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1.  Acute colonic pseudo-obstruction complicating chemotherapy in paediatric oncohaematological patients: clinical and imaging features 
The British Journal of Radiology  2012;85(1012):377-381.
Although acute colonic pseudo-obstruction (ACPO) complicating chemotherapy is still a controversial entity, it is one with which radiologists should be familiar. We describe the imaging features of ACPO in children following chemotherapy for treatment of a haematological malignancy.
We retrospectively reviewed the imaging features of eight children (age 3–14 years) with chemotherapy-related ACPO, all of whom had undergone plain radiography and CT examinations. The diagnosis of ACPO was based on both clinical features and imaging findings.
Abnormalities noted on plain radiography included faecal gaseous distension of the transverse colon (4/8), faecal gaseous distension of the ascending colon (3/8), gaseous distended transverse colon (3/8) and gaseous small bowel loops (6/8). As seen on CT scans, findings of faecal fluid distended the ascending and transverse colon (5/8), faecal gas distended the transverse and ascending colon (3/8), and small bowel dilatation (5/8) and pneumatosis intestinalis (2/8) were noted. Seven of the eight patients had colonic dilatation from the caecum to the transverse colon with the transition zone near the splenic flexure.
In children presenting with abdominal pain and constipation following chemotherapy, imaging features of progressive colonic dilatation seen on radiography and dilatation from the caecum to the transverse colon with the transition zone near the splenic flexure, as noted on CT, are suggestive of ACPO. CT is more successful than plain radiography for evaluating this finding, particularly in colonic segments filled primarily with fluid, but CT should not be necessary for making the diagnosis as plain radiographs and clinical evaluation should be adequate.
PMCID: PMC3486651  PMID: 21828148
2.  Favorable surgical treatment outcomes for chronic constipation with features of colonic pseudo-obstruction 
AIM: To determine long-term outcomes of surgical treatments for patients with constipation and features of colonic pseudo-obstruction.
METHODS: Consecutive 42 patients who underwent surgery for chronic constipation within the last 13 years were prospectively collected. We identified a subgroup with colonic pseudo-obstruction (CPO) features, with dilatation of the colon proximal to the narrowed transitional zone, in contrast to typical slow-transit constipation (STC), without any dilated colonic segments. The outcomes of surgical treatments for chronic constipation with features of CPO were analyzed and compared with outcomes for STC.
RESULTS: Of the 42 patients who underwent surgery for constipation, 33 patients had CPO with dilatation of the colon proximal to the narrowed transitional zone. There were 16 males and 17 females with a mean age of 51.2 ± 16.1 years. All had symptoms of chronic intestinal obstruction, including abdominal distension, pain, nausea, or vomiting, and the mean duration of symptoms was 67 mo (range: 6-252 mo). Preoperative defecation frequency was 1.5 ± 0.6 times/wk (range: 1-2 times/wk). Thirty-two patients underwent total colectomy, and one patient underwent diverting transverse colostomy. There was no surgery-related mortality. Postoperative histologic examination showed hypoganglionosis or agangliosis in 23 patients and hypoganglionosis combined with visceral neuropathy or myopathy in 10 patients. In contrast, histology of STC group revealed intestinal neuronal dysplasia type B (n = 6) and visceral myopathy (n = 3). Early postoperative complications developed in six patients with CPO; wound infection (n = 3), paralytic ileus (n = 2), and intraabdominal abscess (n = 1). Defecation frequencies 3 mo after surgery improved to 4.2 ± 3.2 times/d (range: 1-15 times/d). Long-term follow-up (median: 39.7 mo) was available in 32 patients; all patients had improvements in constipation symptoms, but two patients needed intermittent medication for management of diarrhea. All 32 patients had distinct improvements in constipation symptoms (with a mean bowel frequency of 3.3 ± 1.3 times/d), social activities, and body mass index (20.5 kg/m2 to 22.1 kg/m2) and were satisfied with the results of their surgical treatment. In comparison with nine patients who underwent colectomy for STC without colon dilatation, those in the CPO group had a lower incidence of small bowel obstructions (0% vs 55.6%, P < 0.01) and less difficulty with long-distance travel (6.7% vs 66.7%, P = 0.007) on long-term follow-up.
CONCLUSION: Chronic constipation patients with features of CPO caused by narrowed transitional zone in the left colon had favorable outcomes after total colectomy.
PMCID: PMC3436063  PMID: 22969211
Constipation; Total colectomy; Pseudo-obstruction; Surgical outcome; Hypoganglionosis
3.  Large tubular colonic duplication in an adult treated with a small midline incision 
Tubular colonic duplication presenting in adults is rare and difficult to diagnose preoperatively. Only a few cases have been reported in the literature. We report a case of a 29-year-old lady presenting with a long history of chronic constipation, abdominal mass and repeated episodes of abdominal pain. The abdominal-pelvic computed tomography scan showed segmental bowel wall thickening thought to be small bowel, and dilatation with stasis of intraluminal content. The provisional diagnosis was small bowel duplication. She was scheduled for single port laparoscopic resection. However, a T-shaped tubular colonic duplication at sigmoid colon was found intraoperatively. Resection of the large T-shaped tubular colonic duplication containing multiple impacted large fecaloma and primary anastomosis was performed. There was no perioperative complication. We report, herein, the case of a T-shaped tubular colonic duplication at sigmoid colon in an adult who was successfully treated through mini-laparotomy assisted by single port laparoscopic surgery.
