Successful hemostasis of active lower GI bleeding using a hemostatic powder as monotherapy, combination therapy, or rescue therapy.

BACKGROUND AND AIMS: Acute lower GI bleeding is a frequent cause of hospital admission. The objective of this study was to evaluate the safety and performance of a hemostatic powder (TC-325/Hemospray) in the treatment of nonvariceal lower GI bleeding. METHODS: Patients were enrolled into this prospective, multicenter, single-arm study at 4 tertiary care centers in Canada. Fifty patients with active lower GI bleeding of multiple different causes (52 bleeding sites) underwent topical endoscopic application of hemostatic powder. The primary endpoint was powder-related adverse events within 30 days of the index procedure. Secondary endpoints were initial hemostasis as well as recurrent bleeding and mortality within 30 days of the index procedure. RESULTS: Most patients (96%) had a single bleeding site, and most bleeding (73%) was due to polypectomy. Overall, the powder was applied as monotherapy in 13 bleeding sites (25%), as combination therapy in 22 bleeding sites (42.3%), and as rescue therapy in 17 bleeding sites (32.7%). Hemostasis was achieved in 98% of patients. No patient experienced a powder-related adverse event. Five patients (10%) developed recurrent bleeding within 30 days. One patient (2%) died within 30 days of powder application, but the death was not directly related to hemostatic powder use. CONCLUSIONS: The hemostatic powder is a safe and effective option for patients with lower GI bleeding of varying causes, and in particular, postpolypectomy hemorrhage. The hemostatic powder is effective as monotherapy, part of a combination approach, or as a rescue therapeutic option for the treatment of nonvariceal lower GI bleeding. (Clinical trial registration number: NCT02099435.).

Diverticulitis of the cecal appendix: a case report.

Appendicular diverticulosis is a rare condition. It is important to know its insidious form of presentation for its early diagnosis and treatment, thus diminishing morbimortality. In case of incidental findings, an appendicectomy will be performed to prevent complications and the development of malignancy.

Outcome of Surgical and Medical Management of Cecal Impaction in 150 Horses (1991-2011).

OBJECTIVE: To evaluate short- and long-term outcome after medical and surgical management of horses with cecal impaction and to determine reasons for death or euthanasia. STUDY DESIGN: Retrospective case series. ANIMALS: Horses (n = 150). METHODS: Data collected from medical records (1991-2011) of horses with a diagnosis of cecal impaction, included signalment, history of recent disease/surgical procedure, admission data, management (medical, typhlotomy alone, jejunocolostomy), complications, and outcome. Short-term outcome (alive or dead at discharge) and long-term outcome (alive or dead at ≥1 year) were determined by telephone interview. Data were analyzed using a χ(2) or Fisher's exact test. Level of significance was P < .05. RESULTS: Of 150 horses hospitalized with a diagnosis of cecal impaction, 102 (68%) had a history of recent disease or a surgical procedure. Thirty-eight horses (25%) had cecal perforation at admission and 3 horses (2%) were euthanatized without treatment. Of 109 horses treated, 59 (54%) were managed medically and 50 (46%) surgically (typhlotomy [26]; jejunocolostomy [24]). The proportion of horses alive at hospital discharge was significantly lower for horses managed medically (61%) compared with surgically (82%; P = .02) but there was no difference between horses managed with typhlotomy alone (77%) or with jejunocolostomy (88%; P = .47). There were 57% of horses managed medically alive at 1 year. There was a similar proportion of horses alive at 1 year after typhlotomy alone (73%) and jejunocolostomy (70%; P = .86). CONCLUSIONS: Compared to the recent reports, the proportion of horses alive at hospital discharge was lower for both medically and surgically managed horses with cecal impaction. There was decreased survival for horses treated medically than those treated surgically; however, no significant difference was seen in survival between horses managed with typhlotomy alone versus jejunocolostomy.

Outcome and complications of endoscopic balloon dilatations in various types of ileocaecal and colonic stenosis in patients with Crohn's disease.

