Abstract Background The clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with portal hypertensive colopathy (PHC). Case presentation We report three cirrhotic patients who were admitted with abdominal sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient underwent emergency colectomy for PC, and subsequently died from multiple organ failure. Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration of submucosal blood vessels. Conclusions These data suggest that cirrhotic patients with PHC may progress towards PC, which, in turn, may be the cause for life-threatening sepsis.</p

G Bresci

G Garcia-Tsao

J Mendeloff

Laurent Spahr

M Pfaffli

Pascal Bucher

Pascal Gervaz

Philippe Morel

S Naveau

SH Pang

SP Misra

T Satoh

Thomas Holzer

Thomas McKee

TR Viggiano

English

PubMed

Springer - Publisher Connector

Phlegmonous colitis: another source of sepsis in cirrhotic patients?

BioMed CentralBMC Gastroenterology
ssOpen AcceCase report
Phlegmonous colitis: another source of sepsis in cirrhotic patients?
Thomas Holzer1, Pascal Gervaz*1, Laurent Spahr2, Thomas McKee3, 
Pascal Bucher1 and Philippe Morel1
Address: 1Department of Surgery, Geneva University Hospital and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland, 
2Department of Gastroenterology, Geneva University Hospital and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland and 
3Department of Pathology, Geneva University Hospital and Medical School, 1 rue Michel-Servet, 1211 Geneva, Switzerland
Email: Thomas Holzer - thomas.holzer@hcuge.ch; Pascal Gervaz* - pascal.gervaz@hcuge.ch; Laurent Spahr - laurent.spahr@hcuge.ch; 
Thomas McKee - thomas.mckee@hcuge.ch; Pascal Bucher - pascal.bucher@hcuge.ch; Philippe Morel - philippe.morel@hcuge.ch
* Corresponding author    
Abstract
Background: The clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic
patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with
portal hypertensive colopathy (PHC).
Case presentation: We report three cirrhotic patients who were admitted with abdominal
sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic
alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-
negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient
underwent emergency colectomy for PC, and subsequently died from multiple organ failure.
Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated
micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration
of submucosal blood vessels.
Conclusions: These data suggest that cirrhotic patients with PHC may progress towards PC,
which, in turn, may be the cause for life-threatening sepsis.
Background
Portal hypertension diffusely affects the gastrointestinal
tract, and the colon is no exception; however, portal
hypertensive colopathy (PHC), which was initially
described in the 1990s, is a poorly defined entity [1].
Colonic alterations associated with liver cirrhosis include
a combination of vascular ectasias, mucosal oedema, rec-
tal varices, and hyperemia [2,3]. It is estimated that vascu-
lar ectasias and rectal varices are present in up to 50% of
cirrhotic patients; yet, the risk of clinically significant
colonic bleeding in these patients was inferior to 6% in a
prospective study with a 2-year follow-up period [4].
Thus, despite the fact that colonic lesions are frequent in
cirrhotic patients, and that the fundamental pathologic
change is a vasculopathy, these hemodynamic alterations
are probably not associated with significant risk of lower
gastro intestinal (GI) bleeding.
Phlegmonous colitis (PC) was first recognized in 1975 as
a source of bacteraemia in patients with end-stage liver
disease [5]. In 2009, PC remains almost exclusively an
autopsy finding, and was actually detected post-mortem in
2.5% of patients with cirrhosis: thirteen autopsy cases
showed some or all of the following clinico-pathologic
Published: 15 December 2009
BMC Gastroenterology 2009, 9:94 doi:10.1186/1471-230X-9-94
Received: 30 July 2009
Accepted: 15 December 2009
This article is available from: http://www.biomedcentral.com/1471-230X/9/94
© 2009 Holzer et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