PMCID: PMC3294114  PMID: 22403754
Colonic duplication; Congenital abnormalities; Adult; Laparoscopy
4.  Stercoral perforation of the colon in sigmoid colostomy patients: Two case reports☆ 
Stercoral perforation of the colon has rarely been reported. Only 3 cases of stercoral perforation of the colon proximal to an end colostomy have been reported. We present two cases of stercoral perforation of the colon in end colostomy patients.
A 70-year-old man who had undergone abdomino-perineal excision for anal cancer was referred for left lower quadrant pain and fever. Stercoral perforation was discovered along the distal descending colon, proximal to the end sigmoid colostomy. The patient underwent segmental resection of the colon and revision of the stoma and was discharged on postoperative day 32. A 71-year-old woman who had undergone abdomino-perineal excision for distal rectal cancer with preoperative chemoradiation presented fever with 2 days of low abdominal pain. The patient had sacral bone and lung metastases from rectal cancer and suffered from chronic constipation. Stercoral perforation was found around the sigmoid colon, just proximal to the end sigmoid colostomy. The patient underwent simple repair of the perforated colon through the parastomal incision. On postoperative day 8, leakage occurred at the repair site. Segmental resection of the colon and revision of the stoma were performed. She was discharged 44 days after the initial surgery.
Segmental resection of the perforated colon, rather than simple repair, appears to improve postoperative outcomes.
As the number of cancer survivors increases, appropriate management of constipation is important to prevent stercoral perforation during follow-up.
PMCID: PMC3825961  PMID: 24121050
Stercoral perforation; Colon; Colostomy
5.  Congenital Pouch Colon with Unilateral Renal Agenesis and Monorchism 
Iranian Journal of Pediatrics  2010;20(4):491-494.
Congenital pouch colon, also known as congenital short colon or “Pouch colon syndrome”, is a rare condition that occurs in association with anorectal malformations; colon is either partially or completely replaced by pouch-like dilatation and communicates with the urogenital tract by means of a fistula. This anomaly is exclusively seen in Northern parts of India with only a few cases reported from elsewhere.
Case Presentation
A 1-day old neonate was presented with abdominal distension due to lack of passage of meconium. Clinical and radiological investigations revealed ano-rectal malformation. Incidental findings were left sided renal agenesis and right sided anorchia. Laparotomy revealed congenital pouch colon which was dealt accordingly. The baby is now healthy and awaiting further reconstructive surgery.
Although urogenital anomalies are not uncommon with congenital pouch colon, the finding of renal agenesis with unilateral anorchia is quite rare.
PMCID: PMC3446092  PMID: 23056753
Renal; Agenesis; Congenital; Colonic Pouches; Monorchism
6.  Clinical Characteristics of Multiple Primary Colorectal Cancers 
Although multiple primary colorectal cancer has been recognized as a significant clinical entity, its clinical and pathological features and its prognosis are still controversial. The purpose of this study was to clarify clinical and pathological features of multiple primary colorectal cancer.
Materials and Methods
Among 1669 patients who underwent surgery for primary colorectal cancer from January 1997 to June 2005, 26 patients (1.6%) with multiple primary colorectal cancer were identified. We reviewed clinical characteristics including diagnostic interval, lesions, operating methods, and TNM stage, and we defined the index lesion as the most advanced lesion among the synchronous lesions. For the purposes of the study, the colon and rectum were classified into three segments. The right-side colon included the appendix, cecum, ascending colon, hepatic flexure, and transverse colon, and the left-side colon included the splenic flexure, descending colon, and sigmoid colon.
Of the 26 patients with multiple primary colorectal cancers, nineteen patients were male and seven patients were female, with a mean age of 61.5 years. Nineteen patients had synchronous colorectal cancers and seven patients had metachronous colorectal cancers. In the metachronous cases, the mean diagnostic interval was 36.8 months. The site of the first lesion in metachronous colorectal cancers was the right colon in five cases (71.4%) and the left colon in two cases (28.6%), and the site of the second lesion was the rectum in six cases (55.5%), the right colon in three cases (33.3%), and the left colon in one case. The TNM stage of the second lesions in the metachronous colorectal cancers was stage II in four cases (57.1%), stage III in one case (14.3%), and stage IV in one case (14.3%). For the synchronous colorectal cancers, the operation methods were single-segment resection combined with endoscopic mucosal resection in five cases (26.3%), single-segment resection alone in six cases, two-segment resection in six cases, and total colectomy in two cases.
In metachronous colorectal cancers, the secondary lesions were later-stage cancer. Therefore, careful postoperative follow-up is necessary for patients who have undergone surgery for colorectal cancers. Further study of therapeutic modalities is important for synchronous colorectal cancers.
PMCID: PMC2697483  PMID: 19688051
Colorectal neoplasms; Multiple primary cancers; Synchronous; Metachronous
7.  Clinical features of idiopathic megarectum and idiopathic megacolon. 
Gut  1997;41(1):93-99.
BACKGROUND: Dilatation of the rectum and/or colon, in the absence of demonstrable organic disease, is an uncommon and poorly characterised condition. AIMS: To characterise the clinical and diagnostic features, and response to treatment, of patients with idiopathic megarectum (IMR) and idiopathic megacolon (IMC). METHODS: A retrospective review was undertaken of all patients operated on for these conditions over a 23 year period. In addition all patients treated over a three year period were prospectively studied by means of a questionnaire, contrast studies of the upper and lower intestine, spine x rays to exclude spinal dysraphism, anorectal physiological studies, and assessment of clinical outcome. Patients with Hirschsprung's disease and other known causes of gut dilatation were excluded. RESULTS: (i) Retrospective study: Of 63 operated patients, 22 had IMR, 23 had IMR and IMC, and 18 had IMC only. Five patients with IMC had previous sigmoid volvulus, and three had associated non-gastrointestinal congenital abnormalities. Faecal incontinence was always associated with rectal impaction and 14 patients (82%) with IMR alone had had manual disimpaction. (ii) Prospective study: Twenty two patients had IMR, with a median rectal diameter of 10 cm (normal < 6.5 cm). Six patients had IMC and one patient had IMR and IMC. Patients with IMR were significantly (p = 0.0007) younger than patients with IMC. All patients with IMR became symptomatic in childhood, compared with half the patients with IMC who developed symptoms as adults. Patients with IMR all presented with soiling and impaction, compared with patients with IMC whose symptoms were variable and included constipation or increased bowel frequency, pain, and variable need for laxatives. No upper gut dilatation was seen in either group of patients. Spinal dysraphism was seen in two of 18 patients with IMR and two of four with IMC, suggesting extrinsic denervation as a possible cause in a minority. Twelve of 22 patients with IMR had a maximum anal resting pressure below normal, indicating sphincter damage or inhibition. Both IMR and IMC patients had altered rectal sensitivity to distension, suggesting that despite lack of dilatation the rectum in IMC has altered viscoelasticity, tone, or sensory function. Fifteen of 22 patients with IMR were successfully managed with laxatives or enemas, but seven required surgery. Two of seven patients with IMC required surgery, including one for sigmoid volvulus. CONCLUSIONS: Patients with IMR differ clinically, diagnostically, and in their outcome from patients with IMC. These conditions demand specific investigation, and intensive treatment, to achieve optimum care.
PMCID: PMC1027235  PMID: 9274479
8.  Colonic duplication in an adult who presented with chronic constipation attributed to hypothyroidism 
Gastrointestinal duplications are an uncommon congenital abnormality that manifest before the age of two in 80% of cases. Ileal duplication is the most common while colonic duplication, either cystic or tubular, occurs in 10%-15% of cases and remains asymptomatic and undiagnosed in most cases. Mostly occurring in pediatric patients, colonic duplication is encountered in adults in only a few cases. The most common clinical manifestations are abdominal pain and intestinal obstruction. Rarely, duplications present with signs of acute abdomen or acute bleeding. This study reports a case of colonic duplication in an adult who presented with chronic constipation. Complete diagnostic workup was made on several occasions during the previous eight year period, but no pathology was found and chronic constipation was attributed to hypothyroidism caused by long standing Hashimoto thyroiditis. Multislice CT, performed because of abdominal distension, defined colonic pathology but the definite diagnosis of duplication of the transversal colon was made at operation. The cystic duplication and the adjacent part of the ascending and transversal colon were excised en-block. This study implies that colonic duplication, though uncommon, should be included in the differential diagnosis of chronic constipation even when precipitating factors for constipation, such as hypothyroidism are present.
PMCID: PMC2681163  PMID: 18203304
Colonic duplication; Constipation; Abdominal distension; Hypothyroidism
9.  Surgical management of inflammatory bowel disease 
Archives of Disease in Childhood  2006;92(4):312-316.
To evaluate the outcome and morbidity after major surgical interventions for inflammatory bowel disease (IBD).
Retrospective case note analysis of 227 children referred to a tertiary referral centre between 1994 and 2002 for treatment of IBD.
