"Lower" gastrointestinal tract hemorrhage: new concepts based on arteriography.
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Extrapelvic spread of disease, particularly from gastrointestinal tract perforations which may be clinically occult, may first present in the buttock, hip, thigh, and even lower leg, and the extraperitoneal space of the abdomen itself. Clinical manifestations at these remote sites may be very misleading. Anatomic and roentgenologic observations establish the preferential pathways of extrapelvic spread. These are related to the insertions and fascial investments of the iliopsoas, pyriformis, and obturator internus muscles and the ensheathed penetrations of the superior gluteal arteries. Superiorly, extension from the pelvic tissues seeks out the posterior pararenal compartment of the extraperitoneal region of the abdomen. Roentgenologic signs may first identify the presence, extent, and localization of the primary process.
The barium enemas of 119 patients with colorectal cancer and 119 age-matched controls were examined for evidence of diverticula. Amongst men, 39.6% of patients with colorectal cancer had diverticulosis, compared with 50% in the control group. In the women, 39.3% of patients with colorectal cancer had diverticular disease, compared with 36% of the controls. There appears to be no significant aetiologic association between the two conditions, since they do not occur together more frequently than in controls, although each is reputedly the result of fibre lack.
Protein kinase C (PKC) activity was measured in the inflamed colonic mucosa of 24 patients with ulcerative colitis and in the normal colonic mucosa of 10 patients with other benign diseases. The particulate fraction activity in ulcerative colitis mucosa was significantly increased compared with that of normal mucosa (320 +/- 47 versus 200 +/- 30 pmol/min/mg protein; p less than 0.05). Inflamed ulcerative colitis mucosa also showed significantly increased total PKC activity in the particulate fractions compared with normal mucosa (147 +/- 26 versus 37 +/- 8 pmol/min/mg tissue; p less than 0.05). Mucosal samples from ulcerative colitis patients were divided into 12 with mild and 12 with severe inflammation by histologic examination. The particulate PKC activity of severely inflamed mucosa was significantly lower than that of mildly inflamed mucosa (p less than 0.05). These results indicate that colonic inflammation in ulcerative colitis may be associated with altered cellular PKC activity.
BACKGROUND: Similar epidemiologic characteristics suggest a common etiology for colon cancer (CC) and diverticular disease of the colon (DD). The relationship between the 2 diseases is still unclear, and the impact of DD in patients diagnosed with CC on disease-free survival (DFS) and overall survival (OS) is unknown. National Surgical Adjuvant Breast and Bowel Project (NASBP) protocol C-06 is a clinical trial comparing oral uracil/tegafur/leucovorin with 5-fluorouracil/leucovorin in patients with resected stage II/III carcinoma of the colon. PATIENTS AND METHODS: The NASBP enrolled 1,608 patients who had undergone potentially curative resection for stage II/III colon cancer from 256 medical sites between February 14, 1997, and March 31, 1999. RESULTS: Pathology reports from 1561 eligible patients retrospectively reviewed for the presence of DD revealed that 160 (10.2%) had this disease. The median ages of patients with CC and DD and without DD were 67 and 61 years, respectively (P < 0.05). The majority of patients were white, and Hispanic patients were better represented in the group with DD (P < 0.05). Colon cancer was located in the rectosigmoid in 46.88% of patients with DD and in 31.92% of patients without DD (P < 0.05). A baseline diagnosis of DD made no significant contribution to DFS or OS without adjustment for confoundin factors (P = 0.2 and P = 0.32, respectively) or adjusted for Dukes classification and age (P = 0.49 and P = 0.68, respectively). CONCLUSION: The prevalence of DD in patients diagnosed and treated for CC was 10.2%. Patients with CC with and without DD differed from each other with respect to age, tumor location, and ethnicity. There was no negative impact of having DD on DFS and OS in patients treated for stage II/III CC.
We studied 258 patients with rectal bleeding and 46 patients with anemia and occult blood in the stool. All 304 patients had negative proctosigmoidoscopies, single-contrast barium studies that were negative or showed diverticula only, and colonoscopic evaluation. In the 258 patients, the overall incidence of finding significant lesions by colonoscopy was 41.5%. Twenty-nine patients (11.2%) had carcinoma and 17 patients (6.6%) had cecal telangiectasia. In the 46 patients, the overall incidence of finding significant lesions was 19.6%. Three patients with carcinoma were found in this group. A significant number of both benign and malignant lesions were detected by colonoscopy proximal to the splenic flexure. Colonoscopy should be done in patients with rectal bleeding or anemia and occult blood in the stool who have had negative proctosigmoidoscopies and single-contrast barium studies interpreted as normal or showing diverticula.
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This is the first in vivo demonstration of the pathway of the gaseous column arising from an intra-abdominal source, traveling in the retroperitoneal space alongside the great vessels into the mediastinum, resulting in a pneumomediastinum.
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AIM: This is a retrospective analysis of a series of 60 cases diverticular disease. MATERIAL AND METHOD: From May 1991 to April 1999, 60 laparoscopic colorectal resections were performed for diverticulitis. RESULTS: Conversion to a classical procedure was necessary in 3 patients (5%). There was no mortality and 9 postoperative complications (3 reoperations). The mean length of hospital stay was 9 days, and 6.3 days for patients in whom surgery was performed after January 1998. CONCLUSION: Laparoscopic surgery for diverticular disease is associated with acceptable morbidity and mortality rates and a short median postoperative stay.
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Angiography has added a new dimension to the management of hemorrhage from the large bowel. In patients with diverticular hemorrhage, mesenteric angiography not only localizes the bleeding site but, in addition, the bleeding can be acutely controlled with intraarterial infusion of vasopressin, making an emergency colectomy unnecessary. Similarly in patients bleeding from inflammatory bowel disease or in patients with post-operative hemorrhage, angiography provides information about the nature of the lesion and selective arterial infusions of vasopressin can control the bleeding. At times intestinal varices have angiographically been demonstrated as a potential source of rectal hemorrhage while in patients with unexplained lower gastrointestinal bleeding and repeatedly negative barium and endoscopic examinations, angiography has been valuable for the diagnosis of angiodysplasia of the colon.
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OBJECTIVE: To determine if epidural anesthesia after the subcutaneous injection of low-dose unfractionated heparin (LDUH) in patients who undergo elective bowel surgery is safe with respect to hemorrhagic complications. DESIGN: A prospective cohort study. SETTING: Two hospitals affiliated with the Université de Montréal. PATIENTS: Fifty patients scheduled for elective bowel surgery. INTERVENTION: Subcutaneous injection of 5000 units of LDUH and elective surgery for colonic carcinoma, chronic diverticulosis or inflammatory bowel disease. MAIN OUTCOME MEASURES: Activated partial thromboplastin time (APTT), anti-IIa and anti-Xa heparin levels measured before and 2 and 4 hours after injection of LDUH. RESULTS: In no case was the heparin anti-IIa or anti-Xa level higher than 0.20 U/mL, which is considered a significant detectable level of heparin. CONCLUSION: LDUH given subcutaneously is not associated with significant detectable heparin levels, so epidural anesthesia should be safe when performed 2 hours after LDUH injection in patients who undergo general abdominal surgery in the absence of any other impairment of hemostasis.
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