Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis.

INTRODUCTION: Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms. MATERIAL AND METHODS: We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea. RESULTS: Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group. CONCLUSIONS: Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.

The colon revisited or the key to wellness, health and disease.

The hypothesis being advanced in this paper is that there is a new medical paradigm emerging from the biomedical research carried out in this century, mainly due to the explosion of the so called "omics" and associated techniques. The main idea is that there is a common pathway from wellbeing and health to chronic disease ("chronopathy") and even to death, which comprises following steps: 1) unhealthy diet, sedentary life style and permanent exposition to xenobiotics and all kinds of noxious stimuli;→2) intestinal dysbiosis;→3) alteration of the intestinal mucus layer (especially that of the colon);→4) disruption of the endothelial tight junctions;→5) metabolic endotoxemia+bacterial translocation;→6) inflammation;→7) exacerbation of the enteric nervous system (ENS) and consequent maladaptation and malfunctioning of the colon;→8) epigenetic manifestations;→9) "chronopathy" and premature death. Therefore, in order to maintain a good health or to improve or even reverse chronic diseases in a person, the main outcome to look for is a homeostatic balance of the intestinal microbiota (eubiosis), most of which is located in the colon. Lynn Margulis was one of the main scientists to highlight the importance of the role played by bacteria not only in the origin of all biological species now present on earth, but also on their role in global homeostasis. Bacteria do not rely on other living beings for their existence, while the latter depend completely on the former. Humans are no exemption, and new evidence emerges each day about the pivotal role of intestinal microbiota in human health, disease and, in general, in its wellbeing. The following facts about intestinal microbiota are nowadays generally accepted: there are about 10 times more bacteria in the gut than human cells in every human being; the microbioma is about 100-150 times bigger that the human genome, and there is a clear link between intestinal microbiota and many of the most common chronic diseases, from obesity and diabetes to depression and Parkinson disease and different kinds of cancer. The main implication of this theory is that we should become a sort of microbiota farmers, that is, we ought to be more conscious of our intestinal microbiota, take care of it and monitor it permanently. Thus, as part of our good life habits (healthy eating, physical exercise), we should probably undergo periodic seasons of fasting and colon cleansing, as it was common in older times.

Electroneurostimulation for the management of bladder bowel dysfunction in childhood.

Both non-invasive and invasive electroneurostimulation (ENS) modalities for bladder bowel dysfunction have been studied and reported in children. A summary of the proposed mechanism of actions and the more commonly used and recently reported techniques and outcomes are described. This includes transcutaneous electrical nerve stimulation, functional electrical nerve stimulation, intravesical electrical nerve stimulation, percutaneous tibial nerve stimulation and sacral neuromodulation in conditions including overactive bladder, enuresis, dysfunctional voiding, constipation, combined bladder bowel dysfunction and neuropathic bladder and bowel dysfunction. There is a need for further high quality randomised trials as well as long-term outcomes to establish whether ENS is able to alter the long-term trajectory for an individual child with bladder bowel dysfunction.

A review of pathophysiology and management of fetuses and neonates with meconium ileus for the pediatric surgeon.

PURPOSE: Meconium ileus (MI) is the earliest clinical manifestation of cystic fibrosis (CF), occurring in up to 20% of patients with CF. Our aim was to review and integrate current knowledge about the diagnosis and management of fetuses and neonates with MI that may aid the pediatric surgeon in caring for these patients. METHODS: We identified areas of interest including pathophysiology, prenatal diagnosis, nonoperative and operative management, postoperative management, and prognosis. We performed a Medline search using the search term meconium ileus for English language articles published in the last 20 years. We reviewed reference lists to identify other articles of historical significance. RESULTS: Meconium ileus is primarily associated with CF transmembrane (conductance) regulator mutations F508del, G542X, W1282X, R553X, and G551D, and modifier genes have been found to explain approximately 17% of the phenotypic variability. Mouse, pig, and ferret models for CF demonstrate neonatal bowel obstruction mimicking MI. Sonographic findings of hyperechoic masses and dilated bowel in a high-risk fetus are suggestive of MI. Less than 7% of low-risk fetuses with hyperechoic bowel will have MI. Contemporary series of noninvasive management with Gastrografin enema report success rates of 36% to 39%, significantly lower than historical values. The optimal surgical technique remains controversial, although primary anastomosis results in surgical complication rates between 21% and 31%, higher than those noted with delayed anastomosis. Pulmonary function for patients with CF and MI at 15 and 25 years old is similar to those without MI, although height and weight percentiles may be lower. CONCLUSIONS: This review for pediatric surgeons presents an examination of the literature and synthesizes current information about the pathophysiology, prenatal diagnosis, nonoperative and operative management, postoperative management, and prognosis of the patient with CF and MI.

