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PubMed1982

Ogilvie's syndrome (acute colonic pseudo-obstruction): review of the literature (October 1948 to March 1980) and report of four additional cases.

Four additional cases of Ogilvie's syndrome (acute colonic pseudo-obstruction), representing the first cases described in Italy, are reported. The medical literature concerning the subject is also thoroughly reviewed. Ogilvie's syndrome is an acute massive dilatation of the large bowel without organic obstruction of the distal colon. Three hundred and fifty-one cases have been described in the literature to date. Eighty-eight per cent of the cases were associated with various extracolonic affections (metabolic and organ dysfunctions, postoperative and posttraumatic states, etc.). Twelve per cent of cases were not associated with known disorders and were defined as idiopathic. The pathophysiology of the syndrome is still unknown. Ogilvie, who first described the syndrome in 1948, suggested an imbalance between the sympathetic and parasympathetic innervation of the colon: this neurogenic hypothesis has been shared by other authors, although explanations may differ slightly. The clinical and radiologic picture closely resembles mechanical obstruction of the large bowel. The most marked dilatation usually takes place in the right colon and cecum: if the distended cecum reaches a diameter larger than 9 to 12 cm, perforation is likely to occur; if perforation occurs, the mortality rate increases from 25 to 31 per cent to about 43 to 46 per cent. If conservative management fails to control the dilatation and cecal rupture is impending or suspected emergency surgery is indicated, the surgical procedure of choice is dictated by the general conditions of the patient as well as by the intestinal findings: operation may consist of cecostomy, colostomy, or right hemicolectomy or simply emptying the bowel.

Adult↗
PubMed1983

Neutropenic typhlitis. A plea for conservatism.

Neutropenic typhlitis is an acute inflammation of the cecum occurring in neutropenic patients. Two cases are described, both presenting typical features of the disease. It is our experience that the treatment approach should consist of bowel rest, fluid therapy, and massive administration of broad spectrum antibiotics. In some cases, full recovery will follow. If abdominal signs persist, surgery should be deferred until hematologic convalescence occurs. At this time, cecostomy and drainage should be adequate. Only in very severe cases, with wide-spread necrosis, should a right hemicolectomy be performed.

Acute Disease↗
PubMed1983

Colonoscopic decompression and intubation of the cecum for Ogilvie's syndrome.

Cecal distention due to pseudo-obstruction of the left colon may result in perforation or necrosis of the right colon with catastrophic consequences. This problem occurs in people who are ill from other causes; therefore, the mortality and morbidity is high in Ogilvie's syndrome whether treated operatively or nonoperatively. The treatment of choice has been tube cecostomy when cecal diameter exceeds 12 cm on supine films. Fiberoptic colonoscopy has provided a new treatment modality for this condition. The cecum can be decompressed safely in most cases. Recurrent distention can be avoided by transanal intubation of the cecum. A case is discussed, and the technique of cecal intubation is described.

Cecal Diseases↗
PubMed1980

Pseudo-obstruction of the colon (Ogilvie's syndrome).

Pseudo-obstruction of the colon is an acute abdominal problem that can occur from a variety of causes and multiple organ failures. It is characterized by massive colonic dilatation and a clinical picture suggestive of mechanical large-intestinal obstruction, without any organic obstruction. Decompression should be cautiously attempted with proctoscopy and, possibly, colonoscopy; if these fail, then surgical decompression, usually be a cecostomy, is indicated.

Aged↗
PubMed2002

Successful management and outcome of a postoperative aortogastric fistula in a patient with recurrent gastric cancer: report of a case.

The case of a 57-year-old patient is described, who presented with regional gastric cancer recurrence 1 year after a gastrectomy for a T3N1M0 (Stage IIIA) adenocarcinoma of the stomach. He underwent a radical resection with intraoperative radiation to the regional field. Two months postoperatively, massive upper gastrointestinal bleeding occurred. Operative management included a left thoracotomy, aortic cross-clamping, laparotomy, and suture repair of a fistula from the root of the celiac trunk to the gastric remnant, with a completion gastrectomy. The patient survived and underwent a delayed reconstruction and closure. Subsequently, several repeat bleeding episodes took place, from sources including the celiac, common hepatic, and proper hepatic arteries. Multiple angiographic coil embolization and surgical procedures became necessary, ultimately requiring an esophagostomy and cecostomy for intestinal diversion. A rectus abdominis flap coverage of the exposed large arteries was performed. Although two more bleeding episodes took place, the patient was ultimately managed successfully. He is currently free of disease 3 years after reexploration, able to take oral nutrition, with intermittent jejunostomy feeding supplements. The discussion highlights aspects relevant to this case: the importance of a complete regional resection during a gastric cancer resection, the management strategy for an acute catastrophic intra-abdominal bleeding, and possible mechanisms that could contribute to such bleeding, including intraoperative radiation and postoperative infection.

