Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

[Andean megacolon and sigmoid volvulus in the high altitude. Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru]. / Megacolon andino y vólvulo del sigmoides de la altura. Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge Puno, Perú.

OBJECTIVE: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. MATERIAL AND METHODS: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. RESULTS: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). CONCLUSIONS: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

Megarectosigmoid in children with anorectal malformations: long term outcome after surgical or conservative treatment.

PURPOSE: Megarectosigmoid (MRS) is commonly seen in children with anorectal malformations (ARM) and contributes to the high incidence of constipation. Surgical resection has been advocated by some, whereas others propose intense bowel management as the treatment of choice. The aim of this study was to evaluate outcome of both bowel function and configuration after surgical or conservative treatment of MRS in ARM patients. MATERIALS AND METHODS: The study included 79 patients with ARM, excluding perineal fistula, (48 boys, 31 girls) from 1986 to 2007. MRS was diagnosed at colostomy formation or contrast enema performed in the neonatal period. Early in the period, the majority of the patients were treated surgically, whereas in the late 1990 s, a conservative approach with intensified bowel treatment was implemented. Contrast enema and bowel function investigations were performed repeatedly during follow-up. RESULTS: MRS, according to radiological criteria, was diagnosed in 26/79 (33%) of the ARM children. Bowel functional outcome was similar regardless of surgical or conservative treatment and comparable to function in ARM children with non-MRS. The radiological signs of rectal dilatation and elongation disappeared after surgical intervention, but normalisation of the rectosigmoidal configuration was also seen with age in the conservative group. CONCLUSIONS: Bowel functional outcome in ARM children with MRS was similar after either surgical or conservative treatment during follow-up. The radiological signs of rectal dilatation and elongation disappeared also in the conservatively treated patients over time.

Physical therapy combined with a laxative fruit drink for treatment of chagasic megacolon.

CONTEXT: The treatment of Chagas' disease colopathy is limited to clinical management in the initial of the process, and for patients for whom surgery is not indicated or is not possible, anti-constipation diets are used, along with judicious administration of laxatives and enemas. OBJECTIVE: To evaluate over time the effects of physical-therapy interventions combined with daily ingestion of a laxative fruit drink in the treatment of chagasic megacolon. METHOD: In a quantitative, prospective, and comparative study, 12 patients of both sexes and with a mean age of 67 ± 12 years were clinically evaluated to receive 12 sessions of physical therapy twice a week, along with fruit drink, and were evaluated for intestinal constipation before and after treatment. RESULTS: A significant difference (P<0.0022) was observed in the constipation scores before and after 6 weeks of intervention in 91.7% of the patients, and in 72.7% after 12 months, with reduction of laxative medications, softer stools, and increased number of bowel movements. With respect to gender, age, and whether or not the patient had received surgical treatment, there was no significant difference (P>0.05). CONCLUSION: The proposed protocol is easy to implement, safe, non-invasive, and low-cost, with the potential to be deployed in health care by providing benefits independent of gender, age, or whether the participant has undergone surgery, improving the condition of patients with chagasic megacolon.

Physical therapy combined with a laxative fruit drink for treatment of chagasic megacolon / Intervenção fisioterapêutica associada ao uso de coquetel de frutas no tratamento do megacolo chagásico

CONTEXT: The treatment of Chagas' disease colopathy is limited to clinical management in the initial of the process, and for patients for whom surgery is not indicated or is not possible, anti-constipation diets are used, along with judicious administration of laxatives and enemas. OBJECTIVE: To evaluate over time the effects of physical-therapy interventions combined with daily ingestion of a laxative fruit drink in the treatment of chagasic megacolon. METHOD: In a quantitative, prospective, and comparative study, 12 patients of both sexes and with a mean age of 67 ± 12 years were clinically evaluated to receive 12 sessions of physical therapy twice a week, along with fruit drink, and were evaluated for intestinal constipation before and after treatment. RESULTS: A significant difference (P<0.0022) was observed in the constipation scores before and after 6 weeks of intervention in 91.7 percent of the patients, and in 72.7 percent after 12 months, with reduction of laxative medications, softer stools, and increased number of bowel movements. With respect to gender, age, and whether or not the patient had received surgical treatment, there was no significant difference (P>0.05). CONCLUSION: The proposed protocol is easy to implement, safe, non-invasive, and low-cost, with the potential to be deployed in health care by providing benefits independent of gender, age, or whether the participant has undergone surgery, improving the condition of patients with chagasic megacolon.

