Fecal impaction is associated with postoperative urinary retention after hip fracture surgery.

BACKGROUND: Postoperative urinary retention (POUR) is a common hip fracture (HF) complication. Although fecal impaction (FI) is one of the oft-cited causes of POUR in clinical practice, evidence regarding this association is scarce. OBJECTIVE: The aim of this study was to determine whether FI was associated with POUR after HF surgery in older patients. METHODS: All patients consecutively admitted after a HF surgery in a geriatric perioperative unit were included in this cross-sectional study. FI was systematically assessed by a digital rectal exam at admission and according to clinical suspicion during the hospital stay. The dependent variable was POUR, systematically screened according to the department protocol and defined as a bladder volume>400ml requiring catheterization. The association between FI and POUR was assessed by multivariable analysis. RESULTS: A total of 256 patients were included (mean [SD] age 86 [6] years), (76% women): 108 (42%) presented FI and 63 (25%) POUR. The frequency of FI was higher with than without POUR (73% vs. 32%, P<0.001). On multivariable analysis, after adjusting for age, sex, Cumulative Illness Rating Scale score and anticholinergic load, FI was the only factor independently associated with POUR (odds ratio 4.78) [95% confidence interval 2.44-9.71], P<0.001. CONCLUSIONS: FI was the only independent factor associated with POUR after HF surgery in older adults. Further studies are needed to optimize perioperative geriatric care including FI and POUR assessment and management.

Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor.

BACKGROUND: Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation. METHODS: Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated). RESULTS: Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h. CONCLUSIONS: Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.

Use of gastrografin in the management of faecal impaction in patients with severe chronic constipation: a randomized clinical trial.

BACKGROUND/AIM: Faecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction. Gastrografin is a water-soluble radiologic contrast agent that may be orally or rectally administered, with proved therapeutic benefits in adhesive small bowel obstruction. Enemas have long been advocated as the best treatment for FI. The purpose of this study was to demonstrate that enteral administration of gastrografin might be more effective than enema in FI treatment inducing intestinal obstruction. METHODS: A double-blinded, controlled and randomized trial was conducted. Participants received 100 mL of gastrografin (gastrografin group) through nasointestinal tube or enemas (enema group) once daily for six consecutive days. Successful faecal disimpaction, FI time to resolution, Bristol Stool Scale, constipation severity, symptom assessment and adverse events were evaluated. RESULTS: A total of 124 patients were eligible, but only 83 were enrolled to this trial (mean age: 44 ± 15.8 years). Forty-two patients received enemas, and 41 patients received gastrografin, with six dropouts in each group. Successful disimpaction was achieved with enemas (69.44%) and gastrografin (88.57%; P = 0.034), mean duration of impaction was strikingly different between the two groups (67.13 versus 31.67, respectively; P < 0.01). Constipation severity and symptom assessment were significantly reduced in the gastrografin group. CONCLUSION: Gastrografin given through nasointestinal tube was more effective than enema in the treatment of FI inducing colon obstruction. Gastrografin might be taken into consideration as an effective and safe therapeutic option for FI.

Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study.

Non-operative treatment of uncomplicated appendicitis in children is gaining ground. Pending definitive evidence regarding its effectiveness, there is a call to evaluate clinical recovery after non-operative treatment. In this study, we analyzed data collected during initial admission of a multicenter prospective cohort in which children, 7-17 year, were treated non-operatively for uncomplicated appendicitis. During admission clinical parameters (pain and gastro-intestinal symptoms), inflammation parameters and sequential abdominal ultrasound were recorded. In total, 45 children were included, 42(93%) were discharged without the need for appendectomy; median [IQR] pain scores on admission were 5 [4-7], decreasing to 2 [0-3] after 1 day of treatment. Initially, 28/42 (67%) reported nausea and 19/42 (45%) vomiting; after 1 day, this was 3/42 (7%) and 1/42 (2%), respectively. White blood cell count declined from a median [IQR] of 12.9 [10.7-16.7] 10E9/L on admission to 7.0 [5.8-9.9] 10E9/L on day 1. Median [IQR] C-reactive protein levels increased from 27.5 [9-69] mg/L on admission to 48 [22-80] mg/L on day 1, declining to 21.5 [11-42] mg/L on day 2. Follow-up ultrasound showed no signs of complicated appendicitis in any of the patients.Conclusion: Clinical symptoms resolved in most children after 1 day of non-operative treatment. This suggests that non-operative treatment is a viable alternative to appendectomy regarding clinical recovery.Trail registration: NCT01356641 What is Known: • Non-operative treatment of uncomplicated appendicitis in children is safe and its use around the world is gaining ground, however high quality evidence from adequately designed randomized trials is still lacking. • Concerns have been raised regarding the potentially prolonged clinical recovery associated with non-operative treatment. What is New: • Most clinical symptoms resolve after 1 day of non-operative treatment in the majority of children.