Effects of electroacupuncture at different points on colorectal distention-induced changes in blood pressure, electrogastrogram, gastric tension and gastric blood flow.

OBJECTIVE: To investigate the specificity of the effects of electroacupuncture (EA) at different acupoints on gastric functional activity and gastric blood flow after colorectal distension (CRD) in the rat. METHODS: Fifty Wistar rats were randomly divided into 5 groups: a control group, a Zusanli group, a non-point group, a Taichong group and a Neiguan group. Rats were anesthetized after 18 h of fasting, and a rat model of nociceptive blood pressure elevation and abnormal electrogastrogram (EGG) and gastric tension (GT) was prepared by gasbag-induced CRD. EA was given bilaterally, and its effects on gastric blood flow (GBF) of the arcus vasculosi of the greater omentum, blood pressure, EGG fast wave properties, and gastric smooth muscle tension (GT) were quantified. RESULTS: CRD induced an increase in blood pressure that was significantly inhibited by EA at all points (all P < 0.05), and the inhibitory effects were greater in the Zusanli and Neiguan groups compared to the non-point group (both P < 0.05). CRD also caused reductions in GT and GBF, and in the amplitude, frequency and duration of EGG waves (all P < 0.05). These effects were also reversed by EA. The effects of EA on EGG wave amplitude, GT, and GBF were superior in the Zusanli group compared to the Taichong group, Neiguan group, and the non-point group. CONCLUSION: EA significantly counteracted CRD-induced changes in blood pressure, GBF, EGG, and GT. The effects of stimulation at Zusanli (ST 36) were significantly greater compared to other points, indicating relative specificity of this acupoint.

Using biofeedback to treat constipation, faecal incontinence and other bowel disorders.

Biofeedback is a behavioural therapy used to treat people with bowel dysfunction, such as constipation or faecal incontinence, who do not respond to standard treatment. This article highlights how biofeedback therapy is used to treat these problems and improve patients' quality of life.

Role for NMDA receptors in visceral nociceptive transmission in the anterior cingulate cortex of viscerally hypersensitive rats.

We have identified colorectal distension (CRD)-responsive neurons in the anterior cingulate cortex (ACC) and demonstrated that persistence of a heightened visceral afferent nociceptive input to the ACC induces ACC sensitization. In the present study, we confirmed that rostral ACC neurons of sensitized rats [induced by chicken egg albumin (EA)] exhibit enhanced spike responses to CRD. Simultaneous in vivo recording and reverse microdialysis of single ACC neurons showed that a low dose of glutamate (50 microM) did not change basal ACC neuronal firing in normal rats but increased ACC neuronal firing in EA rats from 18 +/- 2 to 32 +/- 3.8 impulses/10 s. A high dose of glutamate (500 microM) produced 1.95-fold and a 4.27-fold increases of ACC neuronal firing in sham-treated rats and in EA rats, respectively, suggesting enhanced glutamatergic transmission in the ACC neurons of EA rats. Reverse microdialysis of the 3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA)/kainite receptor antagonist 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; 10 microM) reduced basal and abolished CRD-induced ACC neuronal firing in normal rats. In contrast, microdialysis of N-methyl-d-aspartate (NMDA) receptor antagonist AP5 had no effect on ACC neuronal firing in normal rats. However, AP5 produced 86% inhibition of ACC neuronal firing evoked by 50 mmHg CRD in the EA rats. In conclusion, ACC nociceptive transmissions are mediated by glutamate AMPA receptors in the control rats. ACC responses to CRD are enhanced in viscerally hypersensitive rats. The enhancement of excitatory glutamatergic transmission in the ACC appears to mediate this response. Furthermore, NMDA receptors mediate ACC synaptic responses after the induction of visceral hypersensitivity.

Colonic manometry as predictor of cecostomy success in children with defecation disorders.

PURPOSE: The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders. METHODS: Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n = 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical success was defined as normal defecation frequency with no or occasional fecal incontinence. RESULTS: Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility. CONCLUSION: Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.

