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PubMed1991

Fate of the rectum after colectomy and ileostomy for Crohn's colitis.

Eighty-four patients had colectomy with ileostomy and oversewing of the rectum for Crohn's colitis. Seventy-two patients were operated on because of intractable disease, colitis in combination with rectal fistulas, and toxic megacolon. The operative mortality was 6 percent, and neither emergency surgery nor treatment with steroids correlated with operative morbidity. After a median 7.7 years of follow-up, 25 ileorectal anastomoses had been undertaken, 16 of which were successful. Twenty-nine protectomies were performed; the resulting 10-year cumulative risk of proctectomy was 50 percent. While the risk of proctectomy was significantly less among patients with a normal rectum at colectomy compared with patients with proctitis, the initial macroscopic degree of proctitis did not correlate with the risk of subsequent proctectomy. The 5-year cumulative ileal resection rate in 29 patients with a rectum in situ but out of circuit was 29 percent. The possibility of a future ileorectal anastomosis should still be considered in patients with proctocolitis.

Adolescent↗
PubMed2001

Outcome analysis of HIV-positive patients with anal squamous cell carcinoma.

PURPOSE: With improved antiretroviral therapy, HIV-positive patients are achieving a longer life expectancy. An increased incidence of anal squamous cell carcinomas has been noted in these patients. The purpose of this study was to determine the outcome of HIV-positive patients with anal squamous cell carcinomas. METHODS: We conducted a review based on our tumor registry from 1980 through 1999. We identified 73 patients with anal squamous cell carcinoma treated at the University of Texas Southwestern Medical Center affiliated hospitals; 23 were HIV positive (18 had AIDS). In the HIV-positive group, 9 had in situ squamous carcinomas and 14 had invasive squamous cell carcinomas. Data collected included age, CD4 count, treatment, complications, and survival; these data were analyzed by Student's t-test. RESULTS: All patients were male. Those with squamous cell cancer of the anus were offered radiation therapy and chemotherapy. Beginning in 1998, all patients received highly active antiretroviral therapy before treatment. Seven of 14 anal squamous cell carcinoma patients had their therapy adjusted owing to toxicity. Morbidity included proctocolitis and diarrhea (n = 2) requiring diversion (n = 1), hemorrhagic cystitis (n = 1), neutropenic fever (n = 3), bone marrow suppression (n = 1), and urethral stricture (n = 1). Mean age was 42 years for anal squamous cell carcinoma patients and 36 years for squamous cell carcinoma in situ patients (P = 0.05). Mean CD4 count was 222 cells/ml in patients with infiltrating carcinoma and 200 in the in situ patients (P = NS). One-year and five-year mortality rates, respectively, were 40 percent and 80 percent for infiltrating carcinoma patients and 17 percent and 50 percent for the in situ patients. Both of the in situ patients who died had CD4 counts <20 cells/ml at diagnosis, whereas the rest had CD4 counts >100 cells/ml and are currently without anal disease. Mean CD4 count at diagnosis for all patients who died was 133 cells/ml, whereas for those surviving, it was 261 cells/ml (P = 0.03). Eight (all with infiltrating carcinoma) of the 10 patients who died had persistent anal disease, but none had metastasis. CONCLUSION: HIV-positive patients with in situ carcinomas present at an earlier age than those with infiltrating lesions. In situ patients with CD4 counts as low as 105 cells/ml do well with local excision. A low CD4 count at diagnosis without highly active antiretroviral therapy predicts a poor prognosis. Because these patients appear to succumb to their HIV status and not the anal disease, anal squamous cell carcinoma should be included with cervical squamous cell carcinoma as an AIDS-defining illness. HIV-positive patients, particularly AIDS patients, with invasive anal cancers and without effective antiretroviral therapy obtain little benefit and significant toxicity from current radiation therapy and chemotherapy. Initiation of highly active antiretroviral therapy in HIV-positive patients before radiation therapy and chemotherapy are begun may decrease toxicity and improve survival. Additional clinical trials are warranted to test this theory.

Adult↗
PubMed1999

Can quinolones cause hemorrhagic colitis of late onset? Report of three cases.

