Management of barium enema-induced colorectal perforation.

Unless recognized and treated promptly, colorectal perforation induced by barium enema examination is a life-threatening complication. Between 1977 and 1986, 13,000 barium enemas were performed at the Mayo Medical Center. Colorectal perforation occurred in five patients (overall incidence: 0.04%). The two colonic perforations were managed by immediate celiotomy with resection in one and primary repair in the other. The three rectal perforations were managed conservatively in two patients and by proximal diversion in one. All patients recovered. Perforations were believed to be related to the tip of the enema catheter or presumably to excessive hydrostatic pressure. In contrast to other reports, barium enema-induced colorectal perforation is not always fatal when recognized early and treated aggressively. Localized, contained extraperitoneal rectal perforation may be managed conservatively in selected patients.

Chronic constipation. Important aspects of workup and management.

Constipation is at best an annoying problem and at worst an incapacitating one. Two common causes are a faulty diet and inactivity. Drs Nivatvongs and Hooks propose a trial of dietary fiber for patients in whom an organic cause for constipation cannot be found. Such a trial may prove to be not only diagnostic but also therapeutic. They also discuss the proper use of laxatives, enemas, and surgical procedures.

The shape of the buttocks. A useful guide for selection of anesthesia and patient position in anorectal surgery.

Recognition of the different shapes of the buttocks will help surgeons to appropriately select patients for anorectal surgery. Basically, there are three types of buttocks. In Type A, the mounds of the buttock make a low and gentle slope with the anal verge. In Type B, the mounds of the buttock are high and rise almost straight up from the anal verge. In Type C, the anus is located more anteriorly than normally. Patients with Type A buttocks are ideal candidates to use local anesthesia for hemorrhoidectomy and lateral internal sphincterotomy because it is easy to infiltrate the anesthetic agent into the anal canal. With Type C, this is somewhat more difficult, but no significant problem exists. For Type B buttocks, general or spinal anesthesia is recommended. For Types A and C buttocks, a lithotomy position will give an excellent exposure of the anorectal lumen for stripping the mucosa and submucosa. For Type B buttocks, a prone jack-knife position gives the best exposure.

Distribution of large-bowel cancers detected by occult blood test in asymptomatic patients.

A randomized, controlled study on occult blood in stool was conducted in 48,000 asymptomatic participants, ages 50 to 80 years. Those with positive hemoccult test results underwent a complete colonic workup including colonoscopy and, in some cases, an air-contrast barium-enema examination when total colonoscopy could not be accomplished. From April 1976 to December 1980, 113 patients (62 men and 51 women), with an average age of 66 years, were found to have invasive carcinomas of the large bowel: right colon--25 per cent, transverse colon (included both flexures)--9 per cent, descending colon--10 percent, sigmoid and rectosigmoid--42 per cent, rectum--12 per cent, anal canal--2 per cent. The stages of the cancers were: Dukes' A--57 per cent, Dukes' B--21 per cent, Dukes' C--19 per cent, Dukes' D--3 per cent. The findings suggest that a complete colonic workup is required for the detection and diagnosis of large-bowel cancers in asymptomatic patients.

Alternative positioning of patients for hemorrhoidectomy.

The left anterolateral position is an excellent alternative for hemorrhoidectomy under local anesthesia. The pain over the pubis and the low backache, frequently encountered in the prone position, are totally eliminated. Exposure of the operative fields is excellent. Occasional incomplete exposure at the right posterior quadrant with the Fansler speculum can be easily corrected by using a Pratt speculum instead.