Like a Rolling (Gall)Stone: Optimal Treatment of Gallstone Obstruction of the Sigmoid Colon.

BACKGROUND: Sigmoid gallstone ileus is a rare complication of cholelithiasis, accounting for 1-4% of all cases of large-bowel obstruction. This is a highly morbid, and often fatal, condition due to its challenging diagnosis and late presentation. CASE PRESENTATION: We report a case of a 90-year-old woman admitted to Emergency Department with abdominal pain and large-bowel obstruction due to a 6 cm gallstone lodged in a diverticulum of the proximal sigmoid colon as a consequence of a cholecysto-colonic fistula. Colonoscopy was deferred due to gallstone size carrying a high possibility of failure. The patient underwent urgent laparotomy with gallstone removal via colotomy. The cholecystocolonic fistula was left untreated. The post-operative course was uneventful; the patient was discharged on 6th post-operative day. CONCLUSION: A multidisciplinary discussion between endoscopists and surgeons is often needed to choose the best therapeutic option, especially in high-risk patients.

Endoscopic resolution of intestinal obstruction secondary to colonic gallstone ileus and radicular stenosis of the sigma.

A 93-year-old woman with a history of endometrial adenocarcinoma treated with surgery and pelvic radiotherapy that led to radicular stenosis in the sigma and acute biliary pancreatitis, without subsequent cholecystectomy. She attended the emergency department for abdominal pain, vomiting and abdominal distension, with metallic noises. An abdominal CT scan showed a gallbladder with cholelithiasis, in wide contact with the colonic framework and dilation of the colonic loops with hydro-aerial levels with a partially calcified image embedded in the known sigmoid stenosis, compatible with intestinal obstruction. Given the high surgical risk, colonoscopy was performed, which identified an impassable punctate stricture with a fibrous appearance. Pneumatic dilatation and subsequent removal of gallstones with biopsy forceps was performed, with an adequate evolution. While gallstone ileus is a rare condition that accounts for 5% of episodes of intestinal obstruction, its location in the colon is even rarer. It is usually managed surgically, with a significant impact on morbidity. This case is of interest because of the infrequent occurrence of obstruction secondary to these two concomitant causes and the possible usefulness of endoscopic treatment in patients at high surgical risk.

Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess.

PURPOSE: The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess. METHODS: Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30-90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition. RESULTS: Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001). CONCLUSION: The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.

Acute abdominal pain from epiploic appendagitis.

Evaluating patients for abdominal pain is common in the ED and can involve many differential diagnoses and treatment options. This case report describes a 35-year-old active duty military man whose abdominal pain evaluation at a military treatment facility led to the diagnosis of epiploic appendagitis.

Laparoscopic peritoneal lavage versus laparoscopic sigmoidectomy in complicated acute diverticulitis: a multicenter prospective observational study.

PURPOSE: Laparoscopic peritoneal lavage (LPL) is feasible in selected patients with pelvic abscess and generalized purulent peritonitis caused by acute diverticulitis. We aimed to compare LPL and laparoscopic sigmoidectomy (LS) in complicated acute diverticulitis. METHODS: This prospective, observational, multicenter study included patients with a pelvic abscess not amenable to conservative management and patients with Hinchey III acute diverticulitis, from 2015 to 2018. Sixty-six patients were enrolled: 28 (42%) underwent LPL and 38 (58%) underwent LS. In LS, patients had a primary anastomosis, with or without ileostomy, or an end colostomy (HA). Major outcomes were mortality, morbidity, failure of source control, reoperation, length of stay, and diverticulitis recurrence. RESULTS: Patient demographics were similar in the two groups. In LPL, ASA score > 2 and Mannheim Peritonitis Index were significantly higher (p = 0.05 and 0.004). In LS, 24 patients (63%) had a PA and 14 (37%) an HA. No death was recorded. Overall, morbidity was 33% in LPL and 18% in LS (p = 0.169). However, failure to achieve source control of the peritoneal infection and the need to return to the operating room were more frequent in LPL (p = 0.002 and p = 0.006). Mean postoperative length of stay was comparable (p = 0.08). Diverticular recurrence was significantly higher in LPL (p = 0.003). CONCLUSION: LPL is related to a higher reoperation rate, more frequent postoperative ongoing sepsis, and higher recurrence rates. Therefore, laparoscopic lavage for perforated diverticulitis carries a high risk of failure in daily practice.

The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis.