PURPOSE: This study was undertaken to demonstrate that quinolones may cause acute colitis resembling penicillin-induced hemorrhagic colitis. METHODS: We reviewed the medical records of patients with acute colitis in our institutes. Twenty-eight patients with acute hemorrhagic colitis in which no pathogenic microorganisms were identified were the subjects of this study. Pseudomembranous colitis caused by Clostridium difficile was excluded. Ulcerative colitis, Crohn's disease, and radiation proctocolitis were also excluded. RESULTS: Among these patients, 25 had a history of recent administration of penicillin derivatives. The remaining three patients had never been given any penicillin derivatives, but had ingested quinolones approximately four weeks before the developing colitis had been identified. Klebsiella oxytoca was also isolated in these three patients. CONCLUSIONS: Quinolones may cause acute hemorrhagic colitis. The time interval from antibiotic ingestion to onset of the condition may be much longer in quinolones than in penicillin derivatives.

Acute Disease↗
PubMed1986

Carcinoma in Crohn's disease of the colon.

Two cases of carcinoma in Crohn's disease of the colon are reported. One patient was a 30-year-old man who had asymptomatic Crohn's ileocolitis resulting in an acute presentation due to toxic dilatation of the colon. This was preceded by a short prodromal period of four weeks, characterized by intermittent diarrhea on the basis of a coloileal tumor fistula. A mucus-secreting adenocarcinoma was present in the sigmoid colon associated with both adjacent and one nearby focus of high-grade mucosal dysplasia. Pelvic wall and abdominal metastases were present, and the patient died two months later. The other patient was a 60-year-old woman who had a nine-year history of biopsy-proven Crohn's proctocolitis. A stricture of the sigmoid colon due to Crohn's disease also harbored an invasive adenocarcinoma. The carcinoma was not evident preoperatively or on initial gross pathologic examination. The presentation and pathology of large intestinal carcinoma in Crohn's colitis are discussed and illustrated.

Adenocarcinoma↗
PubMed1984

Rectocolonic calcification due to schistosomiasis. A clinicoradiologic study.

Four patients who had intravenous pyelography were found to have radiologically visible calcification of the rectocolon and urinary tract due to schistosomiasis. All four patients had mild proctocolitis colonoscopically and multiple calcified schistosomal ova were found in the submucosa histologically. The authors believe that radiologically visible rectocolonic calcification is more common than reported and that it is associated with a clinically mild or latent form of schistosomiasis.

Adult↗
PubMed1988

Emergency colectomy for cytomegalovirus ileocolitis in patients with the acquired immune deficiency syndrome.

The charts of all patients with the acquired immune deficiency syndrome (AIDS) who underwent emergency intra-abdominal surgery between January 1981 and July 1987 were reviewed. Eleven AIDS patients underwent 13 emergency laparotomies. Seven of these patients (64 percent) had cytomegalovirus (CMV) ileocolitis as the pathologic process requiring emergent surgical intervention. Four patients had hemorrhagic CMV proctocolitis and three had perforations of CMV ulcers of the ileum or rectosigmoid. The operations performed included three subtotal colectomies, two segmental resections, and two diverting stomas. The postoperative mortality rate in the CMV group was 28 percent at one day, 71 percent at one month, and 86 percent at six months. Furthermore, CMV ileocolonic pathology was directly responsible for 70 percent of the deaths in AIDS patients who underwent emergent exploratory laparotomy.

Acquired Immunodeficiency Syndrome↗
PubMed1981

Simultaneous onset of ulcerative colitis in the rectum and in a segment of colon used for colpopoiesis: report of a case.

A patient is described in whom a segment of colon used to construct an artificial vagina was therefore removed from intestinal continuity and was affected by typical idiopathic ulcerative colitis. The onset of disease was simultaneous in this loop of colon and in the rectum. There was no evidence of local infection. An increased ratio of IgE-plasma cells was found in both the mucosa of the grafted colon and that of the rectum, but anticolonic antibodies were not detected in the serum. After removal of the loop of colon used for colpopoiesis, the patient continued to suffer from distal proctocolitis for almost a year, but has since then maintained a stable remission without treatment. The etiology of ulcerative colitis is discussed, and attention is drawn to the unusual psychologic aspects of this case.

Adult↗
PubMed1996

Anatomic basis of mesenteric elongation for ileo-anal anastomosis with J-shaped reservoir: comparison of two techniques of vascular section.

