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[An index of the severity of intestinal gangrene due to colonic volvulus].

This retrospective analysis evaluated 50 patients with gangrenous colonic volvulus two cases with ileocecal volvulus, one case with volvulus of the colon transverse and 47 cases with sigmoid volvulus- who were managed by primary resection with anastomosis (n = 21) or resection plus colostomy (n = 29) at Belén Hospital, Trujillo, Perú, from January 1, 1967 to July 31, 1993. The principal aim of the study was to identify by univariate analysis the combination of predictive risk factors for postoperative mortality. The following factors were associated with increased mortality: mean arterial pressure lower than 70 mmHg (p = 0.004), presence of purulent or fecaloid peritoneal fluid (p = 0.013) or evidence of macroscopic bowel perforation (p < 0.001). A method of quantifying the risk of mortality following gangrene of the loop using these factors was described. Each factor was given a weight value ranging from 0 a 2 (0 = major, 1 = moderate, 2 = minor) according to the severity of injury estimate. The sum of the individual factor scores comprised the final score of the Severity of Gangrenous Colon by Volvulus (S.S.G.C.). In this series the 30-day mortality rate was of 30%. A S.S.G.C. resulted greater than 4 in 34 (68%) of the patients. This was associated with a 9% mortality rate and contrasted to a 75% when the S.S.G.C. was equal to or less than 4. Mortality developed in 33% of the patients operated on using an immediate anastomosis (S.S.G.C., 4.2 +/- 0.99) and it was of 28% in those whose operation was resection plus colostomy (S.S.G.C., 3 +/- 0.87).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2003

[Cholestatic icterus during parenteral nutrition and the therapeutic effect of enteral feeding--case report].

An acute operation was made on a 56-year woman for inflammatory perforation of colon. A series of repeated operations followed due to relapsing iatrogenic intestinal fistula and peritonitis. From the day 70 the patient was treated at the Intensive Metabolic Care Unit of the Gerontological and Metabolic Clinic of Faculty Hospital in Hradec Králové. Having cured the septic shock the authors prepared the patient to a reconstruction operation on alimentary tract by administering parenteral nutrition, treating the wounds and by motion rehabilitation. From day 150 on the patient was treated with low doses of enteral nutrition into the segment of intestine between the fistulas, in connection with the subsequent decrease of two-month lasting hyperbilirubinemia of 200-260 mumol/l. A successful reconstruction of the alimentary tract was performed on the day 205 of the treatment with the time lapse of 146 days after the last surgical intervention. A three-fold anastomosis on small intestine and a resection of the fistula on the transversal colon was made. The post-operation fistula was healed-up conservatively, while the parenteral nutrition continued, as verified on day 246 by enteroclysis. The paper draws attention to the importance of conservative metabolic care in the therapy of dishiscences of intestinal anastomoses not treated by acute surgery in time. A favourable additive effect of enteral nutrition on the persisting cholestasis during parenteral nutrition is discussed.

Cholestasis↗
PubMed2006

Recurrent complicated colon diverticulitis in renal transplanted patient.

Colon perforation due to diverticulitis is a life-threatening complication in the postoperative course of kidney transplantation. In the immunocompromised patient a diagnosis of diverticulitis is difficult to make. We report a 53-year-old woman being kidney transplanted 14 years ago with known diverticulosis. She was admitted with acute severe pain in the lower left abdomen. Abdominal computed tomography (CT) scan indicated a diagnosis of intestinal abscess in the small pelvis. Laparotomy showed a covered sigma perforation with abscess located in the small pelvis (Hinchey-I). Because of the immunocompromised situation of the patient we performed a Hartmann procedure. Her postoperative course was uneventful. In a 6-month interval the intestinal continuity restoration was performed. Twelve days after discharge the patient was readmitted with reduced renal function and increased infection parameters. During physical examination the abdomen was tender. The patient complained of abdominal pain in the left upper abdomen and additional pain in the left shoulder. An antibiotic therapy using ciprofloxacin was already initiated owing to a urinary tract infection. An abdominal CT scan was performed and indicated an intestinal abscess in the left upper abdomen. Laparotomy showed an abscess involving transverse colon, distal jejunum, and proximal ileum (Hinchey-II). Segmental resection of the left colonic flexure, proximal jejunum, and ileum was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The present casuistry emphasizes that the immunocompromised patient can undergo diverticulitis twice, and that primary anastomosis is a feasible option for patients with localized peritonitis due to complicated diverticulitis.

