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[Linitis plastica extending through the entire digestive tract. A case report].

A 43-year-old man who presented a perplexing diagnostic challenge, had diffuse linitis plastica involving the entire gastrointestinal tract (autopsy). Although the usual primary site is the stomach in case of linitis plastica, invasion of the large and small bowel is rarely seen, but must be searched with proctoscopic exam and barium enema. We review the literature and discuss the pathogeny of this disorder.

Adenocarcinoma, Scirrhous↗

[A case of rectal cancer with malacoplakia].

A 59-year-old man was hospitalized for rectal bleeding. Barium enema and proctoscopy revealed an elevated tumor, completely stenosing the rectum. The microscopic features of the specimens obtained by proctoscopic biopsy of the tumor comprised aggregations of histiocytes with intracytoplasmic inclusions (von Hansemann cells and Michaelis-Gutmann bodies). Rectal malacoplakia was diagnosed. In the course of laparotomy, the tumor was found to be strongly infiltrated to the pelvis. Thus, radical surgery was not performed, and an artificial anus was made. Excisional biopsy from the tumor tissue revealed the features of well-differentiated adenocarcinoma and malacoplakia. Forty-three cases of malacoplakia of the gastrointestinal tract from a review of the literature including ours were collected and discussed.

Adenocarcinoma↗

Surgical treatment of low-lying carcinoma of the rectum.

The standard operative treatment of low-lying rectal cancer has been abdominoperineal resection. In the elderly patient, this treatment has significant risk. One-fourth of the patients had major complications and another one-fourth had minor complications. The operative mortality was 6.8 per cent for patients 65 years of age and over and 7.7 per cent for patients 70 years old and over. Patients with metastatic disease at the time of diagnosis had a dismal prognosis despite treatment with abdominoperineal resection. Postoperative pelvic radiotherapy should help reduce pelvic recurrence. Generally, patients with tumors less than 5 cm in diameter and less than 5 cm from the dentate line should be considered for initial transanal excision. It appears that very good local tumor control can be achieved by transanal excision for tumors confined to the bowel wall. Only 6.9 per cent of patients with tumors confined to the bowel wall had lymph node metastasis. The low risk of occult lymph node metastasis from tumors confined to the bowel wall is offset by the operative risk of abdominoperineal resection. Further evaluation of transanal excision of selected rectal cancers is indicated. Patients with villous adenomas with superficial carcinoma can be adequately treated repetitively with transanal local excision. In this case, there was a 50 per cent local recurrence rate. Local recurrence occurred in some patients five or more years after the initial treatment, thus emphasizing the need for prolonged close proctoscopic follow-up.

Adenocarcinoma↗

Evaluation of the Proximate-ILS circular stapler. A prospective study.

In a prospective open study of the Proximate ILS circular stapler, the results of 125 intestinal anastomoses in 119 patients were reviewed. Intraoperative leakage was observed in five instances, after intraluminal povidone instillation, necessitating suture-line reinforcement. In three instances, incomplete tissue rings (donuts) were found. Temporary fecal diversion was used in seven of 84 patients with anastomoses made to the rectum or anal canal. Roentgenographic assessment of 79 of these anastomoses using Gastrografin demonstrated a leak in three (3.8%). There was one clinical leak (0.9%) in the series. Three patients died (2.5%), none from anastomotic complications. Transient anastomotic strictures were found in three of 82 operative survivors where the anastomosis was within range of the proctoscope. There were no instances of significant hemorrhage from the anastomosis. No patient required anastomotic revision, and of the 51 survivors of cancer surgery where proctoscopy could evaluate the anastomosis, there was no evidence of local recurrence in the period of follow up (mean 16.3 months). The authors conclude: that the Proximate ILS is a safe, reliable and effective instrument for construction of intestinal anastomoses.

Aged↗

Rectal gunshot wounds. Management of civilian injuries.

The diagnosis and operative management of 43 consecutive low velocity wounds of the rectum were evaluated with regard to postoperative morbidity and mortality. Rectal and proctoscopic examinations, although frequently positive (80% and 91%, respectively), were not uniformly reliable in making the preoperative diagnosis. Diversion of the fecal stream by colostomy occupies a key role in operative management. Loop colostomy appears not only as efficacious as end colostomy and mucus fistula, but also requires less time to perform and subsequently close. Distal rectal washout is an important adjunct which reduces the incidence of rectal and intra-abdominal infectious complications. Civilian and military wounds of the rectum appear to differ in terms of the postoperative complications, mortality rate, and management techniques.