Total proctocolectomy followed by ileo-anal anastomosis with a reservoir is the operation of choice for the treatment of familial adenomatous polyposis and of certain forms of hemorrhagic proctocolitis. Vascular section is sometimes necessary to enable the extremity of the reservoir to reach the anal sphincter without traction. The aim of this study was to compare the gain in length obtained by two different techniques of vascular section and to assess in terms of the vascular anatomy of the last small intestinal loop which technique best preserved the vascularisation of the reservoir as a whole. Twenty-two fresh cadavers had an ileal J-shaped reservoir of 18 cm fashioned from the last loop of small intestinal loop after section of the root of the mesentery. The gains in length so obtained were measured after section of the ileocolic a. at its origin (group A) or section between the two vascular arches of the last small intestinal loop (group B); the superior mesenteric vessels were then injected with colored resin. The gain in length obtained by these two methods was identical (2.3 +/- 1.1 cm for group A as against 2.18 +/- 0.9 cm for group B), but only if the section of the ileocolic a. was accompanied by section of the mesenteric peritoneum up to the vascular arch formed by the anastomosis between the terminal branch of the superior mesenteric a. and the ileocolic a. The constancy of this anastomosis always allowed section of the ileocolic a. while preserving good vascular distribution to the entirety of the reservoir. Section between the two arches was difficult when the distance separating them was small.

Anal Canal↗
PubMed2005

Adenocarcinoma of the ileoanal pouch for ulcerative colitis--a complication of severe chronic atrophic pouchitis?

BACKGROUND: The appearance of a carcinoma in the ileal pouch after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative proctocolitis is rare. Most of these adenocarcinomas previously described in literature develop from residual viable rectal mucosa. We report a case of an adenocarcinoma arising in all probability from the ileal pouch after malignant transformation of the ileal pouch mucosa based on a chronic atrophic pouchitis. PATIENT AND METHODS: A 34-year-old man developed an adenocarcinoma after a double-stapled ileorectal J-pouch for ulcerative colitis (UC) proceeded from malignant ileal transformation. Before surgery, he had a 20-year history of UC refractory to medical therapy, but no occurrence of backwash ileitis, dysplasia or colitis-associated illness. He experienced severe pouchitis after IPAA since the ileostomy closure. Carcinoma was ensured by endoscopy, and the patient underwent an abdominoperineal pouch extirpation combined with excision of perirectal tissues and anal canal. Histology after surgery showed a pT4,pN2(4/16)pM0,G3 adenocarcinoma with global severe chronic atrophic pouchitis (CAP), villous atrophy and malignant ileal transformation. No metaplasia of the rectal mucosa was found, not even malignant epithelial transformation of the anal canal. CONCLUSION: This case suggests that a malignant transformation of the ileal pouch mucosa may occur as a pure complication of severe CAP, even in the absence of backwash ileitis or a previous history of cancer. The absence of metaplasia of the rectal mucosa revealed the passage from CAP to dysplastic epithelium and to cancer. A multifactorial development of carcinogenesis is supposed, but we emphasize the importance of severe CAP, and that careful surveillance is needed in patients after IPAA. We must submit that this is just a case report and cannot stand for general cancer development in ulcerative colitis, but it may point out the risk factor of chronic inflammation and leads the surgeon to skillful working when building the pouch.

Adenocarcinoma↗
PubMed2002

Mucosal assessment for dysplasia and cancer in the ileal pouch mucosa in patients operated on for ulcerative colitis--a 30-year follow-up study.

PURPOSE: Sporadic reports of epithelial dysplasia and the occasional development of adenocarcinoma in the ileal pouch mucosa have recently appeared in the literature, pointing toward yet another long-term complication of the continent ileostomy and the pelvic pouch. The incidence of dysplasia and the risk for developing cancer has not been critically evaluated, however, and the reports are contradictory, with most having short observation times. The purpose of this study was to report long-term mucosal adaptation patterns and the incidence of dysplasia in Kock pouches after a mean follow-up of 30 years for patients previously operated on for ulcerative proctocolitis. METHODS: Two sets of two pathologists each (in Gothenburg, Sweden, and Manchester, United Kingdom) examined sequential, small-intestinal biopsy specimens from 40 patients with Kock pouch to observe long-term epithelial changes, with particular reference to the presence of dysplasia. RESULTS: There was full agreement between the two groups regarding the absence of high-grade dysplasia and invasive carcinoma (Categories 4 and 5 of the Vienna classification). There was, however, significant disagreement in reporting the frequency of low-grade and indefinite categories of dysplasia (Categories 2 and 3, of the Vienna classification). No attempt was made to report the differences within each set of pathologists. CONCLUSION: Because no case of high-grade dysplasia or invasive carcinoma was found in this study after a mean follow-up of 30 years, we conclude that it is very unlikely for invasive carcinoma to be a complication in ileal pouch mucosa.