CONTEXTO: O tratamento da colopatia chagásica restringe-se ao manejo clínico no início do processo e, para pacientes sem indicação ou condição cirúrgica, utiliza-se de dietas anticonstipantes e administração judiciosa de laxantes e lavagens intestinais. OBJETIVO: Avaliar ao longo do tempo os efeitos das intervenções da fisioterapia associada à ingestão diária de coquetel de frutas no tratamento do megacolo chagásico. MÉTODO: Em estudo quantitativo prospectivo e comparativo, 12 pacientes de ambos os sexos e com média de idade de 67 ± 12 anos foram avaliados clinicamente para realizarem 12 sessões de fisioterapia, 2 vezes por semana, associadas ao uso de coquetel de frutas. Os resultados foram quantificados pela escala de avaliação de constipação intestinal antes e após o tratamento. RESULTADOS: Foi observada diferença significante (P<0,0022) nos valores da escala de constipação antes e após 6 semanas de intervenção em 91,7 por cento dos pacientes e em 72,7 por cento após 12 meses com a diminuição de medicações laxativas, fezes mais amolecidas e aumento da frequência de evacuações. As variáveis como sexo, idade e realização ou não de cirurgia não interferiram nos resultados obtidos (P>0,05). CONCLUSÃO: O protocolo proposto é de fácil execução, seguro, não-invasivo, de baixo custo, com potencial para ser implantado nos serviços de saúde por apresentar benefícios, independente do sexo, da idade e do participante ter sofrido intervenção cirúrgica, melhorando a condição clínica de portadores de megacolo chagásico.

Is rectal disimpact always necessary in children with chronic constipation? Evaluation with pelvic ultrasound.

PURPOSE: The aim of study was to evaluate if pelvic ultrasound can be useful in managing children with chronic idiopathic constipation. METHODS: A total of 270 children with idiopathic chronic constipation were enrolled in the study. At baseline and at monthly checkups children were evaluated by clinical score and pelvic ultrasound (US). Patients have been divided in 2 groups, based on pelvic US results: group A with a rectal diameter >3 cm, group B with a rectal diameter <3 cm or rectum not visualized. Both groups were subsequently randomly divided in two subgroups (A1, A2, B1, B2) on the basis of the prescribed treatment (disimpaction for the first week and daily laxative or only daily laxative). RESULTS: After 1 month of therapy all clinical features improved in group A1 and at pelvic US, rectal size reduced and became not visualized; group A2 showed poor clinical response and transverse diameter of rectum did not modify significantly; B1 and B2 groups showed significant improvement only after 2-3 months. CONCLUSIONS: Rectal disimpaction is necessary only in presence of MR. Pelvic US is a useful to diagnose MR and to set up the most appropriate treatment protocol for different chronic constipation cases.

[Effects of electroacupuncture of different acupoints on changes of blood pressure and autonomic nerve system after colorectal distension in rats].