26 of 125 children with Crohn's disease (21%) required surgical management. 13 with disease proximal to the left colon underwent limited segmental resections and primary anastomosis, without significant morbidity. Primary surgery for 13 children with disease distal to the transverse colon included 6 subtotal‐colectomies or panprocto‐colectomies. All seven children undergoing conservative segmental resections (three with primary anastomosis, four with stoma formation), required further colonic resection or defunctioning stoma formation. All three children undergoing primary anastomosis developed a leak or fistula formation. 22 of 102 children with ulcerative colitis (22%) required surgery. Definitive procedures (n = 17) included J‐pouch ileoanal anastomosis (n = 11), ileorectal anastomosis (n = 2), straight ileoanal anastomosis (n = 3), and proctectomy/ileostomy (n = 1). Five children await restorative surgery after subtotal colectomy. Median daily stool frequency after J‐pouch surgery was 5 (range 3–15), and 10 of 11 children reported full daytime continence. All three children with straight ileoanal anastomosis had unacceptable stool frequency and remain diverted.
The complication rate after resectional surgery for IBD was 57% for Crohn's disease, and 31% for ulcerative colitis. In children with Crohn's disease, limited resection with primary anastomosis is safe proximal to the left colon. Where surgery is indicated for disease distal to the transverse colon, subtotal or panproctocolectomy is indicated, and an anastomosis should be avoided. Children with ulcerative colitis had a good functional outcome after J‐pouch reconstruction. However, the overall failure rate of attempted reconstructive surgery was 24%, largely owing to the poor results of straight ileoanal anastomosis.
PMCID: PMC2083695  PMID: 16670116
10.  HIRSCHSPRUNG'S DISEASE—The Clinical Differentiation and Treatment of Children with Hirschsprung's Disease and Pseudo-Hirschsprung's Disease 
California Medicine  1958;89(1):7-13.
Hirschsprung's disease is marked by constipation from the time of birth, with the development, if uncorrected, of a protuberant abdomen and flared costal margins. The rectal ampulla is empty and the abdomen is filled with fecal masses. Pain is not prominent. Flatus is passed in large amounts. Encopresis does not occur. Barium enema shows the characteristic narrowed distal rectal segment and biopsy of the rectum shows absence of the ganglion cells of the myenteric plexus.
Treatment is operative resection of the distal narrow segment and a primary anastomosis.
Hirschsprung's disease may be mimicked in children with:
1. Psychogenic constipation—pseudo-Hirschsprung's disease. Unlike Hirschsprung's disease, symptoms do not appear at birth, encopresis is common, and the barium enema shows no narrow distal segment.
2. Mental retardation and cerebral defect.
3. Corrected imperforate anus—on the basis of stenosis, imperfect innervation or poor habit training.
4. Cretinism—with severe constipation and intestinal dilatation perhaps the presenting symptoms.
Treatment of these four groups of children with severe constipation not due to Hirschsprung's disease is:
For Group 1, open discussion with parent and child. Assumption by the physician of full control of the details of treatment, and relegation of parent to the role of the physician's agent in following the prescribed regimen.
For Group 2, an enema regimen. Whereas fairly rapid restoration (and then persistence) of normal bowel habit can be expected in Group 1, the basic defects in Group 2 may require indefinite continuation of treatment.
For Group 3, regular enema regimen, in the less severe cases—one identical with that used in Group 1, and dilatation of strictures or anoplasty.
In Group 4, thyroid hormone therapy relieves the constipation of hypothyroidism and causes reversion of radiographic changes in the colon and rectum.
PMCID: PMC1512951  PMID: 13561108
11.  Oesophageal manometry in the evaluation of megacolon with onset in adult life. 
Gut  1997;40(2):188-191.
BACKGROUND: Oesophageal motility is often impaired in patients with megaduodenum and other forms of intestinal pseudo-obstruction in which a visceral myopathy or neuropathy may be present. Idiopathic longstanding megacolon with onset in adult life is still a poorly defined entity, which may also be part of a more widespread motility disorder but in which oesophageal motility has not been yet systematically studied. AIMS: To assess oesophageal motility in patients with longstanding idiopathic megacolon with onset in adult life. PATIENTS: 14 consecutive subjects with idiopathic megacolon whose symptoms began after the age of 10 and a clinical history of 2-22 years. METHODS: Standard barium enema, water perfused oesophageal manometry, and also anorectal manometry. RESULTS: Oesophageal motility was impaired in five patients (36%; 95% confidence intervals 16 to 61%). Normal peristalsis was substituted by low amplitude multiple peaked simultaneous contractions in four subjects and by undetectable contractions in one. In three of them the lower oesophageal sphincter did not relax after swallows; in the same patients anal relaxation after rectal distension was also undetectable. All five patients with impaired oesophageal motility had a colonic dilatation sparing the rectum. Three of them reported constipation and a history of pesudo-obstruction and the other two only abdominal distension. CONCLUSIONS: Oesophageal manometry should be performed in patients with longstanding idiopathic megacolon with onset in adult life, in particular if the rectum is not dilated and even in absence of pseudo-obstruction. This simple test may disclose a more widespread visceral neuropathy or myopathy. Such a diagnosis helps to better understand the cause of the colonic dilatation and may be clinically relevant for treatment of the patients.