Adolescent↗

Endoscopic evaluation of the effect of indomethacin capsules and suppositories on the gastric mucosa in rheumatic patients.

Twelve patients with rheumatic diseases took part in a 6-week double-blind crossover trial comparing 14 days of oral with 14 days of rectal indomethacin treatment, 50 mg 3 X /day, with a 14-day placebo period. The patients had a gastroscopic and a proctoscopic examination after each of the 3 periods. The gastric acid production, serum concentrations and the 24-h urine excretion of indomethacin was measured. Both indomethacin capsules and suppositories caused an equal amount of gastric damage, indicating that the irritative effect of indomethacin on the gastric mucosa is not a local effect, but due to a systemic effect of indomethacin. Although the suppositories caused some mucus discharge no mucosal damage was found by proctoscopy.

Adult↗

Antibiotic-associated diarrhea treated with oral tetracycline.

Three patients developed severe, incapacitating diarrhea after antibiotic administration. Presenting features included abdominal discomfort, hematochezia, and hypokalemia from voluminous diarrhea. Roetgenographic studies in 1 patient were normal and proctoscopic examinations in 2 patients failed to show antibiotic-associated colitis. Stool cultures were negative. Despite cessation of antibiotics and symptomatic therapy, the diarrhea continued. After the administration of oral tetracycline, the diarrhea stopped without recurrence even after the tetracycline was discontinued. These clinical results suggest that patients with antibiotic-associated diarrhea may benefit from tetracycline when standard medical therapy fails.

Administration, Oral↗

Japanese adult siblings with Tangier disease and statistical analysis of reported cases.

A 28 year old Japanese female was admitted to our university hospital because of extremely low plasma cholesterol levels (50mg/dl). On physical examination, tonsillar remnants and several flat patches of yellow-orange lymphoid tissues in the pharynx were found. Her plasma HDL was as low as 2.4 mg/dl. Laparoscopic findings showed typical yellow patches on the surface of the liver, and liver biospy specimens contained cholesterol esters demonstrated by the Schultz reaction. Colonofiberscopy showed orange-brown spots present throughout the rectum. Histologically, "foam cells" were recognized in the lymphoid tissue of the pharynx and rectal mucosa. Her sister, 26 years old, also revealed yellow-orange tonsils, low plasma cholesterol levels (39mg/dl) and low plasma HDL levels (8mg/dl), and was also diagnosed as Tangier disease. From a statistical analysis of the reported cases, it is noteworthy that yellow-orange tonsils, which were said to be the hallmark of Tangier disease, were not found in 20% of the patients. However, it is important that we could find rectal mucosa studded with orange-brown spots in all of the cases examined, and it contained "foam cells" histologically. It was concluded that when we suspect Tangier disease on account of hypocholesterolemia, we must first do a proctoscopic examination.

Adult↗

[Septic complications after total colectomy, excision of the rectal mucosa ileoanastomy and its prevention--with special reference to pelvic sepsis].

Forty-two patients had total colectomy, excision of th rectal mucosa and ileoanastomy for adenomatosis coli or ulcerative colitis. The essential operative management for prevention of pelvic sepsis are 1) intraoperative bowel irrigation with antimicrobes, 2) creation of temporary defunctioning ileostomy, 3) effective drainage of the rectal cuff. With these methods pelvic sepsis developed in ten out of forty contaminated case. Whereas in one contaminated case both pelvic sepsis and wound infection developed. Age of the patients, the presence of underlying diseases, type of reservoir and surgeon's experience had no correlation with the incidence of pelvic sepsis, however the short rectal cuff seemed significant for its prevention. The stenosis of the transposed ileum had developed in two cases, one of which case had recurrence of pelvic sepsis after closure of ileostomy. One patient had chronic fistula between transposed ileum and perineum after removal of the transperineal drainage. These complications are very difficult to manage. Three patients had closure of ileostomy with satisfactory result. Proctoscopic examination were essential to identify with anastomotic break down and pus discharge. Irrigation of the transposed ileum with antimicrobes for aerobes and anaerobes should be started after diagnosis. Incision and drainage were necessary when irrigation failed to heal cuff abscess.

Adenoma↗

[Influence of rectal preparation by enema on cell proliferation in the normal rectal mucosa in man].

