Lethal phlegmonous colitis

A 52-year-old man died soon after admission to hospital with a severe metabolic acidosis and likely sepsis. He had a past history of alcohol abuse with withdrawal seizures. An abdominal computed tomography scan showed thickened bowel loops but no obvious ischaemic changes, and a blood culture yielded a pure growth of Escherichia coli. At autopsy, the liver showed well-established micro-nodular cirrhosis with steatosis. The peritoneal cavity contained 200 mL of turbid yellow-brown fluid, and the caecum and ascending colon were unusually thickened. Microscopy of the caecum and ascending colon showed oedema, with a florid submucosal acute inflammatory infiltrate and large numbers of rod-shaped bacilli typical of phlegmonous colitis. This rare acute infectious condition predominately involves the caecum and ascending colon and is associated with liver cirrhosis. It should therefore always be considered at autopsy in individuals with cirrhosis, with careful examination and microscopic sampling of the caecum and proximal ascending colon, including ancillary blood/fluid bacterial cultures if the condition is suspected based on the macroscopic findings and/or history.