BACKGROUND: Nowadays sigmoidectomy is recommended as "gold standard" treatment for generalized purulent or faecal peritonitis from sigmoid perforated diverticulitis. This systematic review and meta-analysis aimed to assess effectiveness and safety of laparoscopic access versus open sigmoidectomy in acute setting. METHODS: A systematic literature search was performed for randomized controlled trials (RCTs) and non-RCTs published in PubMed, SCOPUS and Web of Science. RESULTS: The search yielded four non-RCTs encompassing 436 patients undergoing either laparoscopic (181 patients, 41.51%) versus open sigmoid resection (255 patients, 58.49%). All studies reported ASA scores, but only four studies reported other severity scoring systems (Mannheim Peritonitis Index, P-POSSUM). Level of surgical expertise was reported in only one study. Laparoscopy improves slightly the rates of overall post-operative complications and post-operative hospital stay, respectively (RR 0.62, 95% CI 0.49 to 0.80 and MD -6.53, 95% CI -16.05 to 2.99). Laparoscopy did not seem to improve the other clinical outcomes: rate of Hartmann's vs anastomosis, operating time, reoperation rate and postoperative 30-day mortality. CONCLUSION: In this review four prospective studies were included, over 20 + year period, including overall 400 + patients. This meta-analysis revealed significant advantages associated with a laparoscopic over open approach to emergency sigmoidectomy in acute diverticulitis in terms of postoperative complication rates, although no differences were found in other outcomes. The lack of hemodynamic data and reasons for operative approach hamper interpretation of the data suggesting that patients undergoing open surgery were sicker and these results must be considered with extreme caution and this hypothesis requires confirmation by future prospective randomised controlled trials.

A rare cause of rectal bleeding.

A 54-year-old male patient, with recent medical history of acute myocardial infarction, performed a colonoscopy in context of rectal bleeding that revealed, in the sigmoid and rectum colon, erythematous and hemorrhagic lesions, with high friability to the touch, surrounded by normal mucosa. Histologically, the lesions was compatible with a chronic inflammatory process, with eosinophilic structures and hyaline material evident, characterized as amyloid substance after staining with Congo Red. The authors describe the present clinical case because of its rarity, highlighting the importance of a careful differential diagnosis in the approach of these clinical signs present in the daily practice of Gastroenterology.

Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe.

BACKGROUND: Initial nonoperative management of diverticular abscess has become the standard of care; however, the need for elective resection after this index episode is unclear. OBJECTIVE: The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess. DESIGN: This was a retrospective chart review with prospective telephone follow-up of patients. SETTINGS: The study was conducted at a large tertiary academic colorectal surgery practice in Canada. PATIENTS: Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included. INTERVENTIONS: Long-term definitive nonoperative management of diverticular abscess. MAIN OUTCOME MEASURES: The primary outcome was emergency sigmoidectomy or death from recurrent diverticulitis. Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis. RESULTS: Of 135 patients with acute diverticulitis complicated by abscess, a total of 73 patients were managed with nonoperative intent and long-term expectant management. The median follow-up was 62 (Q1 to Q3: 28-98) months. After resolution of the index episode, 22 patients [30.1% (95% CI, 19.6%-40.6%)] experienced a recurrent episode of diverticulitis at a median of 23 (range, 9-40) months. Two patients [2.7% (95% CI, -1.0% to 6.4%)] had a recurrent episode with peritonitis that required sigmoidectomy with stoma at 6 and 64 months. Both patients underwent reversal after 4 and 8 months. Seven [9.6% (95% CI, 2.8%-16.4%)] patients experienced a complicated recurrence and underwent an elective sigmoidectomy [median time to colectomy, 33 (range, 16-56) months]. Thirteen patients [17.8% (95% CI, 9.0%-26.6%)] experienced an uncomplicated recurrence, all of whom were managed with continued nonoperative intent [median follow-up, 81 (range, 34-115) months]. No mortality occurred. On multivariate logistic regression, female gender (p = 0.048) and a previous episode of uncomplicated diverticulitis before the index diverticular abscess (p = 0.020) were associated with a recurrent episode. LIMITATIONS: This study was limited by its retrospective design and modest sample size. CONCLUSIONS: After initial successful nonoperative management of diverticulitis with abscess, expectant management with nonoperative intent is a safe long-term option with low rates of surgery, especially in the emergency setting. See Video, Supplemental Digital Content 1, on the nonoperative management of diverticular abscess at http://links.lww.com/DCR/A234.