Anastomosis, Surgical↗
PubMed1989

[Clinical study of colic vessels with respect to their significance in the replacement of the esophagus by the colon].

In 162 cases of esophageal replacement by colon we observed the configuration, distribution and pulsation of the middle, left, right and marginal colic arteries. Observation showed that the middle colic artery had only one major stem in 120 cases, 2-4 branches in 37 cases, and was absent in 5 cases. The middle colic artery originated from the superior mesenteric artery in 126 cases, had one stem originating from the superior mesenteric artery and another from the right colic artery in 10 cases. The middle and the right colic arteries forming one stem and originating from the superior mesenteric artery were seen in 21 cases. The distributive patterns of the middle colic arteries showing "T" type was seen in 37 cases, "V" type in 28 cases, and multiple paralleled branches in 9 cases. Vascular anastomoses between the ascending branch of the left colic artery and the middle colic artery were available in 157 cases (97%), 12 cases with the arc of Riolan. The nearest distance between the marginal artery and the colic wall was at the splenic flexure. The origin of the right colic artery varied greatly and its distributive area was small. We advocated the use of the ascending branch of the left colic artery for blood supply and the transverse colon for replacement of the esophagus in an isoperistaltic fashion (131/162 cases) to be the procedure of choice.

Adolescent↗
PubMed1991

A critical analysis of the largest reported mass fecal occult blood screening program in the United States.

Fecal occult blood testing for the detection of colon cancer remains controversial. We performed a mass screening program from January 24, 1988, to February 19, 1988, with intensive media promotion, including 121 minutes of televised air time. A total of 5,000 primary practitioners were notified by mail. Hemoccult-II tests were distributed to 156,000 individuals; 55,051 (35%) were returned. Ninety-five percent of the respondents were informed of the program by television. A total of 3,375 persons (6%) tested positive for fecal occult blood; of these, 2,469 (73%) informed the center that they saw their physician to initiate a work-up. Information from physicians regarding work-ups was returned on only 1,356 (55%) patients. Diagnostic tests numbered 2,227 (1.6 tests per patient). However, 5% had no testing, 16% had a repeat Hemoccult only, and 35% had neither a barium enema nor colonoscopy performed. Thirty-six colorectal cancers and 212 polyps were identified. The predictive value (i.e., number of cancers per number of patients who tested positive) increased directly by decade. Thirty-three of 36 patients (92%) with cancer underwent either a barium enema or colonoscopy versus only 185 of 438 (42%) patients with a "negative" work-up. Cancers found were carcinoma in situ in 10 patients (29%), Dukes A in 12 (35%), Dukes B in 4 (12%), and Dukes C in 8 (24%); distant metastases were not found in any participant. Thirty-six percent of the tumors were located in either the right or transverse colon. We conclude that: (1) Screening identified early cancers. All were potentially curable and 64% were limited to the bowel wall. (2) Massive Hemoccult distribution was possible over a short interval, but patient and physician compliance was disturbingly low. (3) Total colonic evaluation is mandatory, since at least 36% of tumors were beyond the reach of the flexible sigmoidoscope. (4) Many work-ups were unnecessary (repeat Hemoccults) or inadequate, indicating a need for physician education.

Adult↗
PubMed1976

Fruit pit obstruction. "The propitious pit.".

Ingestion of fruit pit must be a frequent and innocuous phenomenon, judging from the expected frequency of such occurrences and the relative dearth of medical reports to the contrary. Reported here are four cases in which fruit pits of varied nature completed an otherwise incomplete intestinal obstruction. On of these was in the terminal ileum, with incomplete obstruction due to regional ileitis, in which the offending pit was seen radiologically but was not recognized as such. The other three were in the transverse colon, at the site of annular carcinomatous lesions. The completion of the obstruction by the fruit pits eventuated in earlier symptoms, diagnosis, and treatment. In one case, the fruit pits were multiple; in the remainder, they were single.

Aged↗
PubMed1979

Gastrocolic fistula as a complication of benign gastric ulcer.