Physical characteristics of free-living sea turtles that had and had not ingested debris in Microregion of the Lakes, Brazil.

The ingestion of detritus by sea turtles results in high mortality and morbidity. The objective of this study was to describe the characteristics of free-living sea turtles that ingested anthropogenic inorganic detritus in comparison to those that did not. A total of 186 necropsy files were analyzed in marine turtles from the beaches of the Microregion dos Lagos, Rio de Janeiro. Among the turtles that ingested detritus, the mean turtle was female and cachectic, with a carapace length of 36,6 cm, detritus accumulated in the large intestine, and fecal compaction. It seems most likely that's low food transit, combined with the multiplicity of ingestion, favored the accumulation of detritus. This ingestion resulted in cachexia associated with fecal compaction, since the greatest accumulation was in the large intestine. The intake of detritus by turtles was not punctual but continuous. These studies demonstrated the vulnerability of these animals to environmental pollution.

IMAGING DIAGNOSIS - RADIOGRAPHY, ULTRASONOGRAPHY, AND COMPUTED TOMOGRAPHY OF A GIANT FECALOMA CAUSING STERCORAL PERFORATION OF THE COLON IN A DOG WITH A PROSTATIC ABSCESS.

A mixed-breed dog presented with tenesmus, hematochezia, and abdominal distension of 2 weeks duration. Radiography showed a large round mass with a "soap-bubble" appearance and shell-like mineralization in the caudal abdomen. Computed tomography revealed a lamellate mineralized mass 8 cm in diameter and containing air in the descending colon and prostatic abscess. Heterogeneously contrast-enhanced, irregularly thickened colonic wall with intramural and peritoneal free gas indicated stercoral colonic perforation. Surgical intervention revealed a tumor-like giant fecaloma in the descending colon adjoining the prostate with extensive wall rupture and fecal peritonitis. Hypothetically, prostatic inflammation may affect colonic motility with resultant fecaloma formation.

Anal Sphincters Evaluation by Endoanal Ultrasound in Obstructed Defecation.

OBJECTIVES: To evaluate anal sphincter abnormalities detected by endoanal ultrasound in obstructed defecation due to rectocele and rectal intussusception. METHODS: The retrospective analysis includes 45 patients with obstructed defecation syndrome due to rectocele and/or rectal intussusception with or without fecal incontinence, and submitted to endoanal ultrasound. RESULTS: Ninety-three percent (n = 42) were women (mean age of 63 ± 12 years), and 47% (n = 21) of the patients had fecal incontinence. In total, 29% (n = 13) had a previous anorectal surgery, and 93% (n = 39) of the women had a previous vaginal delivery. An isolated rectal intussusception was diagnosed in 20% (n = 9) of the patients, an isolated rectocele in 24% (n = 11), and rectal intussusception and rectocele in 56% (n = 25). Thirty-six percent of patients had anal sphincter lacerations (n = 16): 12% (n = 2) had only internal laceration, 69% (n = 11) had only external laceration, and 19% (n = 3) had both. Two patients had a thinner internal anal sphincter with 0.9 and 1.2 mm, respectively. In total, 25% of the patients without fecal incontinence had an occult anal sphincter laceration, and all were women with an external sphincter laceration in the anterior quadrant and a previous vaginal delivery. In patients with obstructed defecation and fecal incontinence, 48% had sphincter lacerations. Previous anorectal surgery was a predictor of anal sphincter laceration (odds ratio [OR] 4.8; 95% confidence interval [CI] = 1.214-18.971; P = .025), but fecal incontinence (OR 2.7; 95% CI = 0.774-9.613; P = .119) and previous vaginal delivery (OR 1.250; 95% CI = 0.104-15.011; P = .860) were not. CONCLUSIONS: Endoanal ultrasound should be considered in obstructed defecation with or without fecal incontinence, especially if surgical correction is planned.

Supergiant fecaloma as manifestation of chronic constipation.

Fecaloma is common in patients with damage to the autonomic nervous system in the large bowel associated with Chagas disease (inflammatory and neoplastic) or Hirschprung's disease, in psychiatric patients and, more commonly, in elderly patients suffering with chronic constipation. Symptoms of fecaloma are usually nonspecific. Clinical examination can give the appearance of an abdominal tumor. Most cases of fecaloma are treated conservatively with digital evacuation and enemas. In severe and unremitting cases, surgery is required to prevent significant complications. Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass. We present the clinical case of an 85-year-old man with a history of chronic constipation presented to the emergency room with vague abdominal pain of 2 days' duration. An erect abdominal X-ray and computed tomography revealed a supergiant faecaloma extending from the pubis up to the diaphragm associated to a megarectum and megacolon. The patient was treated successfully with digital evacuation and enemas.

Intra-abdominal fungal pseudomycetoma in two cats.

BACKGROUND: Pseudomycetomas are deep cutaneous to subcutaneous lesions caused by Microsporum canis mainly described in Persian cats, with few reports of intra-abdominal location. This report describes the clinical signs and lesions of intra-abdominal pseudomycetomas caused by M. canis in two Persian cats. CASE REPORT: Two Persian cats with a history of previous laparotomy (ovariohysterectomy and nephrostomy) and fecal impaction were examined. Cat #1 was euthanized and subjected to necropsy, histopathology and mycological evaluation. Cat #2 presented with chronic dermatophytosis, and an intra-abdominal mass, that was subjected to histopathology evaluation. Cat #1 presented at necropsy a white-grayish, firm mass (6cm×3.5cm×2.8cm) in the uterine cervix. Cat #2 presented a firm whitish mass (6.5cm×1.5cm×0.5cm) located close to the left kidney. Histologically, both masses contained multifocal granules with hyphae and spores surrounded by Splendore-Hoeppli reaction, with a pyogranulomatous inflammatory infiltrate and fibrous connective tissue proliferation in the periphery. Hyphae and spores exhibited marked Grocott and periodic acid-Schiff staining. M. canis was identified by fungal isolation in cat #1. CONCLUSIONS: Pseudomycetoma should be considered as a differential diagnosis in cats, especially in Persian cats presenting with an intra-abdominal mass. Entrance of the agent into the cavity can occur during laparotomy.

[Synchronous acute cholecystolithiasis and perforated acute appendicitis. Case report]. / Colecistitis litiásica crónica agudizada y apendicitis aguda perforada sincrónicas. Reporte de caso.

BACKGROUND: Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate on. However, it is rarely described in its synchronous form. CLINICAL CASE: A 43 year-old woman attending the clinic for right upper quadrant pain of 11 days duration. The patient refers to intermittent radiating pain in the right side, with positive Murphy, tachycardia, and fever. The laboratory results showed white cells 16,200/mm(3), glucose 345 mg/dl, abnormal liver function tests. Acute cholecystitis was reported with ultrasound. A Masson-type incision was made, noting an enlarged pyogenic gallbladder with thickened walls, sub-hepatic abscess of approximately 300 ml, greenish-yellow colour, and foetid. An anterograde subtotal cholecystectomy is performed due to difficulty in identifying elements of Calot triangle due to the inflammatory process, opening it and extracting stones. The right iliac fossa is reviewed, finding a plastron and a sub-serous retrocaecal appendix perforated in its middle third with free fecalith and an abscess in the pelvic cavity. An anterograde appendectomy was performed and the patient progressed satisfactorily, later being discharged due to improvement. DISCUSSION: In this patient, with a history of recurrent episodes of gallbladder pain and disseminated acute abdominal pain without peritoneal irritation, clinical suspicion was exacerbated cholecystitis with probable empyema of the gallbladder. Open surgery approach for this patient allowed access to both the appendix and gallbladder in order to perform a complete exploration of the abdominal cavity. CONCLUSION: The synchronous presentation of cholecystolithiasis and complicated appendicitis has not been reported in the literature.