Aortic Diseases↗
PubMed2004

Mucocele of the appendix: a report of five cases.

Mucocele of the appendix is an uncommon disorder, characterized by a cystic dilatation of the lumen. It is often diagnosed clinically from signs and symptoms of acute appendicitis or, if it is asymptomatic, as an incidental finding during ultrasonography, computed tomography, and radiographic examinations of the gastrointestinal tract, or laparotomy. The incidence of mucocele ranges from 0.2% to 0.3% of all appendectomy specimens. We report five cases of appendiceal mucocele (all women, aged 19-90 years), who were admitted from January 1993 to January 2003 to our hospital. These cases represent 0.29% of the 1720 appendectomies performed during this period. Three of the patients were symptomatic and had appendectomies. The final diagnosis for mucocele was given at laparotomy. No colon neoplasms were identified during surgery, and subsequent colonoscopic examinations were also negative. The other two patients were asymptomatic of appendiceal tumor. Colonoscopy revealed two colonic malignant tumors in one patient and an adenocarcinoma of the sigmoid colon in the other. Mucocele of the appendix was diagnosed pre-operatively by ultrasound and computed tomography. One of the two patients underwent a right hemicolectomy and sigmoidectomy; the other one underwent an appendectomy, cecostomy and sigmoidectomy. Four of the patients recovered and are doing well today; one patient died on the twenty-fifth postoperative day. The most common symptom of mucocele is abdominal pain, although many patients may be asymptomatic. Mucocele is often associated with concomitant colon cancer, thus patients with this tumor should be systematically checked for other colonic lesions.

Adenocarcinoma↗
PubMed2007

An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases.

PURPOSE: This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus. METHODS: The records of 827 patients were reviewed retrospectively. RESULTS: The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent. CONCLUSIONS: Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.

Adolescent↗
PubMed2002

Slow Transit Constipation.

The diagnosis of slow transit functional constipation is based upon diagnostic testing of patients with idiopathic constipation who responded poorly to conservative measures such as fiber supplements, fluids, and stimulant laxatives. These tests include barium enema or colonoscopy, colonic transit of radio-opaque markers, anorectal manometry, and expulsion of a water-filled balloon. Plain abdominal films can identify megacolon, which can be further characterized by barium or gastrografin studies. Colonic transit of radio-opaque markers identifies patients with slow transit with stasis of markers in the proximal colon. However, anorectal function should be characterized to exclude outlet dysfunction, which may coexist with colonic inertia. Because slow colonic transit is defined by studies during which patients consume a high-fiber diet, fiber supplements are generally not effective, nor are osmotic laxatives that consist of unabsorbed sugars. Stimulant laxatives are considered first-line therapy, although studies often show a diminished colonic motor response to such agents. There is no evidence to suggest that chronic use of such laxatives is harmful if they are used two to three times per week. Polyethylene glycol with or without electrolytes may be useful in a minority of patients, often combined with misoprostol. I prefer to start with misoprostol 200 mg every other morning and increase to tolerance or efficacy. I see no advantage in prescribing misoprostol on a TID or QID basis or even daily because it increases cramping unnecessarily. This drug is not acceptable in young women who wish to become pregnant. An alternative may be colchicine, which is reported to be effective when given as 0.6 mg TID. Long-term efficacy has not been studied. Finally, biofeedback is a risk-free approach that has been reported as effective in approximately 60% of patients with slow transit constipation in the absence of outlet dysfunction. Although difficult to understand conceptually, it is worth attempting and certainly so in patients with associated pelvic floor dyssynergia. Subtotal colectomy with ileorectal anastomosis is often effective in those patients with colonic inertia, normal anorectal function, and lack of evidence of generalized intestinal dysmotility. However, morbidity is significant both early and late in the disease process and must be balanced against current disability. Ileostomy is preferred in the presence of anorectal dysfunction or with associated impairment of continence mechanisms. Similar considerations apply to the patient with disabling functional megacolon. An alternative approach is ileostomy with disconnection of the colon, which is more acceptable to some patients who may hope for future reconnection if recovery occurs. An additional alternative approach for patients with colonic inertia or megacolon who are not good surgical risks is tube cecostomy (or in children, use of the appendix as a conduit to the cecum). This permits either decompression (in megacolon) or antegrade enemas (in colonic inertia). Our surgeons are not enthusiastic about this approach, and I have little experience with it. In general, the use of partial resections of the colon should be discouraged, because marker studies do not define pathophysiology in patients with slow transit constipation.