AIM: We examined the outcome and the complications of endoscopic balloon dilatation (EBD) of ileocaecal and colonic strictures due to Crohn's disease. METHODS: We examined 237 dilatation procedures in 77 patients with symptomatic ileocaecal and colonic stenosis regarding outcome, individual perforation risk, the need for further interventions, and other complications within a 10 years observation period. RESULTS: In 50 of 77 patients (64.9%), endoscopic dilatation procedures were successful within a median follow-up period of 24 months (25th and 75th percentile 10-38.5 months). Thirty five patients (45.5%) were successfully dilated with only one endoscopic procedure, while the remaining patients required two or more EBDs. Albeit the EBD, 27 patients of the whole cohort (35.1%) underwent surgical repair of the stenosis in due course. Overall complication rate was 7.6%, with postdilatation bleeding in 1.7% and abdominal pain longer than 24 h in 4.2%. Perforation occurred in 4 of 77 patients (5.2%), resulting in a perforation rate of 1.7% per intervention, or, more importantly, for the individual patient in a long-term perforation rate of 5.2% per patient, respectively. DISCUSSION: Endoscopic balloon dilatation (EBD) is a safe and effective approach to ileocaecal and colonic stenosis in approximately 65% of Crohn's disease patients. Even in case of recurrence, further endoscopic treatments can be undertaken. The perforation rate depending on the number of interventions is low, but for the individual patient a cumulative per patient perforation risk of 5.2% in the long-term should be considered during patient information and decisions for or against surgical interventions.

Cecal pneumatosis intestinalis in obstructing sigmoid cancer: emergency metallic stenting.

An 85-year-old man presented with acute abdomen. Abdominal computed tomography revealed obstructing sigmoid colon cancer with pneumatosis intestinalis of the ascending colon. A surgeon was consulted for colonic obstruction with impending sepsis, who declined surgery considering the patient's advanced age. After discussion, the patient consented for emergent endoscopic metallic colonic stent placement. Complete obstruction of the lumen was observed at the sigmoid colon, followed by successful metallic colonic stent placement through the obstructed area. Normal stool passage was achieved after this, and the patient survived the 9-month follow-up period. Acute colonic obstruction from obstructive colon cancer requires emergency management, wherein the presence of pneumatosis intestinalis poses a high risk of cecal perforation. Emergency endoscopic colonic metallic stent placement provides an alternative therapy, particularly when surgery is not feasible, as described here.

A therapeutic barium enema is a practical option to control bleeding from the appendix.

BACKGROUND: Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable, because it is almost impossible to approach the bleeding point by endoscopy. We herein describe the first case of bleeding from the appendix, which was successively controlled by a therapeutic barium enema administered into the appendix. CASE PRESENTATION: A 71-year-old male visited our hospital because of melena. He has been receiving an anti-coagulation drug, ticlopidine hydrochloride, for 10 years. By an emergency colonoscopy, a hemorrhage was detected in the appendix, and the lesion responsible for the bleeding was regarded to exist in the appendix. Two hundred milliliters of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube. The bleeding could thus be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix. The barium accumulation disappeared by the next day, and no obvious anal bleeding was observed. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent any further refractory hemorrhaging. The patient has had no complaints of any abdominal symptoms or anal bleeding for 10 months. CONCLUSIONS: A therapeutic barium enema is a useful procedure to control bleeding from the appendix and to avoid emergency surgery, such as partial cecectomy and hemicolectomy.

Diverticulosis and diverticulitis of the appendix.

Diverticulosis of the appendix is a relatively rare pathological finding. The majority are acquired pseudodiverticula. True congenital diverticula are very rare. Appendiceal diverticulosis is usually an incidental finding and clinically asymptomatic. When symptomatic, it is usually complicated by acute or chronic diverticulitis with or without acute appendicitis. It presents with atypical abdominal signs and symptoms, mostly in adult males. Appendiceal diverticulitis is a distinct entity with several clinical and pathological differences from acute appendicitis. It has a more rapid progression to perforation and a higher rate of mortality. Therefore, appendiceal diverticulitis should be considered in the clinical differential diagnosis, especially in adult males with chronic abdominal pain. Appendiceal diverticulosis demonstrates a significant association with obstructing or incidental appendiceal neoplasms. It may play an important role in the development of pseudomyxoma peritonei, which is associated with appendiceal mucinous tumors. Therefore, meticulous gross examination and thorough histological examination of the entire appendicectomy specimen are essential. When discovered either by preoperative radiological investigations or during an exploratory operation, prophylactic appendicectomy is advocated to prevent the risk of complications and to rule out the possibility of a coexisting neoplasm.

Spontaneous cecum perforation following rectus abdominis free flap transfer for isolated lower limb trauma.

A case of a 32-year-old motorcyclist, who sustained an open comminuted fracture of the left tibia and subsequently developed spontaneous cecal perforation following successful fixation of the fracture and reconstruction of the soft tissue defect with a rectus abdominis free flap, is reported. Although benign cecal perforation has been described in patients with thermal burns and blunt trauma of the abdomen or pelvis, our association has not been reported previously in the medical literature. It is important to recognize cecal perforation early as it is associated with a high mortality from peritonitis and septicaemia.

Conservative management resulting in complete resolution of a double intussusception in an adult haemophiliac.