BMC Gastroenterology 2009, 9:94 http://www.biomedcentral.com/1471-230X/9/94characteristics: (1) preferential involvement of the cecum;
(2) phlegmonous changes in the submucosa; and (3) bac-
terial infection [6,7]. These results suggest that PC is a
severe and specific complication of portal hypertension.
We postulated that, in parallel with aggravating portal
hypertension, PHC could progress towards PC and sepsis.
We report herein three patients, who illustrate this
sequence of events.
Case Presentation
All three patients were admitted in our institution for
abdominal pain and underwent a CT-scan evaluation,
which demonstrated a colonic inflammation. We report
herein the three patients in increasing order of septic com-
plications. Additional file 1: Table S1 summarizes the
results of various microbiologic analyses performed in
these three patients.
CASE 1
A 43 year-old alcoholic male presented at the Emergency
Department with diffuse abdominal pain. The patient had
been previously diagnosed with Child C cirrhosis, and
suffered one prior episode of upper GI bleeding. On
admission, the patient was hemodynamically stable, with
a distended and diffusely painful abdomen, but no signs
of peritonitis. Blood tests showed a mild inflammatory
syndrome. CT scan revealed a liver with cirrhotic aspect, as
well as all classical signs of portal hypertension, including
ascites, splenomegaly and repermeabilization of the
umbilical vein. There was a marked thickening of the large
bowel, predominantly on the ascending and transverse
colon (Figure 1). Hemocultures were positive for Entero-
coccus faecalis, and the initial antibiotic regimen, consist-
ing of ceftriaxone and metronidazole IV, was replaced by
ertapenem 1 × 1 G/day IV. The patient did well and was
discharged home ten days after his admission.
CASE 2
A 70 year-old male presented at the Emergency Depart-
ment with acute abdominal pain and hypotension. Medi-
cal history was positive for Child B cirrhosis, hepatitis C,
oesophageal varices, and diabetes; he previously suffered
one episode of right colitis of unknown origin that
responded well to a treatment of ceftriaxone and metron-
idazole. On admission, the patient was acutely ill, with a
severe inflammatory syndrome, and was transferred to the
Intensive Care Unit for resuscitation. CT scan showed a
cirrhotic liver, ascites in low quantity, and an aspect of
pancolitis with a thickened and oedematous wall (Figure
2). Hemocultures were positive for Enterococcus and Strep-
tococcus bovis. The patient was treated with a combination
of amoxicilline-clavulanic acid and gentamicine, with
rapid improvement in both clinical and biological signs
of inflammation. The patient was discharged on day 15
after his admission.
CASE 3
A 69-year-old alcoholic male was admitted for abdominal
pain, associated with diarrhoea and hematochezia. The
patient was also known for cirrhosis and type II diabetes.
On admission, the patient was in poor condition and pre-
sented with peritonitis associated with hypotension, acute
renal failure and sepsis. The patient was transferred to the
intensive care unit for resuscitation and IV antibiotics
(ceftriaxone and metronidazole) were administered. CT
scan of the abdomen showed, in addition to cirrhotic
liver, a marked thickening of the whole colon with infil-
CT scan of case 1 showing extensive oedema of the right a tran verse colon, as well as cirrhotic alterations of the liverFigur  1
CT scan of case 1 showing extensive oedema of the 
right a transverse colon, as well as cirrhotic altera-
tions of the liver.
CT scan of case 2 showing again extensive inflammation of the entire colon (pancolitis), with oedema a d thickeni g of large intestine wallFigure 2
CT scan of case 2 showing again extensive inflamma-
tion of the entire colon (pancolitis), with oedema and 
thickening of the large intestine wall.Page 2 of 4
(page number not for citation purposes)
BMC Gastroenterology 2009, 9:94 http://www.biomedcentral.com/1471-230X/9/94tration of the peri-colic fat, and ascites in low quantity. 24
hours after admission, the patient developed increased