Diffuse Autoimmune Enteropathy and Colopathy in an Adult Patient Successfully Treated With Adalimumab and a Review of the Literature.

Autoimmune enteropathy (AIE) is a rare disease that causes intractable diarrhea not responsive to a gluten free diet and must be distinguished from refractory sprue. It is associated with circulating autoantibodies against goblet cells and enterocytes. AIE mainly involves the small intestines, with very few cases reported in adults. Because of the paucity of cases, the epidemiology of the disease remains unclear, and treatment is based on the cases found in the literature. Of the 35 adult cases reported, only 4 involved the colon. Because of the low number of cases, there have been no clear recommendations on treatment modalities with most reports heavily emphasizing steroids as the mainstay of treatment. We present the case of adult female patient who developed postpartum AIE and colopathy with profuse diarrhea successfully treated with adalimumab and a review of the literature. To the best of our knowledge, this case is only the fourth case of a tumor necrosis factor alpha antagonist being used in the treatment of AIE and the first case of adalimumab being used.

Vascular entrapment of the sciatic plexus causing catamenial sciatica and urinary symptoms.

AIM OF THE VIDEO / INTRODUCTION: Pelvic congestion syndrome is a well-known cause of cyclic pelvic pain (Ganeshan et al., Cardiovasc Intervent Radiol 30(6):1105-11, 2007). What is much less well known is that dilated or malformed branches of the internal or external iliac vessels can entrap the nerves of the sacral plexus against the pelvic sidewalls, producing symptoms that are not commonly seen in gynecological practice, such as sciatica, or refractory urinary and anorectal dysfunction (Possover et al., Fertil Steril 95(2):756-8. 2011). The objective of this video is to explain and describe the symptoms suggestive of vascular entrapment of the sacral plexus, as well as the technique for the laparoscopic decompression of these nerves. METHOD: Two anecdotal cases of intrapelvic vascular entrapment are used to review the anatomy of the lumbosacral plexus and demonstrate the laparoscopic surgical technique for decompression at two different sites, one on the sciatic nerve and one on the sacral nerve roots. RESULT: After surgery, the patient with the sciatic entrapment showed full recovery of the sciatica and partial recovery of the myofascial pain. The patient with sacral nerve root entrapment showed full recovery with resolution of symptoms. CONCLUSION: The symptoms suggestive of intrapelvic nerve entrapment are: perineal pain or pain irradiating to the lower limbs in the absence of a spinal disorder, and lower urinary tract symptoms in the absence of prolapse of a bladder lesion. In the presence of such symptoms, the radiologist should provide specific MRI sequences of the intrapelvic portion of the sacral plexus and a team and equipment to expose and decompress the sacral nerves should be prepared.

Emergency Laparoscopic Sigmoidectomy for Perforated Diverticulitis with Generalised Peritonitis: A Systematic Review.

BACKGROUND: Laparoscopic sigmoidectomy for diverticulitis has initially been confined to the elective setting. However, open acute sigmoidectomy for perforated diverticulitis is associated with high morbidity rates that might be reduced after laparoscopic surgery. The aim of this systematic review was to assess the feasibility of emergency laparoscopic sigmoidectomy for perforated diverticulitis. METHODS: We performed a systematic search of PubMed, EMBASE and CENTRAL. All studies reporting on patients with perforated diverticulitis (Hinchey III-IV) treated by laparoscopic sigmoidectomy in the acute phase were included, regardless of design. RESULTS: We included 4 case series and one cohort study (total of 104 patients) out of 1,706 references. Hartmann's procedure (HP) was performed in 84 patients and primary anastomosis in 20. The mean operating time varied between 115 and 200 min. The conversion rate varied from 0 to 19%. The mean length of hospital stay ranged between 6 and 16 days. Surgical re-intervention was necessary in 2 patients. In 20 patients operated upon without defunctioning ileostomy, no anastomotic leakage was reported. Three patients died during the postoperative period. Stoma reversal after HP was performed in 60 out of 79 evaluable patients (76%). CONCLUSIONS: Acute laparoscopic sigmoidectomy for the treatment of perforated diverticulitis is feasible in selected patients provided they are handled by experienced hands.

[How I EXPLORE ... SIGMOID VOLVULUS]. / COMMENT J'EXPLORE.... un volvulus du sigmoïde: le rôle du radiologue.