Acute abdominal pain in haemophiliacs should be approached as haemorrhage until proven otherwise. With advancements in factor repletion and coagulopathic management a conservative approach should be considered. We describe a case of double colo-colonic intussusception lead by an intramural haematoma occurring spontaneously and resolving with conservative management in a young haemophiliac. This demonstrates that intussusception in these cases may be transient, and does not require surgical intervention.

Approach to management of intussusception in adults: a new paradigm in the computed tomography era.

Intussusception has been considered an operative indication in adults as a result of the risk of ischemia and the possibility of a malignant lead point. Computed tomographic (CT) scans can reveal unsuspected intussusception. All CT reports from July 1999 to December 2005 were scanned electronically for letter strings to include the keyword intussusception. Identified CT scans were analyzed to characterize the intussusception and associated findings. Clinical, laboratory, pathological, and follow-up variables were gleaned from medical records. Findings were analyzed by treatment and findings at operation. Review of 380,999 CT reports yielded 170 (0.04%) adult patients (mean age, 41 years) with intussusceptions described as enteroenteric in 149 (87.6%), ileocecal in eight (4.7%), colocolonic in 10 (5.9%), and gastroenteric in three (1.8%). Radiological features included mean length of 4.4 cm (range, 0.8-20.5 cm) and diameter of 3.2 cm (range, 1.6-11.5 cm). Twenty-nine (17.1%) had a lead point, and 12 (7.1%) had bowel obstruction. Clinically, 88 (48.2%) patients reported abdominal pain, 52 (30.6%) had nausea and/or vomiting, and 74 (43.5%) had objective findings on abdominal examination. Thirty of 170 (17.6%) patients underwent operation, but only 15 (8.8%) patients had pathologic findings that correlated with CT findings. Seven had,enteroenteric intussusceptions from benign neoplasms (two), adhesions (one), local inflammation (one), previous anastomosis (one), Crohn's disease (one), and idiopathic (one). Three had ileocolic disease, including cecal cancer (one), metastatic melanoma (one) and idiopathic (one; whereas five patients had colocolonic intussusception from colon cancer (three), tubulovillous adenoma (one), and local inflammation (one). Of the 15 without intussusception at exploration, five had pathology related to trauma, four had nonincarcerated internal hernia after Roux-en-Y gastric bypass, four had negative explorations, one had adhesions, and one had appendicitis that did not correlate with CT findings. No patient in the observation group required subsequent operative exploration for intussusception at mean 14.1 months (range, 0.25-67.5 months) follow up. All operative patients demonstrated gastrointestinal symptoms versus 55.3 per cent of the observation group (P < 0.006). Analysis of CT features demonstrated differences among patients observed without operation, those without intussusception at exploration, and confirmed intussusception with regard to mean intussusception length 3.8 versus 3.8 versus 9.6 cm, diameter 3.0 versus 3.2 versus 4.8 cm, lead point 12.1 per cent versus 30 per cent versus 53.3 per cent, and proximal obstruction 3.8 per cent versus 0 per cent versus 46.7 per cent, respectively. Intussusceptions in adults discovered by CT scanning do not always mandate exploration. Most cases can be treated expectantly despite the presence of gastrointestinal symptoms. Close follow up is recommended with imaging and/or endoscopic surveillance. Length and diameter of the intussusception, presence of a lead point, or bowel obstruction on CT are predictive of findings that warrant exploration.

The usefulness of CT guided drainage of abscesses caused by retained appendicoliths.

OBJECTIVES: To determine the utility of percutaneous computed tomography (CT) guided drainage of abscesses formed secondary to retained appendicoliths. MATERIALS AND METHODS: A retrospective review was conducted over a 5-year period to identify patients who underwent CT guided drainage of abscesses related to retained appendicoliths. Inclusion criteria were a history of prior proven appendicitis treated by laparoscopic appendicectomy, identification of a post-operative abscess related to a visualised retained appendicolith and initial treatment by CT guided drainage. Data regarding initial technical success as well as long-term outcome was recorded in each case. RESULTS: In total, five patients were identified who underwent CT guided abscess drainage related to retained appendicoliths. There were three males and two females (age range 12-54 years). Initial drainage under CT guidance was technically successful in all cases with successful catheter placement and resolution of the abscess cavity. In all five cases however, there was recurrence of abscess formation following catheter removal. In one case, a second attempt with CT guided drainage was performed. Again this was initially successful with abscess recurrence following catheter removal. In all five cases, formal surgical drainage with removal of retained appendicolith resulted in a successful outcome. CONCLUSION: CT guided percutaneous drainage of intra abdominal abscess secondary to retained appendicoliths is only successful in the short term. Formal surgical drainage and removal of the appendicolith is required for long-term success.