Journal Article↗
PubMed1979

Massive cecal dilation: pseudoobstruction versus cecal volvulus?

Seven patients with acute and progressive abdominal distension secondary to massive cecal and right colon ileus are analyzed. Five had pseudoobstruction of the colon and two had cecal volvulus. Two of the patients with pseudoobstruction and one with cecal volvulus died from preexisting diseases. Pseudoobstruction of the colon is not a rare complication of elderly, sick, bedridden patients. Differential diagnoses include cecal and sigmoid volvulus and acute gastric dilation. Initial conservative therapy is warranted if no peritoneal signs are present. If the cecal diameter is more than 12 cm, colonoscopic decompression with a fiberscope should be attempted. If unsuccessful, tube cecostomy will provide curative, life-saving therapy even if taenia splitting is present. Perforation or widely scattered areas of necrosis make resection mandatory.

Aged↗
PubMed1984

Colonoscopic decompression of the colon in patients with Ogilvie's syndrome.

Pseudoobstruction of the large bowel occurs as acute distention of the colon, usually in a high risk and seriously ill patient without any mechanical obstruction. Massive distention of the colon results in perforation of the cecum and fecal peritonitis and is associated with a very high mortality rate. Laparotomy with cecostomy is the recommended surgical therapy for this problem which carries a mortality rate of over 20 percent. We have used the colonoscope to decompress the distended colon, and especially the cecum, in 10 patients with Ogilvie's syndrome, with a 90 percent success rate and no deaths or complications. The surgeon should follow the several technical guidelines mentioned herein for successful and safe performance of the procedure. These guidelines include a tap water enema of about 1,000 ml before the procedure, avoidance of the liberal use of air insufflation during the procedure, and blind insertion of the colonoscope. This procedure is not indicated in any patient with signs of peritonitis and perforation.

Acute Disease↗
PubMed1989

Ogilvie's syndrome in the postcesarean section patient.

Two cases of colonic pseudo-obstruction (the so-called Ogilvie's syndrome) are reported. Both patients were in the immediate postcesarean section puerperium. The importance of early diagnosis in these cases is stressed, because this complication has a high mortality rate, frequently in relation to delayed diagnosis and treatment. One patient was successfully treated with conservative measures because diagnosis was made early. A plain X-ray abdominal film which shows cecum dilatation, with or without ascending and transverse colon dilatation, and no distal air, makes the diagnosis. A cecum diameter of 9 cm or more is a surgical indication, because the possibility of wall perforation is high. Surgical techniques are: puncture decompression or cecostomy. When cecum diameter is less than 9 cm, non-surgical measures (nasogastric suction, correction of any fluid and electrolytic imbalance, and maybe a flatus tube) are indicated. Observation through repeated X-ray abdominal films shows when the surgical indication appears: (1) failure of the conservative treatment (cecal distension continues or increases); or (2) cecal perforation is documented.

Adult↗
PubMed2005

Practice patterns of nonvascular interventional radiology procedures at academic centers in the United States?