OBJECTIVE: To observe the influence of electroacupuncture (EA) of different acupoints on changes of mean arterial pressure (MAP), heart rate (HR) and heart rate variability (HRV) in colorectal distension (CRD) rats, so as to analyze the specificity of actions of acupoints in relieving visceral pain and regulating activities of the autonomic nerve system. METHODS: Forty-five Wistar rats were randomized into control, Zusanli (ST 36), non-acupoint, Neiguan (PC 6) and Taichong (LR 3) groups (n = 9/group). Under anesthesia, CRD was given to the rats by using an aerostat for 5 min. EA (2 Hz/15 Hz, 2 mA) was applied to bilateral ST 36, non-acupoint (1.0 cm lateral to ST 36), PC 6 and LR 3 for 15 min, respectively. Electrocardiogram of the cervico-chest lead was recorded by using a bioelectric amplifier, and MAP recorded by using a pressure transducer and an amplifier. Low frequency and high frequency of HRV were analyzed by Chart 5.0. RESULTS: Following CRD, the HR, MAP, LF and LF/HF levels increased significantly in all the 5 groups (P < 0.05), while HF had no apparent changes (P > 0.05). Compared with the control group, 5 min and 15 min after EA ,and 10 min after ceasing EA, MAP values of ST 36 and PC 6 groups were decreased obviously (P < 0.05). The HR values of ST 36 and PC 6 groups at 15 min after EA and 10 min after ceasing EA were decreased markedly in comparison with those of each of the other groups during CRD (P < 0.05). The LF levels of both ST 36 and PC 6 groups at 5 min after EA, and those of ST 36, PC 6 and LR 3 at 15 min after EA were significantly lower than those of control group (P < 0.05). LF/HF levels of ST 36 and PC 6 at 10 min after ceasing EA were obviously lower than those of control group (P < 0.05). No significant differences were found among ST 36, non-acupoint, PC 6 and LR 3 groups in HR, LF and LF/HF (P > 0.05). CONCLUSION: EA of ST 36 and PC 6 can suppress CRD-induced increase of MAP, HR and LF/HF, suggesting beneficial effects of EA in relieving visceral pain and mediating autonomic nerve system. The aforementioned effects of EA of LR 3 and non-acupoint are not obvious.

Medical management of ulcerative colitis.

Ulcerative colitis (UC) is a chronic and relapsing inflammation limited to the colonic mucosa and always involving the rectum with variable extension towards the cecum. The aim of medical treatment is to induce and maintain clinical remission. In contrast to Crohn's disease for which a 'top-down' or 'early aggressive' therapy is discussed, in UC the concept of a step-up treatment is still valid. This step-up approach includes local or systemic administration of 5-aminosalicylic acid as first-line therapy followed by topical or systemic steroid administration as well as azathioprine, 6-mercaptopurine, cyclosporine, and more recently anti-tumor necrosis factor monoclonal antibodies as options in refractory or chronic active disease. Colectomy may be necessary if medical treatments are unsuccessful or if complications develop. The decision about the individual therapy of UC is dependent on both disease activity and on disease location. Different therapy strategies are applied in ulcerative proctitis, left-sided colitis, pancolitis and fulminant colitis as well as in chronic active disease and maintenance of remission. This overview presents important concepts in the treatment of UC based on the published guidelines.

Novel concepts in the diagnosis, pathophysiology and management of idiopathic megabowel.

A proportion of patients with intractable constipation have persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel (IMB). Whilst uncommon, this condition results in considerable morbidity. Traditional methods of identifying such patients are associated with inherent methodological limitations with anorectal manometry and contrast studies overestimating and underestimating the prevalence of the condition, respectively. Recently, controlled, pressure-based distension during fluoroscopic imaging has allowed more accurate identification of patients on the basis of a rectal diameter > 6.3 cm at the minimum distension pressure. Histopathological abnormalities of all three final effectors of sensorimotor function have been reported, although it remains unclear whether these changes are primary, secondary or epiphenomic. Physiological abnormalities of sensorimotor function, namely impaired perception of rectal distension and delayed colonic transit are well documented in patients with IMB. Further, the recent demonstration of two subgroups of patients, defined on the basis of rectal compliance, suggests the possibility that they differ pathophysiologically, although the clinical relevance of this distinction is uncertain. Surgery is performed when conservative therapy is ineffective or poorly tolerated. Numerous procedures have been attempted with variable success rates and significant mortality and morbidity. Surgery should preferably be performed in specialist centres given the relative infrequency with which such patients are encountered, and that they require comprehensive clinical, psychological and physiological evaluation preoperatively.

Megacolon and stercoral proctitis after frequent fecal impactions: report of an unusual case and review of the literature.