Sigmoid volvulus is a significant cause of bowel obstruction and will become a major cause in the future given its prevalence in the elderly and/or institutionalized patients. Furthermore that's the first cause of bowel obstruction in pregnant women. Given it's a non specific clinical presentation, the clinician has to do complementary exams, above all the x ray examinations. So, the role of radiologist is primordial in diagnostic, sometimes in the treatment given important morbidity and mortality of this pathology. We bring you here a typical case of sigmoid volvulus in 60 years old patient seen in emergency department for bloating and vomiting since several days.

[Coincidence of colonic lymphoma and gallstone ileus - case report]. / Koincidence lymfomu tracníku a biliárního ileu - kazuistika.

INTRODUCTION: Primary colonic lymphoma is a very rare malignant disease of the gastrointestinal tract, accounting for 14% of all malignant diseases in this location. It is classified in the group of extranodal lymphomas; its long-term asymptomatic progression makes it different from common colorectal carcinomas making its diagnosis very difficult, more often accidental. Gallstone ileus is quite an uncommon complication of cholecystolithiasis diagnosed with difficulty. Up to 50% of cases are diagnosed during surgery. The obturated location depends on the size of the stone, location of the conjunction between the biliary and gastrointestinal tracts, and also on any preexisting stenosis due to another unknown pathology. CASE REPORT: We present a case of an 86-year-old man treated for acute diverticulitis with typical clinical symptoms. Following further examination (colonoscopy, computed tomography) revealed a tumour-like infiltration in the sigmoid colon wall and a voluminous polyp was suspected according to the colonoscopy. Computed tomography described an obstruction by a biliary stone tumbling through the cholecystocolonic fistula. Subsequent biopsy supported the suspected malignant etiology. The patient underwent resection of the sigmoid colon sec. Hartmann; an infiltration was found in the subhepatic space, which corresponded to the described fistulisation between the biliary tract and the colon. A large 40 mm gallstone was found in the resected sigmoid colon over the stenosis and the bowel wall showed diffuse thickening with several polyps; final histopathological assessment confirmed malignant lymphoma of the plasmocytoma type. No serious complications occurred in the postoperative period; after healing, the patient was transferred to hematooncology care. CONCLUSION: The article describes the presence of two rare diseases - colonic lymphoma and gallstone ileus. Clearly, without the biliary stone obstruction in the preexisting tumorous stenosis in the sigmoid colon, the malignant hematooncology disease would not have been diagnosed. KEY WORDS: primary colonic lymphoma - gallstone ileus - complication of the cholecystolithiasis - extranodal lymphoma - acute diverticulitis.

The incidence of colon cancer among patients diagnosed with left colonic or sigmoid acute diverticulitis is higher than in the general population.

BACKGROUND: Considering the low incidence of colon cancer after an initial episode of colonic diverticulitis in some categories of patients, some authors suggested to exempt them from colonoscopy. However, this incidence has never been compared to that of a reference population, and predictors of cancer are still poorly investigated. We aimed to determine the 1-year incidence of colon cancer at the site of diverticulitis in patients diagnosed with left colonic or sigmoid acute diverticulitis, to compare this incidence to a reference population to state whether endoscopy is required or not, and to identify predicting factors of cancer to better target subpopulations needing that examination. METHODS: All patients admitted at the University Hospitals of Geneva for left colonic or sigmoid acute diverticulitis were included. Patients with a previous history of colon cancer or non-available for follow-up were excluded. Demographic data, haemoglobin values, and the Hinchey score were documented. This cohort was matched with the Geneva Cancer Registry to look for cancer occurrence at the site of diverticulitis within 1 year. Predictors of cancer were assessed using univariate logistic regression and the risk of cancer by comparing observed cases to a reference population using standardized incidence ratios. RESULTS: The final cohort included 506 patients. Eleven (2.2 %) had a diagnosis of cancer at the site of diverticulitis within 1 year. The mean age was significantly different between patients with cancer and others. No predictor of cancer could be identified, except a trend for an increased risk with advancing age (p = 0.067). The standardized incidence ratios showed a 44-fold increased risk of cancer among the cohort compared to the reference population. CONCLUSIONS: Colonoscopy should be continued after an initial diagnosis of left colonic or sigmoid acute diverticulitis, irrespective of the clinical or radiological presentations.

Acute sigmoid diverticulitis within a nonincarcerated hernia.

Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported.We present a case of sigmoid diverticulitis within a non incarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation.