Crohn's disease isolated to the appendix: truths and fallacies.

Twenty-five cases of Crohn's disease confined to the appendix were reported in eight hospitals in Israel during a 15-year period. Review of the histologic slides confirmed the diagnosis in 22 cases. Re-evaluation of these 22 patients included physical examination and radiologic studies of the small and large bowel. Rectosigmoidoscopy was performed in 16 patients. Signs and symptoms of Crohn's disease at other sites in the gastrointestinal tract did not occur during follow-up periods of two to 15 years (mean, 6.4 years) after appendectomy. This study and a review of the literature indicate that in most cases (93 per cent) Crohn's disease initially limited to the appendix is not a predictor of subsequent involvement of another portion of the bowel. It is concluded that the so-called Crohn's disease isolated to the appendix is a form of chronic granulomatous and follicular appendicitis of unknown etiology that is unrelated nosologically in the majority of the cases to Crohn's disease proper.

Polarization microscopy of picrosirius red stained sections: a useful method for qualitative evaluation of intestinal wall collagen.

Collagen pattern in healing anastomosis of intestinal wall was compared with its normal pattern in the submucosal layer. Polarization colours were recorded for thin (0.8 micron or less) and thick (1.6-2.4 micron) collagen fibres. The polarization colours of thick collagen fibres in the anastomotic site were more greenish-yellow and yellow than those in normal intestine which were more yellowish-orange and orange. These findings indicate that the collagen in the anastomotic site 4 days after operation is less packed than the collagen of normal rat intestine. Examination of the polarization colours of Picrosirius red-stained sections is a useful procedure to follow healing of anastomotic sites or diagnosis of collagen pathology in different pathologic conditions in the intestinal wall.

Carcinoma of the breast in women 30 years of age or younger.

Between 1960 and 1975, 20 women aged 30 years or younger and with carcinoma of the breast were treated at the Chaim Sheba Medical Center. Eight are alive four to 12 years after the primary operative treatment, and 12 have died. The most important factor affecting the ultimate prognosis was the presence of metastasis in axillary nodes, which was found in 70 per cent of the women at surgery. On the other hand, slowly progressing circumscribed tumors of the medullary and intraductal types were more frequently found, occurring in six of the patients. This fact seems to improve the prognosis. Hence, the overall survival rate of women who are 30 years old or younger with carcinoma of the breast is comparable to that of women in other age groups with the same disease.

Scintigraphic demonstration of acute gastrointestinal bleeding caused by gallbladder carcinoma eroding the colon.

Massive lower gastrointestinal (GI) bleeding caused by gallbladder carcinoma eroding into the colonic wall was demonstrated accurately by Tc-99m RBCs. In addition, retrograde bleeding into the gallbladder was also identified while arteriography did not show contrast extravasation. This case supports the use of Tc-99m RBCs over Tc-99m sulfur colloid for more accurate localization of lower GI bleeding.

Indeterminate colitis.

The term indeterminate colitis has been used to describe cases of inflammatory bowel disease that cannot be classified as ulcerative colitis or Crohn's disease. However, this term has suffered varying definitions, which in addition to numerous difficulties in diagnosing inflammatory bowel disease has led to much confusion. The term indeterminate colitis should only be used in cases where a colectomy has been performed and the overlapping features of Crohn's disease and ulcerative colitis do not allow a definitive diagnosis. Over time the majority of patients remain with a diagnosis of indeterminate colitis, or show symptoms similar to ulcerative colitis. Ileal pouch-anal anastomosis surgery can be performed in such patients, with outcomes of pouch failure and functional outcome that are similar to those in patients with ulcerative colitis but with increased risk of postoperative pouch complications. This review addresses the definition of indeterminate colitis, its pathology, natural history, and outcomes of restorative proctocolectomy.

Treatment of bleeding hemorrhoids by injection sclerotherapy and rubber band ligation.

Between March 1981 and September 1982, 178 patients with first- to third-degree bleeding hemorrhoids were treated by injection sclerotherapy and rubber band ligation, as outpatients. Of the treated patients 85 to 90% were asymptomatic during 1 year of follow-up. Complications, ranging from mild to moderate, occurred in only 5.6% of the patients. We conclude that injection sclerotherapy and rubber band ligation, when properly used, are efficient, inexpensive and safe methods for the treatment of bleeding hemorrhoids.

Esophageal replacement in children: 10 years' experience.

Esophageal replacement continues to be a challenging surgical problem. Currently advocated methods entail using reversed gastric tube or colon for the interposition. Between 1969 and 1978, 11 children underwent esophageal reconstruction. Their ages at operation ranged from 1 to 16 years. All the operations were performed in one stage. The right colon was used in seven children and reversed gastric tube in four. There were no postoperative deaths. Temporary salivary fistula and cervical anastomotic stricture were the most common operation-related complications. On the follow-up visit, at least six months after surgery, all the children were able to eat a normal diet. The use of reversed gastric tube avoids intestinal resection, preserves the ileocecal valve, shortens the operative period and preserves the possibility of an alternative procedure (colon interposition) if technical failure occurs. On the basis of our limited experience we advocate the use of reversed gastric tube for esophageal replacement.

Ileal pelvic reservoir: a correlation between motor patterns and clinical behaviour.

An attempt has been made to correlate motility patterns of the pelvic ileal reservoir with patients' clinical experience. In order to evaluate the motility characteristics of the ileal reservoir, we have related its behaviour to the motility pattern observed in ileum proximal to an ileostomy. Seven patients with an ileostomy and 11 patients with a pelvic ileal reservoir have been investigated. The ileum and ileal reservoir were found to behave similarly during the fasting state and in response to distension and eating; however, a quantitative functional difference was discovered. Distension with 30 ml was enough to produce forceful contractions in the normal ileum, while a mean of 322 ml was necessary to initiate similar activity in the ileal reservoir. The ileal reservoir thus behaves as a capacitance organ with the ability to distend without contraction before a considerable volume has accumulated within it. When it does contract, it initiates a sensation of impending evacuation, but escape of ileal content is opposed by active contraction of the intact external anal sphincter.

Healing process of laser-welded intestinal anastomosis.

Intestinal welding by means of low-power laser has been reported as an efficient method for intestinal anastomosis. We designed an experimental model in rats to investigate collagen and DNA concentrations in CO2 laser-welded anastomoses as compared with those in sutured anastomoses on the 4th, 7th, and 10th postoperative days. The results revealed that DNA, total collagen, and insoluble collagen concentrations were significantly lower in the lased anastomoses than in the sutured anastomoses on the 4th postanastomotic day. On the 7th and 10th postanastomotic days, collagen concentrations increased in the laser-treated group attaining significantly higher levels than in the sutured group at that time. These findings are compatible with other studies demonstrating that laser-welded intestinal anastomoses are more prone to dehiscence during the first 4 postanastomotic days, but become at least as effective as the sutured ones with passage of time.

Na2 ethylenediaminetetraacetic acid retention enema in dogs. Biochemical and histological response.

1. The use of Na2 EDTA in a per rectal lavage may facilitate cell harvesting for colonic cytology. So the effect of a Na2 EDTA 0.5% retention enema on serum electrolytes, kidney function tests and blood clotting mechanism as well as its direct effect on colonic mucosa, was evaluated in dogs. 2. The results were compared to a control study with a normal saline enema. 3. Blood samples and colonic biopsies were obtained at four time points. 4. A statistically significant decrease in serum calcium levels reaching a maximum 2 day post experiment, and increase in serum phosphorous and prolongation of prothrombin time at 2 hr post-experiment, were noted. 5. The perturbations were still within normal physiological limits for dogs, and no clinical manifestations of either hypocalcemia nor bleeding tendency occurred. 6. All other parameters evaluated did not change significantly at the examined time points. 7. Light microscopy examination of the colonic mucosa in the experimental group was not different from that of the control study. 8. Na2 EDTA may be used in retention enemas without significant clinical side effects.

Intestinal anastomosis healing in rat: collagen concentration and histochemical characterization by Picrosirius red staining and polarizing microscopy.

The study was designed to characterize collagen fibers in the healing intestinal anastomosis of rat by examining collagen concentration and recording the polarization colors of the collagen fibers in Picrosirius red-stained tissue sections. No significant changes in collagen concentration expressed by hydroxyproline content were noted at the anastomotic site at various postoperative time points. In the normal intestine, the predominant polarization colors were in the yellow to yellow-orange range, signifying tightly packed, matured collagen. During the first postoperative week, collagen fibers at the anastomotic region exhibited mainly polarization colors in the green to green-yellow range, implying less packed intermediate collagen fibers. After 2 weeks, collagen fibers at the anastomotic region gradually reacquired their preoperative polarizing texture. These findings strongly suggest that the "quality" rather than the quantity of collagen fibers plays an important role in maintaining the tensile strength of the healing intestinal anastomosis.

Low-energy CO2 laser intestinal anastomosis: an experimental study.

Intestinal anastomosis was performed in 17 Wistar rats via tissue welding by the low-energy CO2 laser. The postoperative course in the animals studied was uneventful. The integrity of the anastomosis was investigated manometrically, immediately upon completion of the anastomosis as well as 20 days later. Ten additional Wistar rats served as controls in which conventional interrupted one-layer anastomosis was performed. The results show a significant superiority of the intestinal anastomoses that were constructed by means of laser tissue welding. The time to complete the anastomosis was also significantly shorter when laser rather than manual suturing was used. Serial histological examinations for up to 90 days following surgery revealed complete healing and epithelization of the anastomotic site.

Colonic metastases from lobular carcinoma of the breast. Report of a case.

Metastatic involvement of the gastrointestinal tract secondary to breast cancer is rare. A case of diffuse infiltration of the colon by metastatic infiltrating lobular breast cancer is reported. Awareness of this condition may lead to proper investigations including intestinal biopsy, thus avoiding unnecessary surgery.

Spontaneous rupture of the rectosigmoid with small-bowel evisceration through the anus. Report of a case and review of the literature.

A patient with spontaneous rupture of the rectum and evisceration of small bowel through the anus is presented. To the authors' knowledge, this paper represents the third reported case of this type of spontaneous rectal rupture. A discussion of the pathogenesis and treatment of this rather unique complication is presented. It is suggested that rectal or rectosigmoid rupture be considered a rare complication of rectal prolapse.

Free pleuroperitoneal liquid movement indicating diaphragmatic tear.

An unusual radiological feature, not mentioned in the literature, is reported. It has been observed in a patient with traumatic rupture of the diaphragm associated with intra-abdominal bleeding. This injury produced a free pleuroperitoneal movement of liquid demonstrated in the supine and erect chest radiographs. Since there is an associated abdominal injury in most cases of rupture of the diaphragm, this radiological sign might be more common. The importance of supine and erect chest radiography is reinforced in cases of multiple injuries.

The simultaneous coexistence of adenocarcinoma and primary malignant lymphoma in the stomach.

A case of simultaneous adenocarcinoma and primary malignant lymphoma as two independent growths of the stomach is presented. Review of the literature documented two such cases along with nine cases of the collision-tumor type. The differential criteria between this entity and collision tumor and carcinosarcoma are emphasized. Diagnosis and treatment is discussed.