Transvaginal ultrasound with bowel preparation versus transvaginal ultrasound with bowel preparation and water contrast for diagnosing Recto-Sigmoid endometriosis. A systematic review and Meta-Analysis.

Transvaginal ultrasound is effective in diagnosing endometriosis involving the rectosigmoid bowel. Some authors suggest enhanced detection of rectosigmoid involvement with bowel preparation. Conversely, conflicting views argue that bowel preparation may not improve diagnostic precision, yielding similar results to rectal water contrast. No existing meta-analysis compares these approaches. Our study aims to conduct a meta-analysis to evaluate the diagnostic performance of transvaginal ultrasound with bowel preparation, with and without rectal water contrast. Studies published between 2000 and 2023 were searched in PubMed, Scopus, Cochrane and Web of Science. From 561 citations, we selected nine studies to include in this meta-analysis. The study quality was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2). The mean prevalence of endometriosis rectosigmoid was 43.6% (range 17,56-76,66%) in the group with bowel preparation and 64,80% (50,0-83,60%) for the group with bowel preparation and rectal water contrast. Pooled sensitivity and specificity were 93% and 94% for bowel preparation and 92% and 95% and for bowel preparation with water contrast. We conclude that, there was no significant difference between performing transvaginal ultrasound with intestinal preparation with and without water contrast. In clinical practice, the absence of a significant difference between these methods should be taken into account when making recommendations.

Management of Recurrent Sigmoid Volvulus in the Pediatric Population.

Sigmoid volvulus is a rare etiology of bowel obstruction in the pediatric population that can be easily misdiagnosed, leading to delayed treatment and potential complications. Given that sigmoid volvulus is a common cause of bowel obstruction in the adult population and the significant lack of literature on its management in children, treatment strategies for pediatric patients often follow standardized protocols for adults. We report the case of a 15-year-old boy who presented with recurrent episodes of sigmoid volvulus over a 1-month period. Computed tomography demonstrated a sigmoid volvulus without evidence of ischemia or bowel infarction. Colonoscopy demonstrated a descending megacolon, and bowel transit studies demonstrated normal transit time. Acute episodes were managed conservatively with colonoscopic decompression. After a complete study, laparoscopic sigmoidectomy was performed. This work demonstrates the importance of early recognition and treatment of sigmoid volvulus in the pediatric population to limit recurrent episodes.

Sigmoid volvulus management, only endoscopic devolvulation?

Intestinal obstruction due to sigmoid volvulus (SV) represents a relevant percentage of abdominal diseases presenting at the emergency department. Treatment is based on early endoscopic devolvulation (ED), followed by elective surgery as definitive treatment. A 78-year-old man institutionalized with Lewy body dementia presents with abdominal pain, distention, and absence of stool in 72 hours. Coffee bean sign was seen in abdominal x-ray. Previously, he had been admitted three times last year with recurrent SV, managed with ED succesfully. Despite the recurrence, no surgical treatment was indicated after resolution of the acute situation and recovery of intestinal transit. This time, urgent colonoscopy was performed and a 20 cm length of purplish-black (isquemic) sigmoid mucosa was observed. With these findings of stablished intestinal ischemia urgent surgical intervention was performed (sigmoidectomy and terminal "Hartmann" colostomy). Histologically, necrosis, severe ulceration and mixed inflammation was noticed in the surgical piece. The patient develops favorably during a postoperative period without incidents. Therefore, he is discharged to his center. At the moment he is asymptomatic one year after the intervention with no new episodes. Recurrency of SV after ED is up to 86% of cases. In every episode, the incidence of complications such as intestinal ischemia or perforation increases significantly, as well as urgent surgery and mortality. Definitive treatment must be surgical, sigmoidectomy and terminal anastomosis is the choice technique.

Intestinal pneumatosis as a manifestation of systemic sclerosis.

A 60-year-old female patient was admitted to the emergency room for a 7-day history of abdominal bloating, nausea, vomiting, constipation, and lack of flatus. She had been diagnosed with systemic sclerosis (SSc) 10 years ago and had been using methotrexate, sildenafil, and prednisone. She did not present any signs of instability, but physical examination showed malnourishment status and abdominal tenderness and distention. Plain abdominal radiography was suggestive of sigmoid volvulus, confirmed and successfully resolved after endoscopic decompression therapy. Eight months later, the patient developed a new episode of abdominal obstruction. Computed Tomography (CT) scan identified a distended sigmoid colon due to its torsion with gas areas within the bowel wall. This time, endoscopic decompression had failed to treat, so exploratory laparotomy was performed. Colonic distention and sigmoid volvulus were identified during the procedure, after which sigmoidectomy followed by primary anastomosis was performed. Neither perforation nor masses were found. Furthermore, the anatomopathological study was inconsistent with vascular, inflammatory, or neoplastic diseases.

Non-invasive treatment of sigmoid volvulus in a child. The role of the endoscopist.

Sigmoid volvulus (SV) is a rare cause of intestinal obstruction in children. Its varied presentation and rapid progression engender a high risk of morbidity and mortality. We report two cases of SV in teenage boys. Patient 1 is 16 years old and patient 2 is 17. Both presented to our institution with recent-onset abdominal pain, constipation, and nausea and vomiting, and both had previous episodes of SV. Patient 1 had been surgically treated with manual derotation, and patient 2, who had redundant colon, had two past episodes of endoscopically-treated SV. Both patients were in poor condition and had distended but treatable abdomens, with no peritoneal signs. After computed tomography (CT) confirmation of the clinical impression of no ischemia or perforation, we decided to attempt detorsion of the SV and decompression of proximal dilated colon by flexible endoscopy, and planned for elective surgery shortly after the endoscopic procedure. Because sigmoid volvulus is so rare in children, operative and technical details of endoscopic management are gleaned from the larger adult experience. In patients without signs of complication, initial endoscopic reduction is the gold standard, and elective sigmoid resection with primary anastomosis is often required to prevent recurrence. KEY WORDS: Case report, Children, Endoscopy, Endoscopic treatment, Sigmoid volvulus, Volvulus.

Management of sigmoid volvulus during labor : a challenging situation.

Acute intestinal obstruction is rare during pregnancy. Its diagnosis is difficult because the symptoms can be minimal and mimic signs of a regular pregnancy. Sigmoid volvulus is a common cause of these obstructions. The management is challenging because it depends on many factors, and affects maternal-fetal outcomes. We report a case of a 32-year-old woman with sigmoid volvulus associated with fetal demise that came during labor and we discuss the management options.

Stratification of sigmoid volvulus early recurrence risk using a combination of CT features.

PURPOSE: The purpose of this study was to identify computed tomography (CT) features associated with early recurrence of sigmoid volvulus (SV) after a first uncomplicated episode and to develop a score for early SV recurrence risk stratification. MATERIALS AND METHODS: A total of 95 patients (59 men, 36 women; mean age, 72 ± 15 [SD] years; age range: 57-87 years) who underwent abdominal CT examination for a first uncomplicated SV episode from January 1st 2006 to July 31st 2020 in two French University Hospitals were retrospectively included. A SV recurrence occurring within six months was defined as early SV recurrence. CT findings associated with SV were searched for using univariable analysis. CT features associated with early recurrence were computed into a multivariable logistic regression model that was further used to build a score to stratify SV recurrence risk. Kaplan-Meier curves were built to evaluate recurrence-free survival. RESULTS: Early SV recurrence occurred in 53 patients (56%). At multivariable analysis, left lateral section volume < 150 cm3 and maximal colon distension > 10 cm were associated with early SV recurrence (Odds ratio [OR] = 4.62; 95% CI: 1.77-13.33; P = 0.002 and OR = 4.43 95% CI: 1.63-13.63; P = 0.005) respectively), and an early SV recurrence score with 1 point attributed to each of these two variables was built. Early SV recurrence was observed in 26%, 54% and 89% of patients with score of 0, 1 and 2, respectively (P < 0.001). CONCLUSION: A simple CT score allows stratification of early SV recurrence after a first episode and helps to select patient who would not benefit from prophylactic colonic surgery because of a low SV recurrence risk.

Sigmoid volvulus in pregnancy: a case report.

INTRODUCTION: Sigmoid volvulus in pregnancy is a rare cause of intestinal obstruction with high maternal and fetal morbidity and mortality if not diagnosed and managed early. CASE PRESENTATION: A 29-year-old female (Chagga by tribe) presented with clinical features of intestinal obstruction 24 weeks into her second pregnancy. She had symptoms for one week. An emergency laparotomy was performed whereby gangrenous sigmoid volvulus was found; thus, it was resected and Hartmann's colostomy was raised. Unfortunately, she experienced intrauterine fetal death post-operatively. She was discharged clinically stable. CONCLUSION: Early diagnosis and management can prevent adverse effects such as bowel ischemia and preterm labor. Because classic clinical and radiological features may not be evident, high degree of suspicion is warranted.

Long-term Implications of Persistent Diverticulitis: A Retrospective Cohort Study of 915 Patients.

BACKGROUND: Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described. OBJECTIVE: The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis. DESIGN: This was a retrospective cohort study. SETTINGS: Two university-affiliated hospitals in Montreal, Quebec, Canada were included. PATIENTS: The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis. INTERVENTION: Nonoperative management of acute sigmoid diverticulitis was involved. MAIN OUTCOME MEASURES: Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured. RESULTS: In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83)). LIMITATIONS: The study was limited by its observational study design and modest sample size. CONCLUSIONS: Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593. REPERCUSIONES A LARGO PLAZO DE LA DIVERTICULITIS PERSISTENTE ESTUDIO DE UNA COHORTE RETROSPECTIVA DE PACIENTES: ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definición, incidencia y factores de riesgo, así como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISEÑO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canadá.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCIÓN:Tratamiento no quirúrgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y síntomas de diverticulitis continua dentro de los primeros 60 días posteriores al tratamiento del episodio índice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio índice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 días. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresión (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutáneo y 5 (6,7%) resección. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Después de excluir a los pacientes que fueron tratados quirúrgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logarítmico: p <0,001) y colectomía sigmoidea (rango logarítmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente después el episodio índice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asoció con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomía (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseño de estudio observacional, un modesto tamaño de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente después del tratamiento del episodio índice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronóstico, donse se inlcuye la diverticulitis recurente y colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B593.

Transvaginal sonography determines accurately extent of infiltration of rectosigmoid deep endometriosis.

OBJECTIVE: To investigate the agreement of measurements of the three diameters of rectosigmoid deep endometriosis (DE) lesions between presurgical evaluation using transvaginal sonography (TVS) and postsurgical specimen measurement (PSM). METHODS: This was a prospective observational multicenter study including symptomatic women undergoing surgical treatment for DE involving the rectosigmoid, by either discoid or segmental resection, from April 2017 to December 2019. TVS was performed presurgically to evaluate lesion size (craniocaudal-midsagittal length, anteroposterior thickness and transverse diameter), in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement, and was compared with PSM. The agreement of lesion dimensions between the two methods was assessed by Bland-Altman plots and limits of agreement and additionally by the intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. Systematic and proportional bias was assessed using the paired t-test. RESULTS: A total of 207 consecutive women were eligible for inclusion. Forty-one women were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid resections were performed (both procedures were performed in three women). The mean difference between TVS and PSM was 0.90 (95% CI, 0.85-0.95) mm for lesion length measurements, 1.03 (95% CI, 0.98-1.09) mm for lesion thickness measurements and 0.84 (95% CI, 0.79-0.89) mm for transverse diameter measurements. Bland-Altman analysis demonstrated good agreement between the two methods for measurements of lesion length. Furthermore, there was good reliability and correlation between TVS and PSM for lesion length measurements, as demonstrated by an ICC of 0.82 (95% CI, 0.75-0.87) and Pearson's correlation coefficient of 0.72 (95% CI, 0.62-0.80), moderate-to-good reliability and correlation for lesion thickness measurements, with an ICC of 0.76 (95% CI, 0.67-0.82) and Pearson's correlation coefficient of 0.61 (95% CI, 0.51-0.70), and poor-to-moderate reliability and correlation for transverse diameter measurements, with an ICC of 0.58 (95% CI, 0.39-0.71) and Pearson's correlation coefficient of 0.46 (95% CI, 0.33-0.58). CONCLUSION: Preoperative TVS determines accurately rectosigmoid DE lesion length. TVS can thereby contribute to optimal planning of surgical treatment options in women with rectosigmoid DE. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Benign Colonic Strictures.

CASE SUMMARY: A 46-year-old man with no significant medical or surgical history presented to the emergency department with a 1-week history of worsening constipation, abdominal distension, nausea, and nonbloody, nonbilious emesis. Workup included a CT scan that was notable for a 5.3 × 3.9 cm "apple core-type" mass located within the sigmoid colon with proximal large-bowel dilation. Carcinoembryonic antigen was 1.4. No metastatic disease was seen on chest, abdominal, or pelvic CT scans. Flexible sigmoidoscopy identified a sigmoid colon mass 30 cm from the anal verge with near complete obstruction. Biopsies of the mass did not show evidence of dysplasia or malignancy. The Gastroenterology service declined to place a stent without a malignancy diagnosis. The patient subsequently underwent exploratory laparotomy, sigmoid colectomy, and end colostomy. Recovery was uneventful. Final pathology showed diverticulitis with abscess formation and no evidence of malignancy. A completion colonoscopy was unremarkable, and the patient underwent colostomy reversal 3 months later.