In order to study the potential influence of rectal enemas on epithelial cell proliferation, two groups of 13 patients without any disease of the digestive tract were compared, one group having received two warm enemas (Normacol) prior to proctoscopic examination. Cell proliferation was studied by in vitro incorporation of tritiated thymidine in mucosal biopsies and radioautographic analysis of the number and position of labeled nuclei in the glands. The mean number of labeled cells per gland and the mean labeling index were significantly higher in group i (with enemas) than in group II (without enema). In group I there was an extension of the proliferative compartment towards the surface with less than 50 p. 100 of labeled cells located in the lower third of glands. Intraindividual variations of labeling index from gland to gland were more important in group I than in group II. In group I, eight out of 13 patients had rectal glands with elevated labeling indices (15 p. 100) in contrast to one patient in group II. Our results suggest that proliferation abnormalities observed in group I are related to enema administration and indicate that this type of rectal preparation should preferably be excluded whenever cell kinetic parameters are studied in the rectal mucosa.

Adult↗

Campylobacter Gastroenteritis.

Campylobacter fetus ss. jejuni has recently been recognized as a very common cause of gastroenteritis. Symptoms of Campylobacter gastroenteritis include fever, diarrhea, abdominal pain, myalgia and headache. Bloody diarrhea occurs in about 50 percent of patients. This organism is now being isolated more frequently than Salmonella or Shigella in cases of diarrhea. Acute colitis mimicking Crohn's disease or ulcerative colitis on proctoscopic examination and on barium enema x-ray has been described. The drug of choice for therapy is erythromycin.

Adult↗

Diarrhea due to Campylobacter fetus subspecies jejuni. A clinical review of 63 cases.

Campylobacter fetus subspecies jejuni was isolated fom the feces of 63 (3.2%) of the 1,953 patients who had stools cultured at the Mayo Clinic in 1979. In contrast, Salmonella and Shigella combined were isolated from 31 (1.6%) patients. Two patients had double infections with Salmonella species and C. fetus subsp jejuni. Three patients had no diarrhea at the time of stool culture. One patient, who had chronic lymphocytic leukemia, had both blood and stool cultures positive for C. fetus subsp jejuni. There was a seasonal incidence that peaked in July when 7.8% of all patients who had stools cultured had C. fetus subsp jejuni isolated. Thirteen cases occurred in children 5 years of age and younger and 29 cases occurred between the ages of 15 and 30 years. Clinical features often included a prodrome of malaise, which preceded the onset of abdominal cramps, diarrhea, anorexia, fever, nausea, and vomiting. Grossly bloody diarrhea occurred in 33 patients, and massive intestinal bleeding occurred in 1 patient as a late complication after diarrhea had resolved. Transient splenomegaly was attributed to C. fetus subsp jejuni on one occasion. Proctoscopic findings may be similar to those seen in inflammatory bowel disease or pseudomembranous colitis. Three patients were referred to this institution with newly diagnosed chronic ulcerative colitis, and one patient was referred with newly diagnosed Crohn's disease. C. fetus subsp jejuni was isolated from their stools, and the diagnosis of inflammatory bowel disease was subsequently dropped. A selected review of cases illustrates the variety of gastrointestinal manifestations seen with this organism.

Adolescent↗

Large intestinal biopsies from normal dogs.

Proctoscopic examination and rectal and colonic biopsies were performed in 10 clinically normal dogs. There was some variation between individuals in the gross and light microscopic appearance of normal canine large intestine but the findings were distinct from those in disease.

Animals↗

Proctitis and colitis following diversion of the fecal stream.

Inflammation limited to excluded segments of the colon was observed in 10 patients without prior inflammatory bowel disease who had undergone colostomy or ileostomy for various indications. With the exception of 1 patient who complained of mucoid rectal discharge, the patients were asymptomatic when the lesion was discovered; 2 others subsequently developed mild symptoms. The proctoscopic findings were similar in appearance to those of mild ulcerative colitis. In 8 of 10 patients the inflammatory changes were confined to the distal few centimeters of the rectum, while in the remaining 2 patients the entire excluded segment was affected. Microscopic alterations were focal and included crypt abscesses, epithelial cell degeneration, acute and chronic inflammation in the lamina propria, and regenerative changes in the crypts. The inflammation persisted for as long as 8 yr in the 5 patients who did not have restoration of intestinal continuity, but subsided in the 5 patients whose colostomies were closed. The prior as subsequent clinical courses of these patients, together with the focal, nonspecific microscopic features, strongly suggest that the inflammation in these patients resulted from diversion of the fecal stream and was not a recognized form of specific or idiopathic colitis. Diversion-related colitis must not be confused with other forms of inflammation since this may result in improper therapy and/or delay in treatment of the condition for which the fecal diversion was performed.

