A 69-year-old woman with a history of Type 2 Diabetes Mellitus and medical nephropathy was hospitalized for acute pyelonephritis and received amikacin therapy.
A week after discharge, the patient came to the emergency department with a picture compatible with severe septic shock and was admitted to the intensive care unit, requiring mechanical ventilation and vasoactive drugs.
General tests showed leukocytosis of 29,400 cells/mm3 with left shift, C-reactive protein of 34.1 mg/dL (VN < 5 mg/dL), metabolic acidosis and renal failure in anuria.
Intravenous broad-spectrum antibiotic coverage (vancomycin-metronidazole-meropenem-amikacin) was initiated and computed axial tomography was performed, which showed no inflammatory-infectious pancolitis.
The patient was hemodynamically oriented, had perfused malappositions and abundant fluid (1,000-1,500 mL/day) with positive C. difficile PCR, highly suggestive of NAP and vancomycin via enteral tubes.
The patient was admitted with increased vasoactive drug requirements and high volume hemostasis.
On the fifth day of hospitalization, the patient presented greater hemodynamic deterioration and increased vasoactive drugs (noradrenaline up to 0.7 mcg/kg/min), which was evaluated by the coloproctology team, due to its surgical resolution.
Surgical technique: Periumbilical laparotomy of about 5 centimeters was performed, moderate amount of clear free fluid and extensive pancolitis without ischemic involvement or perforation.
It was decided to perform an intraoperative colonic lavage and ileostomy in the loop derivative, for which a loop of distal ileum was extracted to make the ileostomy.
A small enterotomy was performed at the site of loop maturation, advancing a 24F Foley catheter distally and inflating the cuff inside the cecum with manual assistance through umbilical laparotomy.
A colonic lavage was performed with an 8 % polypharmacy at 7.5% via a Foley catheter. Depositions were collected through a Pezzer catheter during the clear year, until the patient was given the catheter.
The laparotomy was closed and the loop ileostomy was matured as shown in Figure 2.
The patient was stable in the operating room, with the indication of anterograde lavage with vancomycin every 6 h through the Foley catheter (Serum Ringer Lactate 500 ml/vancomycin) 500 mg and intravenous metronidazole 1 hour.
1.
At 48 h postoperatively, the patient was extubated, vasoactive drugs were discontinued and spontaneous diuresis was started.
She was admitted with fluids on the third day, and had an uneventful postoperative period, except for a urinary tract infection that was treated.
Colonoscopic control at discharge showed resolution of pseudomelanoma colitis.
The patient was discharged without incidents and without recurrence of ileostomy in outpatient controls.