abdominal pain associated with a septic shock and was
taken to the operating room. At surgery, the colon was
thick, indurated and congestive; lesions predominated
within the ascending colon (Figure 3). A total colectomy
with terminal ileostomy and a hepatic biopsy were per-
formed. Histopathology examination of the surgical spec-
imen revealed: 1) disseminated erosions/ulcerations of
the colonic mucosa (Figure 4); 2) multiple micro-
abscesses located in the sub-mucosa in association with
polynuclear infiltration, and 3) a vasculopathy character-
ized by venous ectasias and numerous venous thrombi
(Figure 5). The hepatic biopsy showed an important cir-
rhotic alteration of the parenchyma with fresh thrombosis
of the branches of the portal vein. One week after surgery,
the patient developed multiple organ failure and died.
Preoperative culture of ascites came back positive for
Pepto-streptococcus.
Conclusion
Cirrhotic patients are particularly susceptible to bacterial
infections and the origin of these microorganisms (most
commonly Escherichia Coli, Enterococcus faecalis, Proteus
mirabilis and Pseudomonas aeruginosa) is often the lower
digestive tract. Most clinicians would concur that: 1) the
colon is the source of bacteraemia in cases 1 and 2; and 2)
bacterial translocation due to increased intestinal perme-
ability is the most likely physiopathology mechanism
involved. However, bacterial translocation has been
mostly documented in small animals [8], and is actually
rare in Child A (3%) and B (8%) patients. In summary,
both patients developed abdominal pain and bacterae-
mia; blood cultures were positive for enteric microorgan-
isms, the colon (predominantly on the right side) was
abnormal with radiologic evidence of severe oedema or
inflammation of the colon and no other possible source
of sepsis was found (Additional file 1).
We hypothesized that PHC may progress towards PC. The
latter condition, which requires a biopsy or a surgical
specimen is rarely (if ever) documented ante mortem.
Another fatal case of phlegmonous colitis has been
recently reported in a cirrhotic patient receiving a combi-
nation of interferon and ribavirin for hepatitis C [9]. We
suspect that this entity goes often unrecognized, because
the patients' poor condition precludes any surgical inter-
vention. Interestingly, in case 3, the only positive culture
was the presence of bacteria in ascites, and it is likely that,
Intra-operative aspect of the ascending colon of case 3Figure 3
Intra-operative aspect of the ascending colon of case 
3. The colon was indurated, congestive, thickened, the gen-
eral appearance being somewhat similar to acute mesenteric 
vein thrombosis.
Histological features of the operative specimen, showing numerous micro-ab cesses in the submucosa (asterisk) as well as deep mucosal ulc ration (arrow)Figure 4
Histological features of the operative specimen, 
showing numerous micro-abscesses in the submu-
cosa (asterisk) as well as deep mucosal ulceration 
(arrow).Page 3 of 4
(page number not for citation purposes)
BMC Gastroenterology 2009, 9:94 http://www.biomedcentral.com/1471-230X/9/94in the absence of an operative specimen, the final diagno-
sis would have been spontaneous bacterial peritonitis
(SBP) due to intestinal translocation. We consider that
this patient had infected ascites indeed, but bacterial peri-
tonitis in that case was secondary to phlegmonous colitis.
The data presented here suggest that in some cirrhotic
patients with portal hypertensive colopathy, phleg-
monous colitis could be the origin of sepsis. The underly-
ing mechanism is a worsening of vasculopathy leading to
complete obliteration of submucosal blood vessels.
Mucosal erosions secondarily appear and are responsible
for disseminated micro-abscesses formation in the sub-
mucosa, which constitutes the probable source of gram-
negative sepsis. PC and PHC are closely related as sug-
gested by the fact that both conditions share similar histo-
logical features: specifically, vascular alterations described
in PHC (dilated venules and vascular ectasias in the sub-
mucosa) are present in PC. By contrast, mucosal ulcera-