A planar gastrointestinal stromal tumor replacing the proper muscle layer causing fecaloma and perforation in the sigmoid colon: a case report and literature review.

A 72-year-old Japanese male with acute abdomen underwent emergency surgery for a preoperative diagnosis of stercoral colonic perforation of the sigmoid colon. A pathological examination revealed a proliferating spindle cell lesion that surrounded the perforation and replaced the muscularis propria without any mass formation. The spindle cells were positive for KIT and CD34 by immunohistochemistry, and somatic mutation of the c-kit gene was found using genomic DNA extracted from the lesion. We diagnosed the spindle cell lesion as a planar gastrointestinal stromal tumor (GIST). We speculate that perforation of the sigmoid colon in this case may be caused by the stasis of stool resulting from abnormal peristalsis of the lesional site. Two other similar cases have been reported in the literature, and showed good prognoses. Although their pathogenesis is unclear, planar GISTs should be considered as a possible cause of idiopathic or stercoral colonic perforation.

Hyperkalemia and ventricular tachycardia after outpatient ureteral valve reimplantation: a case report.

OBJECTIVE: This study aimed to report on a toddler who presented with progressively worsening abdominal pain and obstructive uropathy 1 week after ureteral valve reimplantation. Acute renal failure resulted in critical hyperkalemia. METHODS: Chart review of presentation, physical examination, laboratory tests, and treatment. RESULTS: Initial potassium level was 10 mEq/L; ventricular tachycardia was observed and treated. CONCLUSIONS: More commonly, hyperkalemia results from overuse/overdose of supplementation or in patients with known renal failure. Although less common, obstructive uropathy should be considered in any patient with recent instrumentation of the urinary tract and coincident complications can be significant.

Barolith as a rare cause of acute appendicitis: a case report.

A barolith consists of inspissated barium associated with feces and is seen, rarely, after barium studies for imaging the gastrointestinal system. The barium used in such studies can enter the appendiceal lumen and, rarely, cause appendicitis by obliterating or narrowing the lumen of the appendix. The appendix fills with barium and the entire appendix is visualized in 80-90% of barium swallow or enema studies, and this is accepted as a reliable sign of a non-diseased appendix Post-examination retention of barium in the appendix is very common (90~95%), and 10% of the patients retain barium in the appendix beyond 72 hours. If the barium is retained for more than two months, complicated appendicitis can result. We present a 46-year-old male who was diagnosed with acute appendicitis due to a barolith and required an appendectomy three months after a double-contrast barium enema study. After barium studies, patients should be informed regarding retention of barium in the appendix and the possibility that it can cause acute appendicitis. Thus, if abdominal pain develops, the patient can be referred quickly to a medical center for the appropriate treatment and the complications of acute appendicitis can be prevented with early intervention.

Knowledge and practice styles of pediatricians in Saudi Arabia regarding childhood constipation.

OBJECTIVES: The aim of the present study was to evaluate knowledge and practice styles among medical providers working in 5 regions of Saudi Arabia regarding their approach to childhood constipation. METHODS: A survey of 850 pediatric providers (PPs) conducted in 5 regions of Saudi Arabia. PPs included pediatric specialists (PSs), pediatric consultants (PCs), general practitioners (GPs), family physicians (FPs), and pediatric gastroenterologists (PGs). They were asked anonymously about definition, causes, diagnosis, and management of constipation. Information about family concerns regarding constipation and the source of constipation-related information was also collected. RESULTS: A response rate of 73% yielded 622 questionnaires. Among respondents, 61.2% were aware of the Rome definition of functional constipation. More pediatricians (PSs and PCs) than other physicians (GPs and FPs) reported the definition of constipation correctly (P > 0.05). Stool withholding was reported as the most common cause of constipation by 27% of pediatricians (PSs and PCs), 24% of other physicians (GPs and FPs), and 50% of PGs (P = 0.097). Rectal examination was performed by 39% of all PPs and 78.6% of PGs (P = 0.009). Pediatricians prescribed lactulose significantly more often than physicians (P = 0.001). Pediatricians recommended disimpaction before maintenance treatment significantly more than other physicians (P = 0.001). Twenty-three percent of families believed that constipation was caused by a stricture and 10% feared it was caused by a malignancy. CONCLUSIONS: Significant differences in knowledge and practice patterns exist regarding the approach to pediatric constipation. Identification of knowledge gaps may be useful to develop educational materials to improve proper diagnosis and treatment of childhood constipation.