Fístula duodeno-cólica benigna: reporte de un caso y revisión del tema / Benign duodenal-colic fistula: a case report and subject review

La fístula duodeno-cólica es una entidad de presentación inusual, descrita en la literatura sólo como reportes de casos aislados. Las FDC benignas son una rara complicación de numerosas enfermedades gastro-intestinales, siendo la causa más frecuente la secundaria a la enfermedad de Crohn. Dolor abdominal, signos de malabsorción (diarrea, baja de peso), asociados eventualmente a náuseas y vómitos son la forma de presentación más frecuentes. El enema baritado es el mejor método diagnosticado. El manejo debe ser integral, considerando tanto el manejo de la enfermedad de base, como el soporte nutricional y la resolución quirúrgica de la fístula. Se presenta un caso clínico de esta patología.

Rectal instillation of butyrate provides a novel clinically relevant model of noninflammatory colonic hypersensitivity in rats.

BACKGROUND & AIMS: The treatment of irritable bowel syndrome (IBS), characterized by abdominal pain and bloating, is empirical and often poorly efficient. Research lacks suitable models for studying the pathophysiologic mechanisms of the colonic hypersensitivity and new pharmacologic targets. The present study aimed to develop a novel model of colonic hypersensitivity possessing several of the characteristics encountered in patients with IBS. METHODS: Rats received enemas of a butyrate solution (8-1000 mmol/L) twice daily for 3 days. A time course was determined for colonic hypersensitivity (colorectal distention test) and referred cutaneous lumbar hyperalgesia (von Frey hairs). Macroscopic and histologic analyses were performed on colonic mucosa. The efficacy of morphine, U50488H (a kappa opioid agonist), and trimebutine on the 2 pain parameters was determined. Finally, the involvement of peptidergic C-fibers was evaluated using capsaicin-pretreated animals and treatments with calcitonin gene-related peptide (CGRP) and neurokinin 1 receptor antagonists. RESULTS: Butyrate enemas induced a sustained, concentration-dependent colonic hypersensitivity and, to a lesser extent, a referred cutaneous mechanical hyperalgesia, particularly in female rats, but no macroscopic and histologic modifications of the colonic mucosa, as observed in patients with IBS. Both pain parameters were sensitive to morphine, U50488H, trimebutine, neonatal capsaicin treatment, and the CGRP receptor antagonist but not to the neurokinin 1 receptor antagonist. CONCLUSIONS: These results present our noninflammatory model of chronic colonic hypersensitivity as a useful novel tool for studying IBS. The CGRP receptor antagonist-induced reduction of colonic hypersensitivity suggests that CGRP receptors may provide a promising target for treatment of IBS.

Protective effect of angelica sinensis polysaccharide on experimental immunological colon injury in rats.

AIM: To study the effect of angelica sinensis polysaccharide (ASP) on immunological colon injury and its mechanisms in rats. METHODS: Immunological colitis model of rats was induced by intracolon enema with 2, 4, 6-trinitrobenzene sulfonic acid (TNBS) and ethanol. The experimental animals were randomly divided into normal control, model control, 5-aminosalicylic acid therapy groups and three doses of ASP therapy groups. The 6 groups were treated intracolonically with normal saline, normal saline, 5-aminosalicylic acid (100 mg.kg(-1)), and ASP daily (8:00 am) at the doses of 200, 400 and 800 mg.kg(-1) respectively for 21 days 7 d following induction of colitis. The rat colon mucosa damage index (CMDI), the histopathological score (HS), the score of occult blood test (OBT), and the colonic MPO activity were evaluated. The levels of SOD, MDA, NO, TNF-alpha, IL-2 and IL-10 in colonic tissues were detected biochemically and immunoradiometrically. The expressions of TGF-beta and EGF in colonic tissues were also determined immunochemically. RESULTS: Enhanced colonic mucosal injury, inflammatory response and oxidative stress were observed in colitis rats, which manifested as significant increases of CMDI, HS, OBT, MPO activity, MDA and NO contents, as well as the levels of TNF-alpha and IL-2 in colonic tissues, although colonic TGF-beta protein expression, SOD activity and IL-10 content were significantly decreased compared with the normal control (P<0.01). However, these parameters were found to be significantly ameliorated in colitis rats treated intracolonically with ASP at the doses of 400 and 800 mg.kg(-1) (P<0.05-0.01). Meantime, colonic EGF protein expression in colitis rats was remarkably up-regulated. CONCLUSION: ASP has a protective effect on immunological colon injury induced by TNBS and ethanol enema in rats, which was probably due to the mechanism of antioxidation, immunomodulation and promotion of wound repair.

Unusual complications of preperitoneal mesh implantation in the treatment of inguinal hernia.

