Pigbel disease, [s8]necrotizing enteritis, necrotizing jejunitis, enteritis necroticans

Like typhoid fever, pigbel is much more common in the tropics, but is occasionally seen elsewhere. It is due to the beta toxins of types B and C Clostridium perfringens, which multiply in the gut following a large meal, classically a feast of pork. This gives the disease its New Guinea name ''Pigbel', where it was at one time the commonest condition requiring laparotomy. If you have to resect gut, a patient's chances of death are about 50%.

He is usually a child, or a young adult, who presents with: (1) Acute toxic shock. (2) Severe colicky abdominal pain and vomiting. (3) Constipation with foul flatus, followed by bloody diarrhoea. (4) Vomiting, diarrhoea, and abdominal pain; the diarrhoea stops, but vomiting continues, and his abdomen distends. (5) An obscure abdominal illness, ending in a pelvic abscess that is the result of a perforation. (6) Rectal bleeding (22.3).

Typically, his abdomen distends and is tender all over, sometimes with a soft mass above his umbilicus. He is ill and may have a high fever.

PIGBEL X-RAYS in the erect position show that the patient has multiple fluid levels, with gas in his large gut down to his rectum.

SPECIAL TESTS. He has a leucocytosis (unlike the leucopenia of typhoid). An abdominal tap may reveal bloody peritoneal fluid (66-3).

DIFFERENTIAL DIAGNOSIS. The presence of a mass and bloody stools may lead you to suspect intussusception (10.8).

NON-OPERATIVE TREATMENT often succeeds. Resuscitate him. Pass a nasogastric tube and give him large doses of penicillin.

INDICATIONS FOR LAPAROTOMY. (1) Failure to improve, or deterioration on non-operative treatment. (2) Signs of peritonitis, and persistently large volumes of gastric aspirate.

LAPAROTOMY. You may see the disease at any stage in its development. It usually only involves his small gut, but it may involve his distal stomach, or his large gut.

Classically, several loops of his small gut, from near his duodenal flexure onwards, are acutely inflamed, oedematous, and congested, often with localized necrotic areas mostly on the antemesenteric border, with a sharp line of demarcation between normal and diseased areas. There may be perforations, localized abscesses, and multiple adhesions causing partial obstruction. The necrotic areas are usually separate, but may occasionally extend from his distal stomach to his sigmoid colon. His mesenteric artery is patent, and you can feel pulsation down to the terminal arterioles at the margin of the affected gut. His regional nodes are enlarged, and may be necrotic.

If any gut is non-viable (9.3), resect it with an adequate margin of healthy gut, so that the blood supply to the area of the anastomosis is adequate. Drain abscesses. If you have removed a considerable length of his small gut, follow him up carefully, and treat any small-gut deficiency that he may develop.

If you decide to leave inflamed but not obviously necrotic gut, and he later deteriorates, do a second laparotomy, and resect any gangrenous gut.

Fig. 31-10 INVASIVE AMOEBIASIS. A, an amoeboma of the skin secondary to a liver abscess. B, the caecum and ascending colon with amoebic ulcers. C, [f10]Entamoeba histolytica. [f11]D, an amoebic stool with trophozoites, red cells, and Charcot Leyden crystals. A, after Charles Bowesman, ''Surgery and Clinical Pathology in the Tropics', E and S Livingstone. With kind permission.