RATIONALE AND OBJECTIVES: To determine and analyze the patterns of practice of nonvascular interventional procedures in academic centers in the United States. MATERIALS AND METHODS: A survey was administered via e-mail to the chief residents of 112 academic radiology departments in the United States. Recipients of the survey were asked to identify which sections within their respective radiology departments performed each of 43 types of nonvascular interventional procedures. An additional entry for performance of procedures by non-radiologists was provided. A total of 66 (59%) recipients responded. The statistical method used was the analysis of contingency tables. RESULTS: Percutaneous abdominal biopsies are performed mainly by abdominal and body imaging sections (43/66, 65%), followed by vascular/interventional sections (21/66, 32%). Percutaneous abdominal drainages are performed mostly by abdominal, body imaging, and computed tomography sections (40/66, 61%), followed by vascular/interventional sections. Fluoroscopically guided procedures were performed most commonly by vascular/interventional sections, including percutaneous gastrostomy (40/66, 61%), percutaneous nephrostomy (42/66, 64%), and biliary interventions such as percutaneous transhepatic cholangiography (47/66, 71%). Breast and musculoskeletal procedures are performed by their respective sections most frequently. Non-radiologists perform a significant portion of certain types of procedures: paracenteses, thoracenteses, biliary interventions (particularly stone extractions), enterostomies (particularly percutaneous jejunostomies and cecostomies), and certain biopsies (kidney and prostate). CONCLUSIONS: Academic US radiology sections perform nonvascular interventional radiology procedures in a complex and nonuniform manner. The vascular/interventional sections and organ system and modality (especially CT) sections perform the bulk of the procedures included in the survey. Breast imaging sections predominate in procedures in their disciplines. A substantial number and amount of interventional radiology procedures are performed by non-radiologists.

Academic Medical Centers↗
PubMed2006

[Pseudo-"isolated" intestinal perforation in a very low birth weight infant: exceptional presentation of Hirschsprung's disease].

Intestinal perforations in preterm newborn are characterized with high morbidity and mortality rates. They often are associated with necrotizing enterocolitis and seldom correspond to idiopathic spontaneous intestinal perforation. Perforations upstream of an intestinal organic obstruction (atresia), or of a functionnal obstruction (meconium-ileus, Hirschsprung disease) have been considered to be rare in preterm newborns. We report a case of caecal perforation with a pneumoperitoneum which occurred at 5 days of life, in a 28-week gestational age infant, that was treated by cecostomy. There were no signs of necrotizing enterocolitis. At 43 days of life, the preoperative contrast enema study revealed a left colon transition zone, suggesting a Hirschsprung disease, which was confirmed by rectal biopsies. Transanal pull-through was performed. There were no postoperative complication. This case demonstrates that an isolated intestinal perforation in very preterm newborn can reveal a Hirschsprung disease, especially if it occurs in the caecum.

Cecum↗
PubMed2004

Persistent obstructive symptoms after surgery for Hirschsprung's disease: development of a diagnostic and therapeutic algorithm.

BACKGROUND: Although most children with Hirschsprung's disease (HD) do well after pull-through surgery, some continue to have persistent obstructive symptoms that may lead to significant morbidity. The author's goal was to develop an organized algorithm for the workup and ultimate management of these symptoms. METHODS: All children referred to the author with severe obstructive symptoms after a pull-through for HD were evaluated using an algorithm based on 5 potential etiologies, and appropriate therapeutic interventions were instituted. RESULTS: A total of 49 children were evaluated over 7 years. Mechanical obstruction was found using rectal examination and barium enema in 7, of which, 2 had resection of a Duhamel spur, and 5 had a repeat pull-through (after failed dilatation). Rectal biopsy results showed aganglionosis in 10, of whom, 8 underwent repeat pull-through, and 2 refused further surgery. Abnormal intestinal motility or intestinal neuronal dysplasia was found proximal to the aganglionic segment in 10 children using colonic and small bowel manometry or laparoscopic biopsies; 4 of these had additional colon resected and repeat pull-through, and 6 were treated with a bowel management routine, cecostomy, or stoma formation. Internal sphincter achalasia was felt to be the primary cause of symptoms in 14, and all were treated with intrasphincteric botulinum toxin. Eight were found not to fall into any of the above groups and were treated medically for presumed functional megacolon; 2 of these ultimately had a colostomy. CONCLUSIONS: An organized approach to the diagnosis and management of obstructive symptoms in a child after a pull-through for HD permits accurate diagnosis and effective treatment in the majority of cases.

Algorithms↗
PubMed1985

Colonic pseudo-obstruction in surgical patients.