Adult↗

Local excision of rectal tumours with transanal endoscopic microsurgery.

Transanal Endoscopic Microsurgery (TEM) is a novel technique, first introduced by Buess and coworkers in 1983 for the treatment of large sessile polyps of the rectum. Due to the excellent results the indication was then extended also for the removal of low risk early adenocarcinomas (pT1, G1-G2). TEM allows, by using an operative proctoscope of an outside diameter of only 4 cm., all the conventional surgical manoeuvers within the rectal lumen, up to 20 cm. from the anal verge. The Authors report a consecutive series of 53 patients submitted to TEM over a 37 month period; apart from 7 patients excluded for different reasons, postoperative diagnosis showed 30 adenocarcinomas (65.2%), 15 adenomas (32.6%) and 1 epidermoidal carcinoma (2.2%). The low recurrence rate observed both for adenomas (0%) and pT1 adenocarcinomas (9%) coupled with the optimum vision allowed by the 6-fold magnified stereoscopic view, make this technique the method of choice for selected patients with these kind of pathologies.

Adenoma↗

Transanal endoscopic anorectal mucosectomy with ileal pouch anal anastomosis for familial adenomatous polyposis. A case report.

In patients with familial adenomatous polyposis (FAP) who are undergoing ileal pouch-anal anastomosis (IPAA), transanal mucosectomy can be performed without excessive anal dilatation and manipulation using the operative proctoscope introduced by Buess. In this way, mucosectomy under a direct three-dimensional six-fold magnified view is accurate and bloodless.

Adenomatous Polyposis Coli↗

Antibiotic-associated pseudomembranous colitis.

This review defines the entity pseudomembranous colitis and briefly outlines the supposed etiologic causes of pseudomembranous colitis including antibiotics. The incidence, mortality rate, and natural history of antibiotic-related pseudomembranous colitis is contrasted with other forms and causes of pseudomembranous colitis. The clinical spectrum of antibiotic-related pseudomembranous colitis, ranging from a nonbloody, watery diarrheal state to a life-threatening condition mimicking an acute surgical abdomen, is reviewed. The classic proctoscopic and pathologic findings, as well as common problems encountered in interpretation, are discussed. A complete review of the spectrum of radiographic findings is presented from the nonspecific to the quite characteristic radiographic findings, including both plain film and contrast studies of the colon. These findings are contrasted with the X-ray features of other inflammatory and ischemic colitides and a differential diagnosis is discussed. A section dealing with the treatment of antibiotic-associated pseudomembranous colitis will be included. This section will review the various modes of therapy that have been employed. Finally, a brief section will speculate on the possible etiologic role that antibiotics play in pseudomembranous colitis, including the alteration of the bacterial flora and possible effect on bile salt metabolism.

Administration, Oral↗

[Consensus hemorrhoids (Dutch Society for Surgery)].

On the initiative of the Dutch Surgical Society a consensus meeting was held on December 3rd, 1993 in Utrecht, the Netherlands by the National Organisation for Quality Assurance in Hospitals (CBO), on the diagnosis and treatment of haemorrhoids. The following statements were formulated. Haemorrhoids are vascular cushions, covered by mucosa, originating from the plexus rectalis superior, and are part of the normal anatomy of man. Complaints from haemorrhoids occur if they prolapse. The usual 4-grade classification of haemorrhoids has no direct impact on their treatment. Portal hypertension is not a cause of haemorrhoids. Blood loss, a sensation of prolapse, pruritus and soiling are non-specific symptoms of haemorrhoids. Anaemia may only be attributed to haemorrhoids after other pathology has been excluded. Acute massive anorectal blood loss is frequently caused by traumatic damage to the rectum. Anticoagulant therapy is a risk factor. The presence of unexplained perianal skin lesions neccessitates further proctologic investigation. Haemorrhoids are not palpable on rectal digital examination. In patients under 50 with anorectal blood loss and a history of haemorrhoids, a proctoscopic examination is sufficient. Anorectal blood loss in patients over 50 requires exclusion of higher pathology. The regulation of defaecation and eating habits can have a preventive effect on the development of haemorrhoids. Conservative measures form the basis of treatment for haemorrhoidal complaints. Local antihaemorrhoidal treatment can only be expected to give short-term relief and is not a causal therapy. Barron elastic band ligation and sclerosing, in addition to infrared coagulation are treatment modalities in the outpatient setting that are very effective, inexpensive and optimally patient-friendly.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorrhoids↗