Adenocarcinoma↗
PubMed2003

Proctitis and Sexually Transmissible Diseases of the Colon.

In patients with gastrointestinal symptoms and a history of anal-receptive intercourse, a careful but explicit history concerning sexual preferences and practices is required. Clinically, four infectious syndromes can be distinguished: perianal disease, proctitis, proctocolitis, and enteritis. Each of these syndromes may be caused by a certain range of pathogens. In immunocompromised patients, additional diseases must be considered. Clinical examination, a rectal swab with incubation in specific transport media, as well as a Gram stain of mucus or pus from a rectal swab, in combination with a rectosigmoidoscopy are helpful in differentiating specific diseases. Stool cultures and serologic examinations may identify specific causes of colitis or enteritis, but are of minor importance in the case of anorectal disease. Good treatments are available for most sexually transmitted anorectal diseases. An additional role for the treating physician and other healthcare providers is to educate and counsel patients and their sex partners on ways to adopt safer sexual behavior.

Journal Article↗
PubMed1979

Operative management of radiation injuries of the intestinal tract.

A review of forty cases of radiation-induced gastrointestinal injuries is presented. Based on this experience and reports in the literature, preoperative management and operative technics are discussed. The increased risk of radiation bowel injury is recognized in patients who have had previous operations. Preradiation contrast studies are advised to identify trapped loops of intestine in the pelvis. Small bowel resection is recommended with localized segments of disease. Bypass operations are preferable to avoid any extensive dissections. Bypass operations have anastomotic dehiscence rates similar to those of resections. Proctocolitis is usually managed by diverting colostomy, with resection in a few favorable cases or with treatment failures. Most rectovaginal fistulas are managed by permanent colostomy. Small bowel fistulas are best treated by bypass with partial or total exclusion rather than by primary resection. Vigorous preoperative and postoperative nutritional support and evaluation are vital because of the poor healing qualities of irradiated bowel. Multiple operative procedures should be anticipated because the natural history of radiation bowel injury is slowly progressive.

Aged↗
PubMed1991

The effect of adrenergic agonists and antagonists on cysteine-proteinase inhibitor (cystatin) in rat saliva.

The effect of a number of adrenergic agonists and antagonists on the induction of rat salivary cystatin was investigated. A highly sensitive and specific radioimmunoassay was used to determine cystatin in rat whole saliva. Treatment for 10 consecutive days with a non-specific beta-adrenergic agonist isoproterenol, or the beta 1-adrenergic agonists dobutamine or methoxyphenamine, resulted in the induction of the salivary cystatin. Induction was also found in rats treated for 10 days with arterenol. Only trace quantities of cystatin could be detected in saliva of rats treated with the beta 2-adrenergic agonists terbutaline or salbutamol. When isoproterenol was injected concomitantly with the mixed beta-antagonist propranolol or the beta 1-adrenergic antagonists metaprolol, proctocol or atenolol the production of cystatin was totally suppressed. However, the beta 2-antagonist, ICI 118551, produced only a partial reduction in salivary cystatin induction elicited by isoproterenol. The findings suggest that the induction of salivary cystatin is regulated, in part, by beta 1-adrenergic receptor stimulation.

Adrenergic beta-Agonists↗
PubMed1995

Glutaraldehyde colitis following endoscopy: clinical and pathological features and investigation of an outbreak.

Although potentially noxious compounds are used routinely to disinfect endoscopes, reports of their inadvertent introduction to the gastrointestinal tract, usually attributed to the retention of disinfectant within endoscope channels, are rare. This case report describes the clinical features of glutaraldehyde-induced colitis and the pathology of the mucosal injury in four patients, in at least one of whom the disinfectant was not retained in the endoscope itself. Within 3 months, three patients experienced severe acute proctocolitis < 6 hours after a sigmoidoscopy showing no abnormalities, performed in a small endoscopy unit. Investigation of the unit's protocols suggested that the most likely cause was retention of 2% glutaraldehyde disinfectant in the endoscope channels, and changes were made to prevent this. When a fourth case occurred 5 months later, the source of the glutaraldehyde was found to be the tubing connecting water bottles to the endoscopes, which was disinfected rigorously but flushed inconsistently between cases. Glutaraldehyde-induced colitis seems similar to ischemic colitis in biopsy specimens and cannot be diagnosed by histological analysis alone. Acute colitis occurring within 24 hours of a colonoscopy showing no abnormalities should be considered iatrogenic and should lead to an investigation of procedures in use for cleaning and disinfecting endoscopic equipment.