Colonic pseudo-obstruction (Ogilvie's syndrome) may occur in surgical patients, particularly those who have had orthopedic or blunt trauma, have uremia or diabetes, have complex metabolic or cardiac failure, have metastatic cancer involving the lymph nodes and neural tissue, or are addicted to narcotics. Although a single true cause has not been identified by fulfilling Koch's postulates, the clinical pattern has been recognized in a variety of surgical patients, and this pattern must be distinguished from true obstruction of the colon. Tumor or internal hernia may constitute an obstruction, but the important differential diagnosis of cecal volvulus must be excluded. Ischemic colitis may be confused with Ogilvie's syndrome or may follow it. Gangrene, infarction, and perforation may ensue as colon diameter increases and particularly if cecal distention reaches above 14 cm. This arbitrary number for cecal dilatation should not be awaited before treatment is instituted if signs of devitalization of the gut or peritoneal signs have developed in the patient. Treatment has changed recently with the widespread application of colonoscopy. Endoscopy is helpful in relieving distention but may also be dangerous in the patient with a massively distended colon, particularly at the level of the thin-walled cecum. Colonoscopy also appears to be associated with a high rate of treatment failure and recurrence. Surgical decompression may take the form of cecostomy or may require exteriorization or resection of the colon if infarction has occurred. A series of 12 patients has been presented. The patients were all referred to a single surgeon in a university medical center over a 4 1/2 year period with clinical patterns not suggestive of a common cause but a similar clinical evolution of Ogilvie's syndrome. The prognosis for such patients in whom the complication is recognized early and in whom decompression is performed endoscopically or surgically is encouraging. If recognition is late and particularly if perforation and gangrene result, mortality is nearly 50 percent.

Adult↗
PubMed1985

A technique for temporary control of colostomy prolapse in children.

Stomal prolapse is a common complication of colostomies and, if severe, may affect the timing of the definitive procedure. A simple technique for postreduction bowel fixation without stomal revision is presented. The reduced bowel is attached to the parietal peritoneum using a "U" type suture a few centimeters from the stoma. Two short parallel segments of latex tubing prevent the thread from cutting through. Suture and bolsters are removed when adhesions are established. In one of the four children, a percutaneous cecostomy was employed to connect a prolapse of the entire proximal colon.

Abdominal Muscles↗
PubMed1989

Colonoscopic decompression of pseudo-obstruction and volvulus.

Flexible fiberoptic endoscopy has an integral role in the management of colonic pseudo-obstruction and volvulus. Colonoscopic decompression is the primary method for diagnosis and treatment of colonic pseudo-obstruction. Some patients require repeat endoscopic decompression, but few require tube cecostomy. In the case of sigmoid volvulus, endoscopic examination is useful as a temporizing measure to allow preparation of the colon and patient for elective definitive operative treatment.

Colonic Diseases↗
PubMed1996

Laparoscopic creation of a continent cecal tube for antegrade colonic irrigation.

UNLABELLED: OBJECTIVES; The antegrade continence enema (ACE) procedure has been used for the treatment of overflow fecal incontinence or constipation inpatients with spina bifida. The procedure requires an appendiceal reimplantation into the cecum with creation of a continent abdominal stoma for antegrade colonic washout. To preserve the appendix for potential use in urinary diversion, we developed two surgical techniques for tubularizing an antimesenteric cecal segment to use in place of the appendix. METHODS: The surgery was performed in 6 dogs. The first two procedures used an open surgical technique through a 10-cm midline laparotomy. The cecum was isolated, and a small cecotomy was made. A 10F red rubber catheter was introduced into the cecotomy, and a 4-cm length of cecum was tubularized along its antimesenteric border with a gastrointestinal anastomosis stapler over the catheter. A nipple was created at the base of the tube to enhance continence, and the tubular segment was brought through the lower abdominal wall to create a catheterizable stoma. After our success, four subsequent procedures were performed laparoscopically to create the same tubularized cecal segment. A 4-cm antimesenteric tubularized cecal segment with sufficient lumen to accommodate a 10F to 12F catheter was constructed using a laparoscopic gastrointestinal anastomosis stapler. Rather than creating a nipple at the base of the tubular segment, continence of the stoma was achieved by tunneling the cecal tube through a 2-cm lower quadrant subcutaneous tunnel. A flush stoma was then created and secured to the skin. RESULTS: Stoma viability was grossly confirmed in all 6 dogs during the postoperative period, with no incidence of bowel obstruction. Slight fecal leakage through the stoma was observed in 1 dog with a laparotomy but not in those with laparoscopy. Catheterization was easily performed in all dogs with a 10F red rubber catheter during the postoperative period. The dogs were killed on postoperative day 10, and gross anatomic and histologic examination of the cecal segment confirmed luminal patency and viability. CONCLUSIONS: Open and laparoscopic continent cecostomies were successfully constructed in a canine model and are likely to be applicable to humans with neuropathic constipation.

Animals↗