More and more prosthetic materials are being used in the treatment of inguinal hernia. This report deals with some unusual but devastating complications, occurring after preperitoneal mesh implantation. A 56-year old male patient underwent a Stoppa-repair for a bilateral inguinal hernia. Two years postoperatively, a localized abdominal wall abscess was treated with antibiotics and drainage. A barium enema and a CT-scan of the abdomen were performed to rule out an enteric fistula; the CT-scan unexpectedly revealed a tumoral mass involving the sigmoid colon, and an explorative laparotomy was done. Peroperatively, part of the mesh was found to penetrate the bowel wall and a sigmoidectomy with removal of the mesh was performed. Two years later, ingrowth of the urinary bladder by the remains of the mesh was the unfortunate peroperative finding when the patient was operated on for an inflammatory mass, involving the bladder wall. The patient needed two more interventions for persisting wound fistulas. All the remains of the mesh have been removed and all fistulas have been widely excised. Nowadays, the patient is recovering well with complete healing of all wounds. Although infection of prostheses used in the treatment of hernias has been described, late and serious complications related to mesh implantation, such as perforation of the colon and the bladder, have seldom been reported.

Treating benign colon disorders using laparoscopic colectomy.

Laparoscopic bowel surgery is a recent application of minimally invasive videoscopic techniques. Understanding the anatomy and physiology of the bowel, the background of bowel disorders and their treatment, signs and symptoms of bowel disease, and the patient selection process can help perioperative nurses better care for patients diagnosed with colon polyps, diverticulitis, and inflammatory bowel disease.

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE: Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. METHODS: One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. RESULTS: Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. CONCLUSIONS: Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.

Dynamic rectal examination: its significant clinical value.

The aim of the present study was to carry out a proper correlation between patients' clinical symptoms and the radiological findings obtained by dynamic rectal examination (DRE). At DRE, the small bowel and in females the vagina are routinely opacified in addition to defecography. A prospective study of 248 consecutive patients (193 women and 55 men, ratio 3.5:1) and 14 control subjects was conducted. The parameters assessed included the anorectal angle, the position of the anorectal junction, and the total movement of the pelvic floor during squeezing and defecation. Anatomical changes as rectoceles, enteroceles and intussusceptions were also observed. Based on the findings, the following conclusions can be drawn. There is no indication for measurement of the central or posterior anorectal angle. There is no indication for measurement of the perineal ascent, perineal descent, and anorectal junction level. Anterior rectoceles occur very frequently in females, and are only of clinical relevance if the patients need digital vaginal support to facilitate defecation. DRE is a sensitive method for diagnosing enteroceles and intussusceptions.

Progression of intussusception.

The position of the apex in intussusception indirectly reflects the length of the intussusceptum in the majority of cases in which the intussusception begins in the region of the terminal ileum. The relationship of the apex to the duration of symptoms and the ease of enema reduction suggests that progression of intussusception occurs rapidly after the onset of symptoms and is normally complete by the time the patient presents to hospital. Further increase in length of the intussusception is probably limited by progressive edema of the intussusceptum and by the length of small bowel mesentery available to it. The position of the apex per se is not a contraindication to attempted enema reduction, although once the apex has reached the rectosigmoid region successful enema reduction is less likely.

Gastrocolic fistula presenting as acute diarrhea.

Abdominal pain, diarrhea, weight loss, vomiting, foul eructation, feculent vomiting and melena are among the presenting symptoms of patients with a gastrocolic fistula. A routine physical examination is useful in ruling out the more common causes of the presenting complaints. Barium enema shows the gastrocolic fistula in 90 to 100 percent of cases. En bloc resection of the stomach and colon is the treatment of choice. Alternative therapies include a temporary diverting colostomy, total parenteral nutrition and antacid therapy.

Experience with colonic volvulus.

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility.

Conditions that mimic inflammatory bowel disease. Diagnostic clues and potential pitfalls.

Many of the features that identify idiopathic inflammatory bowel disease are also found with other colorectal conditions that are often encountered by the primary care physician. Although, initially, symptoms of these disorders may appear to be caused by ulcerative colitis or Crohn's disease, the cause could be bacterial, viral, parasitic, or fungal infection. Ischemic colitis and radiation colitis are other conditions that are similar in presentation to ulcerative colitis. In most cases, the physician should be able to make a differential diagnosis from a thorough history and physical examination, anoscopy or sigmoidoscopy, rectal biopsy, stool examination, and serology. An occasional patient, in whom diagnosis is not made by these methods, may require a barium enema study, colonoscopy, or referral to a gastroenterologist.