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Clostridial Necrotizing Enteritis

(Enteritis Necroticans; Pigbel; Darmbrand)

By Joseph R. Lentino, MD, PhD, Chief, Infectious Disease Section and Professor of Medicine, Loyola University Medical Center

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Clostridial necrotizing enteritis is necrotizing inflammation of the jejunum and ileum caused by Clostridium perfringens.

Clostridial necrotizing enteritis is a mild to severe clostridial infection, which can be fatal if not treated promptly.

C. perfringens type C occasionally causes severe inflammatory disease in the small bowel (primarily, the jejunum). Disease is caused by clostridial β-toxin, which is very sensitive to proteolytic enzymes and is inactivated by normal cooking. Inflammation is segmental, involving small or large patches with varying degrees of hemorrhage and necrosis. Perforation may occur.

Disease occurs primarily in populations with multiple risk factors, including the following:

  • Protein deprivation (causing inadequate synthesis of protease enzymes)

  • Poor food hygiene

  • Episodic meat feasting

  • Staple diets containing trypsin inhibitors (eg, sweet potatoes)

  • Ascaris infestation (these parasites secrete a trypsin inhibitor)

These factors are typically present collectively only in the hinterlands of New Guinea and parts of Africa, Central and South America, and Asia. In New Guinea, the disease is known as pigbel and is usually spread through contaminated pork, other meats, and perhaps peanuts.

Severity varies from mild diarrhea to a fulminant course of severe abdominal pain, vomiting, bloody stool, septic shock, and sometimes death within 24 h.

Diagnosis of clostridial necrotizing enteritis is based on clinical presentation plus toxin in stool.

Treatment of clostridial necrotizing enteritis is with antibiotics (penicillin G, metronidazole). Perhaps 50% of seriously ill patients require surgery for perforation, persistent intestinal obstruction, or failure to respond to antibiotics. An experimental toxoid vaccine has been used successfully in endemic areas but is not available commercially.

Neutropenic enterocolitis (typhlitis)

This similar life-threatening syndrome develops in the cecum of neutropenic patients (eg, those with leukemia or receiving cancer chemotherapy). It may be associated with sepsis due to C. septicum.

Symptoms are fever, abdominal pain, GI bleeding, and diarrhea.

Diagnosis of neutropenic enterocolitis is based on symptoms, the presence of severe neutropenia, and results of abdominal CT and blood and stool cultures and toxin tests.

Neutropenic enterocolitis must be distinguished from C. difficile–induced diarrhea, graft-vs-host disease, and colitis due to cytomegalovirus.

Treatment of neutropenic enterocolitis is with antibiotics, but surgery may be necessary.

Neonatal necrotizing enterocolitis

Neonatal necrotizing enterocolitis, which occurs in neonatal ICUs, may be caused by C. perfringens, C. butyricum, or C. difficile, although the role of these organisms needs further study.

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