tions and the presence of microabscesses are dominant
features of PC, which are absent in PHC. In conclusion,
the three cases presented herein suggest that portal hyper-
tensive colopathy could sometimes progress towards
phlegmonous colitis. Whilst portal hypertension-induced
vascular changes are initially similar throughout the GI
tract, the clinical manifestations are eventually dominated
by bleeding for the upper GI, and sepsis for the colon.
Abreviations
PHC: portal hypertensive colopathy; GI: gastro intestinal;
PC: phlegmonous colitis.
Competing interests
The authors declare that they have no competing interests.
Consent
Consent forms signed by the patients' relatives are submit-
ted separately
Authors' contributions
TH: protocol design, editing manuscript. PG: protocol
design, editing manuscript. LS: protocol design, editing
manuscript. TMK: tissues processing, histological analysis
of surgical specimen. PB: surgical operation, editing man-
uscript. PM: final review, supervision of scientific content
of manuscript. All authors have read and approved the
final version of manuscript.
Additional material
References
1. Naveau S, Bedossa P, Poynard T, Mory B, Chaput JC: Portal hyper-
tensive colopathy. A new entity.  Dig Dis Sci 1991, 12:1774-81.
2. Viggiano TR, Gostout CJ: Portal hypertensive intestinal vascu-
lopathy: a review of the clinical, endoscopic and histopatho-
logical features.  Am J Gastroenterol 1992, 87:944-54.
3. Misra SP, Dwivedi M, Misra V, Dharmani S, Kunwar BK, Arora JS:
Colonic changes in patients with cirrhosis and in patients
with extrahepatic portal vein obstruction.  Endoscopy 2005,
37:454-9.
4. Bresci G, Parisi G, Capria A: Clinical relevance of colonic lesions
in cirrhotic patients with portal hypertension.  Endoscopy 2006,
38:830-5.
5. Mendeloff J, Wenger J: Liver disease, phlegmonous colitis, and
gram-negative sepsis.  South Med J 1975, 68:507-10.
6. Satoh T, Sasatomi E, Wu L, Tokunaga O: Phlegmonous colitis: a
specific and severe complication of chronic hepatic disease.
Virchows Arch 2000, 437:656-61.
7. Pfaffli M, Wyler D: Phlegmonous colitis - a rare complication of
chronic liver diseases.  Swiss Med Forum 2008, 8:262-3.
8. Garcia-Tsao G, Lee FY, Barden GE, Cartun R, West AB: Bacterial
translocation to mesenteric lymph nodes is increased in cir-
rhotic rats with ascites.  Gastroenterology 1995, 108:1835-41.
9. Pang SH, de Silva K, Napoli J, Jones BE: A fatal case of phleg-
monous colitis in chronic hepatitis C receiving combination
interferon and ribavirin therapy.  Intern Med J 2009, 39:481-4.
Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-230X/9/94/pre
pub
Additional file 1
Summary of Microbiology Analyses. Results of blood and ascites analyses 
performed in the three patients.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1471-
230X-9-94-S1.ZIP]
Histological features of the operative specimen, showing in addition to confluent micro-abscess s in the submucosa, a severe vasculopathy with disseminat d venous thr mbosisFigure 5
Histological features of the operative specimen, 
showing in addition to confluent micro-abscesses in 
the submucosa, a severe vasculopathy with dissemi-
nated venous thrombosis.Page 4 of 4
(page number not for citation purposes)


Crossref

Abstract Background The clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with portal hypertensive colopathy (PHC). Case presentation We report three cirrhotic patients who were admitted with abdominal sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient underwent emergency colectomy for PC, and subsequently died from multiple organ failure. Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration of submucosal blood vessels. Conclusions These data suggest that cirrhotic patients with PHC may progress towards PC, which, in turn, may be the cause for life-threatening sepsis.</p

Bucher Pascal

McKee Thomas

Spahr Laurent

Gervaz Pascal

Holzer Thomas

Morel Philippe

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Phlegmonous colitis: another source of sepsis in cirrhotic patients?

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