Aged↗
PubMed1994

Gastrointestinal disease in the immunocompromised patient.

Gastrointestinal (GI) disease is frequent in all types of immunocompromised patients but occurs with greatest frequency in patients with acquired immunodeficiency syndrome (AIDS). Thus, much of this review deals with human immunodeficiency virus (HIV)-related GI diseases. Gastrointestinal diseases in other immunocompromised patients are compared with those in patients with AIDS. Conditions unique to transplant recipients, such as graft-versus-host disease (GVHD) and posttransplant lymphoproliferative disorders (PTLDs), are discussed separately. We have divided these GI diseases into four main categories: (1) HIV-related inflammatory conditions other than opportunistic infections (HIV-related enteropathy, proctocolitis, and CD8 lymphocytosis); (2) inflammatory conditions unrelated to HIV or opportunistic infections (neutropenic enterocolitis, regional enteritislike enteropathy, and GVHD); (3) opportunistic infections (illnesses caused by herpesvirus, cytomegalovirus, and miscellaneous other viruses; Mycobacterium, Candida, Histoplasma, Cryptococcus, Cryptosporidium, Microsporida, Isospora, Leishmania, Toxoplasma and Strongyloides organisms as well as Pneumocystitis carinii; and (4) neoplasias (Kaposi's sarcoma [KS], AIDS-related non-Hodgkin's lymphoma [NHL], HIV-related Hodgkin's disease [HD], PTLDs, and miscellaneous neoplasms). The prevalence, pathogenesis, clinical manifestations, gross pathological findings, and microscopic features of each disease entity are discussed.

AIDS-Related Opportunistic Infections↗
PubMed1983

Benoxaprofen in the treatment of active ulcerative colitis.

We have conducted an open pilot trial to assess the therapeutic effect of the lipoxygenase inhibitor, benoxaprofen, in 10 patients with active ulcerative proctocolitis. After 18 days treatment with benoxaprofen (600 mg daily) there was no significant change in bowel habit, rectal bleeding, constitutional upset, sigmoidoscopic appearance, mucosal histology, haemoglobin, ESR, serum albumin or serum orosomucoid. Benoxaprofen itself seems unlikely to prove useful in ulcerative colitis, but evaluation of the therapeutic potential of other lipoxygenase inhibitors in inflammatory bowel disease may be worthwhile.

Adolescent↗
PubMed1992

Medical management of severe inflammatory disease of the rectum: nutritional aspects.

It is clear that the nutritional state of patients with inflammatory bowel disease is often impaired and can be improved by the provision of nutritional support. Improvement in nutritional status can be achieved as effectively with enteral as with parenteral nutrition. Nutritional support appears to have no primary therapeutic effect in patients with ulcerative colitis. With regard to nutritional support in Crohn's disease, parenteral nutrition should be restricted to use as supportive rather than primary therapy. Available information now seems to suggest that most of the benefits of parenteral nutrition in Crohn's disease are related to an improvement in nutritional state rather than as primary therapy, and its use should be restricted to the treatment of specific complications of Crohn's disease, such as intestinal obstruction related to stricture formation or short bowel syndrome following repeated resection. Although some doubt exists over the efficacy of oligopeptide-containing elemental and polymeric enteral diets, the present evidence indicates that chemically defined free amino acid-containing elemental diets have primary therapeutic efficacy in the management of acute exacerbations of Crohn's disease. As such, these diets are worthy of therapeutic trial in patients with severe Crohn's disease involving the distal colon and rectum, particularly in those patients who are malnourished and who prove to be resistant to treatment with a combination of topical corticosteroids and 5-aminosalicylic acid-containing compounds. Clinicians should be aware, though, that the beneficial effects are likely to be restricted to the short term, with high relapse rates by 1 year, this being particularly so in patients with distal Crohn's proctocolitis (Teahon et al, 1988). Volatile fatty acid enemas clearly have potential in the management of patients with severe steroid-resistant proctitis. Finally, one of the most important observations made in recent years is the one concerning the large losses of nitrogen that will occur in patients with inflammatory bowel disease treated with corticosteroids in the absence of adequate protein intake (O'Keefe et al, 1989). Hopefully the days of treating patients with severe inflammatory bowel disease with high dose corticosteroids and a peripheral dextrose or dextrose-saline drip have passed into history.

Colitis, Ulcerative↗