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Katherine Jahnes MD Colorectal Conference St Lukes Roosevelt Hospital Center November 10, 2005
Case A
83 yo male presents with increasing abdominal distention s/p failed sigmoidoscopy/ colonoscopy PMH: Alzheimers Disease, HTN, COPD, glaucoma PSH: pacemaker placement (2001 for bradycardia) and left hip repair (2001) PE: Lungs clear, Abdomen distended but soft with hyperactive BS, TTP diffusely, LLQ>LUQ, no rebound
Case A
20 year history of sigmoid volvulus Managed by sigmoidoscopy reduction as outpatient three time a week On day of admission attempts at reduction where unsuccessful Films were obtained
Case A
around mesentery No sigmoid ischemia Rectum, descending colon healthy and viable Sigmoid resected with primary anastomosis of descending colon to rectum
Case B
71 year old female with 2 week history of increasing abdominal distention and no bowel movements PMH: HTN, DM, CVA- residual aphasia, hemiparesis PSH: none PE: Abdomen:
Case B
Radiology:
Case B
Operative findings:
Colorectal CLL
PseudoobstructionOgilvies syndrome
Distention of colon with signs and symptoms of colonic obstruction without a mechanical cause for the obstruction May be acute or chronic
Acute: usually involves only colon, and more commonly effects patients with chronic renal, respiratory, cerebral or cardiovascular disease Chronic: can effect other parts of the GI tract and tends to recur familial visceral myopathy Diffuse disorder involving autonomic innervation of intestinal wall Associated with: neuroleptics, opiates, metabolic illness, myxedema, DM, uremia, hyperPTH, lupus, scleroderma, Parkinsons, traumatic retroperitoneal hematomas
PseudoobstructionOgilvies syndrome
Diagnosis
Can differentiate between mechanical and Can also be used for treatment
Colonoscopy
Initial treatment
Volvulus
Bowel is twisted on mesenteric axis resulting in complete or partial obstruction of the bowel lumen as well as possible vascular impairment Represents about 5% of large bowel obstructions Associated factors-
chronic constipation Aging institutionalization (neuropyschiatric conditions treated with pyschotrophic drugs) in the developing world- possible association with high fiber diets
Characteristically affected bowel is attached to long floppy mesentery fixed to retroperitoneum with a narrow base
Volvulus
Most commonly sigmoid, also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal basculemobile in caudad to cephalad direction), and rarely transverse colon
(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)
Volvulus
Sudden onset of severe abdominal pain, vomiting, obstipation Abdomen is distended and tympanitic, often dramatically AXR: markedly dilated colon with an air-fluid level, no gas in rectum CT: mesenteric whirl (at right) Contrast enema: birds beak
Radiographic findings-
Volvulus
Treatment:
Neoplasm
Presentation, treatment, and multivariate anaysis of risk factors for obstructive and perforative colorectal carcinoma
Acute obstruction, perforation or both Associated with high morbidity and mortality
Retrospective study
Indications:
history and physical consistent with peritonitis Intrabdominal abscess with systemic signs of sepsis Clinical signs of obstruction and radiographic evidence thereof not responding to conservative measures within 4 days of hospitalization Study excluded pts with crohns, UC, other types of neoplasm, FAP, h/o operations at outside hospitals, and those not requiring surgery
Of 107 pts, 83 (78%) had complete obstruction and 24 (22%) had perforation
Sigmoid was most common location Comorbid conditions were present in 70% of pts- HTN, CV, COPD, DM. Males predominated in the obstruction group Advance tumor stage was seen in 70% of the obstructing pts and in 54% of the perforated pts Overall/ curative resection rate for obstructed pts was 85/ 83% respectively Mean OR time was 145.7 minutes (SD 57.1) 37% required a blood transfusion
Major postop complications in 33%most frequently GI and pulmonary Factors associated with major complications or mortality included:
Crohns disease
Intussusception
A segment of bowel and its associated mesentery (intussusceptum) invaginates into the lumen of an adjacent bowel segment (intussuscipiens) Leading cause of bowel obstruction in children May be caused by intramural, mural, or extramural process-
intraluminal mass pulled forward by peristalsis and drags bowel wall with it
Segment of bowel wall that does not contract normally and the opposite wall rotates the abnormal segment inward causing a kink that acts as a lead point
Intussusception
In the colon, most frequently are colocolic or sigmoidrectal, and comprise 38% of adult intussusceptions Neoplasia causes 2/3 of cases in adults
Association with AIDS- secondary to lymphoma, Kaposis sarcoma, reative lymphoid hyperplasia, atypical mycobacteria infection, CMV, Camphylobacter enteritis Childhood presenting symptoms: acute presentation with episodic crampy abdominal pain and bloody currant jelly stool Adult presentation: often nonspecific chronic or subacute symptoms- crampy abdominal pain, nausea and vomiting, constipation or diarrhea, rarely bleeding or presence of a palpable mass
Intussusception
Radiology: Abdominal plain film Air crescent sign- intraluminal air between the walls of the the intussusceptum and the intussuscipiens Barium enema Coiled spring appearance (fig 12)- a thin central barium stream with or without a leading mass US More useful in childhood intussusceptions Target or doughnut mass with outer hypoechoic rim Ct Target lesion, whirling pattern of mesenteric vessels May see air bubble between opposed layers of bowel Underlying etiology may be difficult to determine Treatment Surgery Reduce or not?