PMCID: PMC1027046  PMID: 9071929
12.  Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society 
Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.
The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.
Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).
Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.
PMCID: PMC3022691  PMID: 21189148
13.  Colonic stent placement as a bridge to surgery in patients with left-sided malignant large bowel obstruction. An observational study 
Il Giornale di Chirurgia  2015;35(11-12):283-289.
Acute left-sided malignant colonic obstruction is common in elderly patients, in which emergency surgery is related with high morbidity and mortality rates, and often necessitates a two-step resection. Although the use of self-expanding metallic stents (SEMS) in elderly patients has not been adequately described yet, there are almost two international important trials which are still in progress, the stenting technique is established to be, by the international literature, an useful treatment with low morbidity and mortality. It’s also a bridge to surgery, since the insertion of a SEMS can decompress the obstruction, making bowel and patient preparation possible and facilitating single-stage surgical resection. Palliative stenting can improve quality of life when compared to surgery in patients with metastasis or high co-morbidity.
The aim of this study is to analyze mortality, avoidance of stoma, short- and long-term survival in patient with malignant left-sided large bowel obstruction who underwent to stent placement in our Emergency Surgery Unit, which is operative since November 2010 in our city Hospital in Ferrara.
Patients and methods
Between November 2010 and December 2012 a total of 15 patients with acute left-sided malignant large bowel obstruction suitable for colonic stent application were admitted to Emergency Surgery Unit. Among these patients, 9 underwent to self-expanding metallic stent placement (group A), the other (group B) 6 patient underwent to emergency surgery.
In this observational not-randomized study we analyzed the efficacy and safety of SEMS placement for patients either as a bridge to surgery or as a palliation, beside the short term and long term outcomes, versus those patients operated straight.
Self-expanding metallic stents were successfully implanted in 9 of the 15 patients with acute left-sided malignant large bowel obstruction. No acute procedure-related complication was observed. All the patients in group A kept the stent in place for an average of 7,7 days, then everyone underwent to surgery. A large bowel resection with one-time recanalization was performed in 8 of the 9 patients. None Hartmann resection was necessary. Only one underwent again to surgery because of a dehiscence, a stoma was necessary.
Between the other 6 patients in group B who underwent directly to surgery, In one case was necessary an Hartmann resection, another one incurred in dehiscence of the anastomosis that required reoperation with stoma creation.
Placement of SEMS seems to be an useful alternative to emergent surgery in the management of acute left-sided bowel obstruction, both as a bridge to surgery and as a palliative procedure. SEMS can provide an effective and safe therapeutic option compared to emergency surgery, most of all in elderly patients, with a lower mortality rate, a significantly higher rate of primary anastomosis and the avoidance of stoma.
However, to fully determine their role for these indications, more data and more high level evidence is required.
PMCID: PMC4321507  PMID: 25644730
Colorectal cancer; Large bowel obstruction; Stent placement; Bridge to surgery
14.  A report of left dorsal displacement of the large colon in a tropical horse 
We report one such case which was diagnosed intraoperatively as left dorsal colon volvulus due to multiple mesenteric abnormalities. A 17-year-old castrated male horse was taken to the Tehran University Veterinary Hospital for treatment of metacarpal wound accompanied by severe abdominal distension and acute colic. The treatment and measurement were taken for a month, and the prepared biopsy indicated that the healing trend was obvious. Unfortunately, prior to discharge, the clinical colic manifestations emerged and the animal suddenly died. Dilated large intestine was palpated per rectum and a ventral midline exploratory laparotomy was performed, a complete volvulus of the ascending colon was identified with multiple mesenteric anomalies of unknown aetiology. The pathologic changes observed in this study accurately reflect those changes reported in horse with naturally occurring colonic volvulus and can serve as a reference for subsequent studies on attenuating bowel injury. The present study results can be used to make a scientific assessment of prognosis in the pre-operative, operative, and post-operative management of horses with large colon volvulus.
PMCID: PMC3634933  PMID: 23620860
Large colon; Horse; Pathology; Volvulus; Laparotomy
15.  Zonal adult Hirschsprung's disease. 
Gut  1996;39(5):765-767.
BACKGROUND: Hirschsprung's disease is a congenital disorder which is rare in adulthood. In typical cases the aganglionosis involves mainly the rectum or rectosigmoid colon and the lesion starts from the anal valve. Zonal segmental aganglionosis is a very rare type even in children. PATIENT: A 54 year old women with zonal segmental aganglionosis had an aganglionic segment 18 cm in length located in the rectosigmoid colon with an 8 cm long normal appearing rectum and dilated proximal colon. Resection of the stenotic segment with end to end anastomosis was performed. CONCLUSION: The functional result was excellent five years after the operation.
PMCID: PMC1383405  PMID: 9014779
16.  Ileosigmoid Knotting 
The Eurasian Journal of Medicine  2009;41(2):116-119.
Ileosigmoid knotting (ISK) is the wrapping of the ileum around the sigmoid colon and its mesentery or vice-versa. The incidence of ISK is not well known, but it generally occurs in areas with a high incidence of sigmoid volvulus, and it is common in adult males. The etiology of ISK is controversial. The main symptoms are abdominal pain, distention, obstipation, and vomiting, while the main signs are abdominal distention and tenderness. There are no specific blood tests for diagnosing ISK. Plain abdominal X-ray radiographs demonstrate a dilated sigmoid colon and multiple small intestinal air-fluid levels. Abdominal CT demonstrates a twisted and dilated sigmoid colon with whirled sigmoid mesentery, in addition to twisted and dilated small intestinal segments. The accurate preoperative diagnosis of ISK is difficult. After rapid and prompt resuscitation, emergency surgery is needed in the treatment of ISK. In gangrenous cases, resection with primary anastomosis is preferred, while, in nongangrenous cases, untying of the knot may be performed as a sole surgical procedure, or a volvulus-preventing procedure may be added. The mean mortality rate for ISK is 6.8–8% in nongangrenous and 20–100% in gangrenous cases.
PMCID: PMC4261469  PMID: 25610081
Ileum; Sigmoid colon; Knotting
17.  Colopexy as a treatment option for the management of acute transverse colon volvulus: a case report 
Transverse colon volvulus is an uncommon acute surgical presentation associated with a higher rate of mortality than volvulae at other locations along the colon. Surgical resection or correction is the only treatment, and various methods have been described in case report literature to relieve the volvulus and prevent recurrence.
Case presentation
We present the case of a 25-year-old Caucasian woman who was admitted with a three-day history of abdominal pain, absolute constipation and abdominal distension. Subsequent radiographic and computed tomography imaging revealed right-sided colonic dilatation suggestive of a volvulus. An emergency laparotomy was performed during which the dilated proximal bowel was decompressed and colopexy executed by using the greater omentum to fix the transverse colon at the hepatic and splenic flexures.
Volvulus of the transverse colon is rare but must form part of the clinician's differential diagnosis when encountering a patient with suspected bowel obstruction, especially in younger patients with no previous surgical history. Laparotomy is the treatment of choice and the technique of using the greater omentum as a fixing point for redundant bowel to the lateral abdominal wall is an option that may be considered especially when the bowel appears viable.
PMCID: PMC3423063  PMID: 22691866
18.  Loss of interstitial cells and a fibromuscular layer on the luminal side of the colonic circular muscle presenting as megacolon in an adult patient 
Gut  1999;45(5):775-779.
BACKGROUND—Animal studies have shown that the neuromuscular structures on the luminal side of the colonic circular muscle coordinate circular muscle activity. These structures have been identified by electron microscopy in the normal human colon, but have never been thoroughly studied in patients with acquired intestinal hypoganglionosis.
AIMS—To perform histological, immunocytochemical, and electron microscopic examinations of the colon of a patient with acquired intestinal hypoganglionosis presenting as megacolon.
PATIENT—A 32 year old man with a one year history of constipation and abdominal distention, a massively dilated ascending and transverse colon, and a normal calibre rectum and descending and sigmoid colon. He had a high titre of circulating serum anti-neuronal nuclear antibodies.
METHODS—Histology, immunocytochemistry (for neurofilaments, neurone specific enolase, synaptophysin, glial fibrillar acidic protein, S100 protein, and smooth muscle α-actin), and electron microscopic examinations on the resected colon.
RESULTS—The number of ganglion cells and nerve trunks was decreased throughout the colon. Disruption of the neural network and a loss of interstitial cells of Cajal were observed on the luminal side of the circular muscle; in their place, the non-dilated colon contained a hypertrophic fibromuscular layer.
CONCLUSIONS—Striking architectural alterations occurred at the site regarded as the source of the coordination of colonic circular muscle activity in an adult patient with acquired intestinal hypoganglionosis presenting as megacolon.

Keywords: megacolon; intestine; hypoganglionosis; pseudo-obstruction; interstitial cells of Cajal
PMCID: PMC1727704  PMID: 10517919
19.  The Whirl CT Sign in Patient with Sigmoid Volvulus due Chagas’ Disease 
The Indian Journal of Surgery  2012;75(2):162-163.
It is believed that sigmoid volvulus (SV) in Brazil is a frequent complication of megacolon caused by Chagas’ disease (CD), differing in some characteristics from volvulus found in other countries. Bowel obstruction in patients with CD, principally when the cause is SV, may be sometimes difficult to diagnosis exclusively with plain abdominal radiograph. Fecaloma impacted in retossigmoidal area is one of the differential diagnoses. In addition, the huge amount of gas and feces, and distension of the colon normally increase the difficulty to make the correct diagnostic. The use of computer tomography (CT) scan can easy elucidate the picture of SV, and can be a great tool in cases of patients with CD and suspicion of this entity. A 62-year-old man showed bowel distention and stop disposal of gas for 5 days. He had previous diagnosis of CD. He also had been suffering from chronic constipation for several years, including impacted fecaloma, with the necessity of manual extraction. Plain abdominal radiographs showed an important colon dilatation and gross amount of feces in the sigmoid colon. Abdominal computer tomography sacan revealed dilated colon filled with feces, as well, the “whirl sign” composed of mesentery and twisted colon. When abdominal radiograph films reveal gross colonic dilatation of unknown etiology in patients with CD, a whirl sign on CT scans raises the possibility of colonic volvulus.
PMCID: PMC3644166  PMID: 24426419
Sigmoid volvulos; Chaga’s disease; Whirl sign; Computer tomography scan; Bowel obstruction
20.  Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo obstruction after resolution of colonic dilation: a prospective, randomised, placebo controlled trial 
Gut  2006;55(5):638-642.
Background and aims
Conservative therapy for patients with acute colonic pseudo obstruction (Ogilvie's syndrome) may be successful initially but relapses are common. The aim of the present study was to evaluate the effect of polyethylene glycol (PEG) electrolyte balanced solution on the relapse rate of the syndrome after initial resolution with neostigmine or endoscopic decompression.
Patients and methods
The study was performed on 30 consecutive patients who presented with abdominal distension and radiographic evidence of colonic dilation, with a caecal diameter ⩾10 cm, that resolved conservatively. Patients then were randomised to receive daily 29.5 g of PEG (n = 15) or similar placebo (n = 15). Patients were monitored daily for a seven day period for stool and flatus evacuations, and colonic diameter on abdominal radiographs. Administration of the test solutions and assessment of patient symptoms and x rays were performed in a blinded fashion. A caecal diameter ⩾8 cm with a concomitant ⩾10% increase after initial successful therapeutic intervention was considered as a relapse and these patients, after a second therapeutic intervention, were eligible to receive open label PEG.
Twenty five patients received neostigmine as the initial therapeutic intervention which resulted in resolution of colonic dilation in 88% of cases. Eight patients had successful endoscopic decompression. Five (33.3%) patients in the placebo group had recurrent caecal dilation compared with none in the PEG group (p = 0.04). Therapy with PEG resulted in a significant increase in stool and flatus evacuations (p = 0.001 and 0.032, respectively) as well as in a significant decrease in the diameter of caecum, ascending and transverse colon, and abdominal circumference (p = 0.017, 0.018, 0.014, and 0.008, respectively).
Administration of PEG in patients with Ogilvie's syndrome after initial resolution of colonic dilation may increase the sustained response rate after initial therapeutic intervention.
PMCID: PMC1856135  PMID: 16306137
colonic pseudo obstruction; Ogilvie's syndrome; polyethylene glycol; constipation
21.  Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn’s disease: A prospective study 
AIM: To examine the long-term results of endoscopic treatment in a prospective study conducted over a period of 10 years, 1997 to January 2007.
METHODS: A total of 25 patients (20 female and five male: aged 18-75 years), with at least one symptom of stricture not passable with the standard colonoscope and with a confirmed scarred Crohn’s stricture of the lower gastrointestinal tract, were included in the study. The main symptom was abdominal pain. The endoscopic balloon dilatation was performed with an 18 mm balloon under endoscopic and radiological control.
RESULTS: Eleven strictures were located in the colon, 13 at the anastomosis after ileocecal resection, three at the Bauhin valve and four in the ileum. Four patients had two strictures and one patient had three strictures. Of the 31 strictures, in 30 was balloon dilatation successful in a single endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. In one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart, sufficient dilatation was not possible. This patient therefore required surgery. Improvement of abdominal symptoms was achieved in all cases which had technically successful balloon dilatation, although in one case perforation occurred after dilatation of a recurrent stricture. Available follow-up was in the range of 54-118 mo (mean of 81 mo). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period.
CONCLUSION: We conclude from these initial results that endoscopic balloon dilatation, especially for short strictures in Crohn’s disease, can be performed with reliable success. Perforation is a rare complication. It is our opinion that in the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure.
PMCID: PMC2691493  PMID: 19496192
Crohn’s disease strictures; Balloon dilatation; Endoscopy; Morbidity; Mortality
22.  Idiopathic adult colo-colonic intussusception: Case report and review of the literature 
Acute colonic intussusception occurring in the absence of organic cause is uncommon in adults.
We report acute colonic intussusception in a 46-year-old female; clinical evidence of a palpable mass, abdominal pain and bloody mucoid stools appeared a few hours after hospital admission. Multislice CT-scan confirmed the clinical diagnosis and surgical exploration revealed right colonic obstruction caused by intussusception of the cecum into the ascending colon. Right hemicolectomy was performed and histopathological examination did not reveal any causative pathology.
Intussusception remains a rare condition in adults, representing 1–5% of bowel obstruction and accounting for 0.003–0.02% of all hospital admissions. Intussusception occurs more frequently in the small (50–80%) than in the large bowel (12–50%). It is estimated that approximately 90% of intussusceptions in adults are secondary to an anatomical or pathological condition, of which more than half are malignant. Idiopathic cases are the exception in adults. The clinical presentation of adult intussusception differs considerably from the classic pediatric presentation of abdominal pain, palpable mass, and blood per rectum, which is rarely seen in adults. A pre-operative CT-scan showed a 10 cm intussuscepted segment of right colon. Surgical resection was considered mandatory because of severe bowel obstruction, and the theoretical possibility of occult malignancy. This approach was vindicated by the presence of widespread ischemic lesions in the wall of the resected bowel, without any obvious lead point.
There are few reports in the medical literature of acute colonic intussusception occurring in the absence of organic cause in adults.
PMCID: PMC3605480  PMID: 23500747
Intussuscption; Idiopathic; Colonic
23.  Transmesocolic Hernia of the Ascending Colon with Intestinal Obstruction 
Case Reports in Gastroenterology  2012;6(2):344-349.
An internal hernia may be either congenital or acquired. The reported incidence of such hernias is 1–2%. In rare cases, internal hernias are the cause of small bowel obstruction, with a reported incidence of 0.2–0.9%. Transmesocolic hernia of the ascending colon is especially rare. We report a case of transmesocolic hernia of the ascending colon with intestinal obstruction diagnosed preoperatively. A 91-year-old Japanese female was admitted to our hospital with abdominal distention and vomiting of 3 days duration. She had no past history of any abdominal surgery. Abdominal examination revealed distention and tenderness in the right iliac fossa. Abdominal computed tomography revealed ileus in the sac at the left side of the ascending colon and dilatation of the oral side of the intestine. We diagnosed a transmesocolic hernia of the ascending colon with intestinal obstruction and performed emergency surgery. At the time of operation, there was internal herniation of ileal loops through a defect in the ascending mesocolon, without any strangulation of the small bowel. The contents were reduced and the tear in the ascending mesocolon was closed. The postoperative course was uneventful and the patient was discharged 14 days after surgery. In conclusion, preoperative diagnosis of bowel obstruction caused by a congenital mesocolic hernia remains difficult despite the techniques currently available, so it is important to consider the possibility of a transmesocolic hernia when diagnosing a patient with ileus with no past history of abdominal surgery.
PMCID: PMC3383250  PMID: 22740809
Transmesocolic hernia; Ascending colon; Intestinal obstruction
24.  Long segment and short segment familial Hirschsprung's disease: variable clinical expression at the RET locus. 
Journal of Medical Genetics  1994;31(8):602-606.
Hirschsprung's disease (aganglionic megacolon, HSCR) is a frequent condition of unknown origin (1/5000 live births) resulting in intestinal obstruction in neonates and severe constipation in infants and adults. In the majority of cases (80%), the aganglionic tract involves the rectum and the sigmoid colon only (short segment HSCR), while in 20% of cases it extends toward the proximal end of the colon (long segment HSCR). In a previous study, we mapped a gene for long segment familial HSCR to the proximal long arm of chromosome 10 (10q11.2). Further linkage analyses in familial HSCR have suggested tight linkage of the disease gene to the RET protoncogene mapped to chromosome 10q11.2. Recently, nonsense and missense mutations of RET have been identified in HSCR patients. However, the question of whether mutations of the RET gene account for both long segment and short segment familial HSCR remained unanswered. We have performed genetic linkage analyses in 11 long segment HSCR families and eight short segment HSCR families using microsatellite DNA markers of chromosome 10q. In both anatomical forms, tight pairwise linkage with no recombinant events was observed between the RET proto-oncogene locus and the disease locus (Zmax = 2.16 and Zmax = 5.38 for short segment and long segment HSCR respectively at 0 = 0%) Multipoint linkage analyses performed in the two groups showed that the maximum likelihood estimate was at the RET locus. Moreover, we show that point mutations of the RET proto-oncogene occur either in long segment or in short segment HSCR families and we provide evidence for incomplete penetrance of the disease causing mutation. These data suggest that the two anatomical forms of familial HSCR, which have been separated on the basis of clinical and genetic criteria, may be regarded as the variable clinical expression of mutations at the RET locus.
PMCID: PMC1050020  PMID: 7815416
25.  Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation—A rare case 
Chilaiditi's syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi's syndrome in association with intestinal malrotation and this case study describes its successful management.
An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic.
In nine of the previously reported cases of Chilaiditi's syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management.
Chilaiditi's syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.
PMCID: PMC4066568  PMID: 24811427
Chilaiditi's syndrome; Colonic volvulus; Internal hernia; Adult malrotation; Nonrotation

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