Persistent megacolon that results from frequent episodes of fecal impaction without adequate treatment is a rare and seldom reported condition in the elderly. This report discusses a 72-year-old white woman presenting with a large abdominal mass, who had at least 4 episodes of radiographically demonstrated fecal impaction over the previous year without adequate treatment. The patient required hospitalization for a bleeding rectal ulcer during the second episode of fecal impaction. Computed tomography (CT) scans on this admission revealed a dilated colon up to 16 x 14 cm in maximal dimensions extending over 30 cm, filled with massive fecal material. Several follow-up abdominal radiographs revealed a persistent megacolon after 10 months despite the absence of significant fecal material in the rectosigmoid colon. While multiple contributing factors were likely involved in her frequent fecal impactions, the clinical course of this case suggests that frequent fecal impactions without adequate treatment can lead to megacolon in high-risk patients. Clinicians should aggressively treat fecal impaction and monitor the adequacy of treatment with abdominal radiography in order to avoid significant complications. Complications and management of fecal impaction and the pathophysiology of megacolon in the literature are reviewed and discussed.

Megacolon: constipation or volvulus?

Pediatric abdominal complaints are common presentations in emergency departments, and emergency physicians are challenged every day with a vast array of gastrointestinal disorders. Differentiating the child with a benign abdominal process from the child with a more serious condition can be difficult. We report a case of massive dilatation of the colon due to fecal impaction. Means for distinguishing constipation from alternative diagnoses are discussed.

[A program-controlled electromyostimulation system in the treatment of rectal diseases]. / Programmno-upravliaemyi kompleks élektromiostimuliatsii dlia lecheniia zabolevanii priamoi kishki.

The paper presents data on a programme-controlled system used to treat functional diseases of the large bowel and the rectal sphincter apparatus and based on a combined stimulation of perineal muscles and intestinal smooth ones by the biological feedback method.

Application of the Malone antegrade continence enema principle in degenerative leiomyopathy.

An 1-year-old boy with degenerative leiomyopathy (DL) presented with a volvulus of the transverse colon. After derotating the volvulus, we constructed a tube colostomy (TC) from the transverse colon. This TC has been used for the past 2 years by the patient for regular deflation of the colon and antegrade colonic enemas (ACE). We present this as a preliminary report of the use of the Malone ACE procedure in a patient with DL and review the relevant literature.

Pathogenesis, diagnosis, and therapy of feline idiopathic megacolon.

Many cats have one or two episodes of constipation without further recurrence, although others progress to complete colonic failure. Middle-aged male cats are particularly at risk for the clinical continuum of constipation, obstipation, and dilated megacolon. Pelvic canal stenosis and nerve injury are minor causes in the development of this syndrome. In most affected cats, the underlying pathogenesis appears to involve colonic smooth muscle dysfunction. In this group of cats, it is not yet clear whether this disorder represents a primary or secondary (resulting from long-standing constipation and colonic distension) abnormality. Many cats with mild to moderate constipation respond to conservative medical management (e.g., dietary fiber supplementation, emollient or hyperosmotic laxatives, colonic prokinetic agents). Indeed, early use of colonic prokinetic agents is likely to prevent the progression of constipation of obstipation and dilated megacolon in many cats. Some cats may become refractory to these therapies, however, as they progress through moderate or recurrent constipation to obstipation and dilated megacolon. These cats eventually require colectomy. Cats have a generally favorable prognosis for recovery following colectomy, although mild to moderate diarrhea may persist for 4 to 6 weeks postoperatively in some cases.

Megacystis and megacolon in an infant with Ehlers-Danlos syndrome.

We report a 14 month old male infant with Ehlers-Danlos syndrome who became 'anuric' due to an acutely dilated urinary bladder. Although the patient was also found to have megacolon, no diverticulum was seen in his gastrointestinal tract or urinary bladder. In order to decompress the urinary bladder and colonic wall, we put an indwelling urinary catheter in place for 2 months, and carried out daily glycerin enema for 3 months. All urological and gastrointestinal symptoms subsided with this intensive medical treatment. The diagnosis of megacystis and megacolon was made very early in life for this patient. This may indicate that the striking extension of gastrointestinal and bladder wall may lead to the development of diverticula of gastrointestinal and urinary tracts in later life.