The symptoms, diagnosis, and management of three patients with gastrocolic fistula secondary to benign peptic ulcer disease are reviewed. To our knowledge, this brings the total of such cases reported in the literature to 50. The most frequent symptoms were abdominal pain, weight loss, diarrhea, and vomiting followed by anemia, foul eructations, and fecal vomiting. Barium meal demonstrated the fistula in about 70% of the patients, whereas barium enema examination demonstrated the fistula in nearly all of them. The diagnostic workup should rule out the possibility of a malignant cause for the fistula. The surgical management of these patients consists of the one-stage, when possible, resection of the involved portion of the antrum and the fistula of the transverse colon with appropriate reconstruction of gastrointestinal continuity. An increased awareness of the benign cause of some gastrocolic fistulas is necessary to avoid unduly extensive surgery in these cases.

Adult↗
PubMed1989

Intra-abdominal recurrence of colorectal cancer detected by radioimmunoguided surgery (RIGS system).

Since 1986, 32 patients with metastatic colorectal cancer have undergone second-look radioimmunoguided surgery (RIGS system). The primary tumor was located in the right and transverse colon in 11 patients, left and sigmoid colon in 16, and rectum in five. The carcinoembryonic antigen level was elevated in 30 patients (94%); all patients underwent a computed tomographic scan of the abdomen and pelvis. The overall sensitivity of the computed tomographic scan was 41% (abdomen other than liver, 27%; liver, 58%; and pelvis, 22%). The RIGS system identified recurrent tumor in 81% of the patients. The most common site of metastasis was the liver (41%), independent of the primary location. Local/regional recurrences alone accounted for 40% of all recurrences. In six patients (18%), recurrent tumor was found only with the RIGS system. The RIGS system is more dependable in localizing clinically obscure metastases than other methods, and carcinoembryonic antigen testing remains the most accurate preoperative method to indicate suspected recurrences.

Abdominal Neoplasms↗
PubMed1993

Diagnosis and treatment of bowel perforation following pediatric orthotopic liver transplantation.

OBJECTIVE: Bowel perforation is a frequent cause of mortality after pediatric orthotopic liver transplantation. The aims of this study were to identify the cause of this phenomenon and to examine current methods of treatment. DESIGN: This is a retrospective analysis of 246 pediatric patients who underwent orthotopic liver transplantation at a large, urban, tertiary care medical center between 1984 and 1992. We examined the frequency of bowel perforations after transplantation and identified predisposing factors and signs. In this series, bowel perforations occurred in 24 of 246 recipients and were common in those who had previous liver-related surgery (22 patients). Clinical signs included fever (13 patients), leukocytosis (14 patients), and free air on abdominal roentgenograms (11 patients). RESULTS: Perforation occurred at the Roux-en-Y limb in 15 of 24 recipients as well as in the right transverse colon (five patients), terminal ileum (three patients), and duodenum (one patient). The repair was resection and/or primary closure (18 patients), or diversion (six patients). Recurrent perforations (nine patients) could not be attributed to the method of the repair. Perforation-related sepsis was the primary cause of death in 12 patients (50%) and was more common among patients who developed recurrent perforation (seven [78%] of nine patients). CONCLUSIONS: The occurrence and location of bowel perforation after pediatric orthotopic liver transplantation suggests that the cause is related to bowel injury during difficult hepatectomy. Mortality may be reduced by early second-look operations in high-risk patients.

Child↗
PubMed1982

Malignant carcinoid tumors in children.

The clinical, light microscopic, and ultrastructural features of four malignant carcinoid tumors in children, three boys and one girl ages 8--14 years, are described. Extensive metastases to multiple organs were present in three, and in the fourth child there was diffuse local infiltration of the bowel wall, which resembled a lymphoma. The primary tumor arose in the ileum in one child and in the transverse colon in another. In two children, the primary sites could not be determined; one patient is still alive and in the other, permission for autopsy was refused. Electron microscopy showed moderate numbers of neurosecretory granules in some cells in all cases. One patient with extensive metastases showed repeated partial response to radiotherapy and chemotherapy. Eight benign appendiceal carcinoids were seen at the same hospital over the same period, suggesting malignant carcinoids may be more common in children than often assumed.

Adolescent↗
PubMed1983

Familial aggregation of neuroectodermal and gastrointestinal tumors.

A family with multiple tumors is presented. Four cases were childhood neoplasms derived from the neuroectoderm, as was a malignant melanoma in a young female and a branchiogenic cyst in her brother. He also had an early onset of an adenocarcinoma of the transverse colon. Four further cases of gastrointestinal tumors and one case of acute myelogenous leukemia had occurred in the family. One of the childhood tumors was a bilateral retinoblastoma. It is discussed as to whether the tumors in the studied family were due to a genetic factor resulting in a neuroectodermal embryopathy, or were caused by a retinoblastoma gene with a pleiotropic effect.

Adult↗
PubMed1985

Female gender is a major determinant of changing subsite distribution of colorectal cancer with age.

Distribution by subsite and sector of 948 colorectal cancers diagnosed in Kansas in 1982 was analyzed in respect to sex and age in a population-based study. Regression analysis of percentage versus age showed decreasing left, increasing right, and unchanged transverse colon occurrence of cancer for both sexes. However, this was statistically significant only for women; left, -0.7066% per year (P = 0.0088) and right +0.6023% per year (P = 0.0012). Regression for seven subsites showed significant changes only for women; with rectosigmoid and sigmoid decreasing and cecum and ascending colon increasing. Similar results were obtained in analysis of the 5822 cases available in the Kansas cancer registry for the years 1978 to 1982. These findings have important implications for screening and diagnosis of colorectal cancer in the elderly, particularly women, and also provide a useful clue in the investigation of colorectal carcinogenesis.

Adult↗
PubMed1992

Carcinoembryonic antigen and carbohydrate 19-9 antigen as markers for colorectal carcinoma in children and adolescents.

Colorectal cancer is rare in patients younger than 20 years of age (incidence, 1 in 10 million). Although carcinoembryonic antigen (CEA) and carbohydrate 19-9 antigen (CA 19-9) have been used widely as markers for the efficacy of therapy or detection of recurrent colorectal carcinomas in adults, no studies evaluating their efficacy in children and adolescents have been performed. Between 1986 and 1989, serial measurements of serum CEA and CA 19-9 levels were obtained from 11 patients (aged 8 to 18 years) treated at the institution of the authors. In contrast to the experience in adults, most (9 of 11) of the tumors were localized in the right or transverse colon. Histologically, 10 of 11 carcinomas were mucinous. Most patients had either Dukes' C (5 of 11) or D (5 of 11) lesions. After surgery, all patients were treated with a combination of 5-fluorouracil with Leucovorin (Lederle Laboratories, Pearl River, NY). With the use of the adult normal standards (CEA less than 3.0 ng/ml and CA 19-9 less than 37 ng/ml)6 for the patients, the specificity and sensitivity of CEA were 77% and 64%, respectively, whereas the specificity of CA 19-9 was 79% and the sensitivity was significantly low (10%). The combined specificity of the two markers was 71%, and the combined sensitivity was 60%. On the basis of these results, the authors believe that CEA and CA 19-9 are not effective markers for detection of recurrent or progressive colorectal carcinomas in children and adolescents.

Adenocarcinoma, Mucinous↗
PubMed2000

Novel germline mutation (300-305delAGTTGA) in the human MSH2 gene in hereditary non-polyposis colorectal cancer (HNPCC).

Hereditary non-polyposis colorectal cancer (HNPCC) is a common hereditary syndrome characterized by the high incidence and early onset of colorectal cancer. The majority of the HNPCC families carry germline mutations in either the MSH2 or the MLH1 mismatch repair gene. A 46 year-old female patient whose family history fulfilled the Amsterdam criteria for HNPCC was diagnosed with undifferentiated adenocarcinoma of the transverse colon. Recognizing the Lynch 2 syndrome (the existance of multiple HNPCC related cancers in a pedigree), we used polymerase chain reaction followed by direct sequencing to screen the coding regions of both the MSH2 and the MLH1 genes for germline mutations in DNA from the patient. We detected a novel germline mutation (300-305delAGTTGA) in exon 2 of human MSH2. We noted microsatellite instability in four microsatellite loci. Immunohistochemistry showed a lack of expression of the MSH2 gene product in the tumor, suggesting that the mutation is a disease-causing mutation.

Base Pair Mismatch↗
PubMed1982

Limb pterygium syndromes: a review and report of eleven patients.

Conditions with limb pterygia and congenital contractures were reviewed as part of a study of over 350 infants with arthrogryposis. Emphasis was placed on inheritance and variability of distinct pterygium conditions. Eleven patients with limb pterygia were recognized in our study and are described here. Seven of the 350 patients with congenital contractures had the autosomal recessively inherited multiple pterygium syndrome (Patients 1-7). Three of the seven are sibs, a fourth was born to consanguineous parents, and three were chance isolated cases. These seven had multiple joint webs, unusual finger contractures, syndactyly, rocker bottom feet, ptosis, antimongoloid slant of palpebral fissures, epicanthal folds, highly arched palate, scoliosis, and short stature. There is intrafamilial variability. Three patients from one family had a lethal multiple pterygium syndrome. Two were monozygotic twins. They had webbing and contractures of the elbows, knees, neck, and fingers, calcaneovalgus deformity of the feet, and an unusual facial appearance: hypertelorism, flat nose, antimongoloid slant of palpebral fissures, apparently low-set ears. One had a cleft palate. Internal malformations included: bilateral pulmonary hypoplasia, small heart, absence of the appendix, and attenuation of the ascending and transverse colon. One sporadic case of lethal popliteal pterygium with facial clefts was studied. Multiple anomalies included: ankyloblepharon filiforme adnatum, upslanting palpebral fissures, hypoplasia of nasal cartilages, frenula, clefts into the oropharynx lateral to the mouth, apparently low-set ears with slit-like canals, large popliteal pterygia, syndactyly with fusion of all digits in hands and feet, and hypoplastic labia.

Abnormalities, Multiple↗
PubMed2003

Gorlin syndrome with ulcerative colitis in a Japanese girl.

We present the case of a 14-year-old Japanese girl who had both Gorlin syndrome and ulcerative colitis. She had complained of blood stools for 6 months and severe scoliosis from her infancy. Physical examination revealed multiple nevi, palmar and plantar pits, jaw cysts, and calcification of the falx cerebri, leading to the diagnosis of Gorlin syndrome. Total colonoscopy revealed an edematous and spotty bleeding mucosa extending from the anus to the transverse colon. Histological examination was also compatible with ulcerative colitis. Thus, we diagnosed her as having Gorlin syndrome with ulcerative colitis. Gene analysis revealed a mutation, 1247InsT, in the human patched gene (PTCH), resulting in the truncation of PTCH protein. Since Gorlin syndrome and ulcerative colitis are rare disorders in childhood, this association is interesting, suggesting a correlation between the hedgehog signaling and intestinal disorders.

Adolescent↗
PubMed1983

Traumatic pericardiophrenic hernia: a report of 3 cases.

Three cases of traumatic intrapericardial diaphragmatic hernia are reported. The defect was limited to the central tendon of the diaphragm in all 3 cases with herniation of the transverse colon (n = 2) or small bowel (n = 1) into the pericardial sac. A correct preoperative diagnosis was made in all 3, using a dilute barium meal in 2 patients, and from the chest X-ray examination alone in 1. Successful operative repair was performed. Previous reports suggest that barium studies of the gastrointestinal tract are the most accurate method of diagnosis but should be used with caution as they may precipitate cardiac tamponade through distension of herniated bowel.

Adult↗
PubMed1985

Pancreatic resection for severe acute pancreatitis.

Non-operative management of acute necrotizing pancreatitis carries a mortality of up to 80 per cent. Over the last 6 years we have pursued an aggressive policy of intensive supportive therapy followed by pancreatic resection in those patients with this severe form of the disease. We have managed 15 patients in this way, 14 by subtotal pancreatic resection (usually body and tail of the gland) and one by total pancreatectomy; 7 had early overwhelming multi-system failure with a median of 4 positive prognostic factors whilst 8 were operated on later between 3 and 8 weeks (plus one at 32 weeks) and had varying clinical pictures. Eight patients had ischaemia of the transverse colon which was noted at operation in four, and presented postoperatively in the remainder. Re-operation was necessary in 13 patients to remove further slough or resect ischaemic bowel. Five patients (33 per cent) died between 10 days and 4 weeks postoperatively, death being due to sepsis and multi-system failure in four and a massive retroperitoneal haemorrhage in one. Of the ten survivors, four require insulin. Timely excision of necrotic pancreatic tissue combined with intensive supportive therapy may help reduce the high mortality in this condition.

Acute Disease↗