[Appendicovesical fistula treated with elective laparoscopic surgery]. / Fístula apendicovesical tratada mediante cirugía laparoscópica electiva.

BACKGROUND: appendicovesical fistula is a rare complication of advanced acute appendicitis and represents a rare type of enterovesical fistula. Its symptoms are vague and imprecise and its diagnosis is difficult, requiring a high level of suspicion. Exploratory laparotomy has been the key for diagnosis and definitive treatment for many years, but recently the laparoscopic approach is standing out among different experienced groups as the method of choice. CLINICAL CASE: we report a new case of appendicovesical fistula in a 45 year old female, who was remitted from Urology with symptoms of persistent dysuria and pyuria. She was finally diagnosed by computerized tomography and the appendicovesical fistula was resolved by laparoscopic surgery. This case adds to the one hundred and fifteen cases published so far and to the four treated by the laparoscopic approach. DISCUSSION: conventional imaging methods are not reliable for the diagnosis of enterovesical fistula. Since most appendicovesical fistula are found to be secondary to non-diagnosed and advanced acute appendicitis in the majority of the consulted publications laparotomy is the key for the diagnosis of apendicovesical fistula. However laparoscopy is described as a diagnostic and therapeutic tool in few articles. We only found three articles in the literature referring to the laparoscopic approach as a therapeutic option. CONCLUSION: computerized tomography is the diagnostic method of choice when communication between the digestive tract and urinary tract is suspected, particularly if the suspected fistula is an appendicovesical one. The laparoscopic approach of an appendicovesical fistula is able to confirm the radiological diagnosis and provide a definitive treatment.

Antecedentes: la fístula apendicovesical es una complicación infrecuente de la apendicitis aguda en estadio avanzado y representa un tipo poco habitual de fístula enterovesical. La laparotomía exploradora ha sido durante muchos años pieza clave para el diagnóstico y su tratamiento efinitivo, pero actualmente el abordaje laparoscópico se está imponiendo entre diferentes grupos experimentados. Caso clínico: aportamos un nuevo caso de fístula apendicovesical en una mujer de 45 años de edad remitida del servicio de Urología por disuria y leucocituria permanente; finalmente, el diagnóstico se estableció mediante técnica de imagen (tomografía computada) y se resolvió por laparoscopia. Este caso se suma a los 115 casos descritos hasta ahora en la bibliografía y a los cuatro tratados mediante laparoscopia. Discusión: los métodos de imagen convencionales no son fiables para el diagnóstico de fístula enterovesical. La mayoría de los casos de fístula apendicovesical son secundarios a una apendicitis aguda no evidenciada y evolucionada. En la mayor parte de las publicaciones consultadas la laparotomía es una herramienta de diagnóstico de la fístula apendicovesical y, en pocos artículos, se describe la laparoscopia como alternativa diagnóstica y terapéutica. En la bibliografía sólo se encontraron tres artículos que hacen referencia al abordaje laparoscópico con fines terapéuticos. Conclusión: ante la sospecha de comunicación entre el tubo digestivo y el aparato urinario, la tomografía computada es el método diagnóstico de elección, sobre todo si se sospecha una fístula apendicovesical. El abordaje laparoscópico de la fístula apendicovesical puede confirmar el diagnóstico radiológico a la vez que constituye una opción quirúrgica definitiva.

Colorectal considerations in pediatric patients.

Colorectal disease in pediatric patients includes a spectrum of diseases, many of which have a significant impact on quality of life and warrant long-term follow-up and treatment into adulthood. Although many diseases, such as inflammatory bowel disease and colon cancer, are managed similar to adults, other disease processes are more common to pediatric patients and are the focus of this article.