINAL ILEUM SECONDARY TO MUCOSAL DAMAGE OF ENTEROAGGREGATIVE ESCHERICHIA COLI AND TOOTHPICK

Nora Rady, MSc (Oxon), OMS-III; James Parrish, MD; VCOM-Louisiana; Department of Surgery, CHRISTUS St. Frances Cabrini Hospital

Background: Enteroaggregative Escherichia Coli (EAEC) is a common form of E. coli that causes gastroenteritis and diarrhea worldwide. Symptoms of gastroenteritis due to EAEC include watery diarrhea with variable blood and mucus, nausea, and vomiting which can last anywhere from less than seven days to greater than two weeks. This strain utilizes aggregative adherence fimbriae and biofilm formation to attach to the intestinal mucosa and initiate an inflammatory cascade in the gastrointestinal tissue. EAEC has significant destructive effects on the mucosa of the small and large intestine via biofilm formation. Small bowel obstruction (SBO) is a condition that prevents food from moving through the small intestines to continue the digestive process. SBO and perforation due to foreign body is uncommon: 80-90% of foreign objects pass through the gastrointestinal tract without additional intervention, and only 15-35% of ingested and sharp foreign bodies cause perforation. However, this risk of SBO and perforation can increase with pre-existing conditions such as presence of intestinal strictures, inflammation, and/or mucosal ulceration. These conditions can have compounding effects preventing the foreign body from passing through the gastrointestinal tract. Objective: We present a unique case of acute enteritis from Enteroaggregative Escherichia Coli (EAEC) with mucosal ulceration and perforation because of co-ingestion of foreign body and

impaction with presence of stricture in the terminal ileum. As toothpicks are used globally, consumption of toothpicks is rare but perforation of different portions of the gastrointestinal tract including the stomach, ileum, and sigmoid colon have been documented. Presentation of toothpick foreign body obstruction and perforation has been previously observed to mimic other conditions of the gastrointestinal tract presenting initially as conditions such as acute appendicitis and colonic diverticulitis which ultimately were perforations of the terminal ileum and colon respectively. Toothpick perforation of the stomach with accompanying ulcerating gastritis of unknown origin has been documented. However, to our knowledge, intestinal perforation and secondary peritonitis related to EAEC enteric infection with mucosal ulceration and perforation secondary to co ingestion of foreign body with intestinal stricture has not been documented. Methods: A 66-year-old Caucasian male presented with a 2-day history of pain in his left lower quadrant with nausea, vomiting, and diarrhea. Stool PCR was positive for Enteroaggregative Escherichia Coli (EAEC). As the patient was unable to tolerate the oral contrast, an abdominal CT with IV contrast only was performed on admission. The patient was started on intravenous Metronidazole and Ciprofloxacin and placed on a clear liquid diet. An initial diagnosis of acute EAEC gastroenteritis was made. Over the next two days, the patient

was improving while on the IV antibiotics and electrolyte replacement. On day 3 and day 4, the patient had non-bilious, non-bloody emesis throughout each night. A nasogastric (NG) tube was placed to decompress small bowel loops on day 4. Abdominal and pelvis CT on day 5 revealed continued inflammatory changes from the prior CT as well as new findings including a large phlegmon above the dome of the urinary bladder and abscess formation. On day 6, surgical consultation recommended exploratory laparotomy and the patient consented for this procedure. Post operatively, the patient was started on total parenteral nutrition which was weaned with return of bowel function. The patient was discharged to inpatient rehabilitation on day 17. Results: The findings of the laparotomy included small bowel loops with dilated appearance and a linear foreign body was palpable in an inflammatory area of the terminal ileum. The foreign body had protruded through the wall of the small bowel into the mesentery and was grossly consistent with an intact toothpick. The small bowel was transected proximally and distally through healthy, noninflamed bowel resulting in resection of a 32 cm loop of terminal ileum with primary anastomosis. The resected segment of terminal ileum contained two areas of ulceration, one of which is stated to be an area where the perforation occurred. Gross histopathologic examination indicated likely biofilm formation in

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