Investigation and surgery in irritable bowel syndrome--a cautionary series

Irritable bowel syndrome is a common problem, and, with a broad symptom complex, likely to present to a wide variety of clinicians. Lack of awareness of these manifestations may lead to inappropriate investigation, and surgery. Six patients with irritable bowel syndrome who had multiple investigations and operations are reported. There was a median of seven years delay in diagnosis, patients seeing a median of six different consultants. Over 13 years of follow-up symptoms were unchanged, but patients had undergone a median of eight (often invasive) investigations, and six operations. Several operations were for complications of, or resulted from, a previous procedure. There were far fewer operations after diagnosis, four over 33 patient-years, than prior to diagnosis, 25 over 43 patient-years (chi-squared = 8.074, 1 df, p < 0.0025). All clinicians should be aware of the diffuse symptomatology of irritable bowel, and its potential to mimic other diseases. Surgery should be avoided.

[Displacement and resection of the ascending colon in the horse: a literature review on the basis of 2 cases]

A review of displacements and surgery of the large colon is given on the basis of two cases. A four-year-old Dutch Warmblood mare was referred, one week before foaling, for colic of twelve hours duration. At rectal palpation a large uterus was found, but no cause for the colic. Laparotomy revealed a colonic volvulus and resection of about 75% of the large colon was necessary. A dead foal was born five days postoperatively, but the mare recovered well. A nine year-old Dutch Warmblood stallion with a history of frequent colic had been treated for nephrosplenic entrapment three times. Resection of the left part of the colon was performed successfully to prevent another entrapment.

[Surgical therapy of chronic constipation]

Results of the surgical treatment for conservative intractable constipation in 70 adult patients are reviewed. 49 patients with severe symptoms have been treated by partial colectomy as sigmoid colectomy (n = 23) or left hemicolectomy (n = 26). 33 patients underwent colectomy with cecorectal anastomosis (n = 25) or ileorectal anastomosis (n = 8). Out of these patients with colectomy seven had undergone previous segmental colonic resection or internal sphincterotomy. Of those patients with cecorectal anastomosis who were dissatisfied, three underwent ileorectal anastomosis. Overall, a mortality rate of 3.3% and morbidity rate of 22.5 resp. 54.5% for partial and total colectomy were observed. The most frequent occurring complication after colectomy was small bowel obstruction in 30% requiring laparotomy in 40%. Of 45 patients who underwent partial colectomy, 34 (75%) had normal bowel function or were markedly improved. In 28 of 32 patients (87.5%) treated by colectomy a successful result has been achieved. The operation of sigmoid colectomy or left hemicolectomy may be recommended as a treatment for constipation only in patients with less severe symptoms or patients with recurrent sigmoid volvulus. For those patients with severe constipation, at present, colectomy with ileorectal anastomosis seems to be the surgical procedure that offers the greatest probability of improvement. However, the significant morbidity claimed the need for a careful patient selection.

Surgical management of colonic inertia

Fourteen patients with chronic constipation due to colonic inertia were treated with total abdominal colectomy and ileorectal anastomosis at the Cleveland Clinic Foundation from 1981 to 1986. All patients were white women ranging in age from 28 to 64 years (mean 41 years). The duration of symptoms averaged 21 years (range six to 47 years) and the average time between bowel movements was ten days. The preoperative evaluation included barium enema in 12 patients and colonoscopy in five (some patients had both studies). Anorectal dysfunction was excluded by manometry in ten patients and by rectal biopsy in six. Colonic transit studies were accomplished in only two patients. The hospital stay averaged 13 days, and there was no operative mortality. Postoperative morbidity included one case of small bowel obstruction, necessitating operative correction on postoperative day 9. Follow-up ranged from three months to five years. At their last clinic visit, the patients averaged two bowel movements per day. All patients had excellent bowel control and were happy with the procedure.

[Clinico-morphologic data in decompensated colonic stasis]

The authors studied the results of surgical treatment of 97 patients with complicated form of the decompensated stage of chronic colonic stasis. The choice of the method and volume of the operation is determined by the location and spread of the stasis in the colon. Histological examination of material removed during the operation revealed predominantly dystrophic changes of the ganglionic cells of the musculo-intestinal plexus and hypertrophy and sclerosis of the muscular coat of the colon. The operation produced a good and satisfactory effect in 83.4% of patients.

Diagnosis and surgical treatment of functional obstruction of the right dorsal colon in a horse

Functional obstruction of the right dorsal colon was found at surgery in a 6-year-old American Saddlebred gelding with a history of anorexia, depression, weight loss, and intermittent colic. Side-to-side anastomosis of the right dorsal colon to the small colon was done to bypass the obstruction. Histopathologic findings of the right dorsal colon and regional colonic lymph nodes were unremarkable. Surgical treatment was successful.

[Syndrome of acute colonic pseudo-obstruction (Ogilvie's syndrome). Study of 13 cases]

Acute pseudo-obstruction of the colon involves acute colic distension without mechanical obstruction or stercoroma in a previously healthy colon. Our study is of 13 patients, all of whom presented a pre-existing extradigestive disorder, for which 12 were taking medication. Nine patients were treated by mechanical ventilation, and five of these had previously presented meteorism. Colic dilatation was maximal in the cecum, the diameter of which measured 9 to 14.5 cm. Two patients were treated by decompression colonoscopy, which completely cured meteorism in one case. Two patients treated by digestive aspiration died due to extra-abdominal causes. Operations were carried out on 6 patients: once for peritonitis due to cecal perforation five times for deterioration of meteorism. Five patients died due to postoperative complications. These observations show that the diameter of the cecum should be monitored daily. When it exceeds 9 cm, decompression colonoscopy must be performed. Surgery should only be envisaged when there are setbacks, due to the seriousness of the operation and the possibility of postoperative complications.

Precancerous changes in the anal canal epithelium in resection specimens

Systematic histological examination for precancerous changes was carried out on 139 anal canals resected for anal or colo-rectal tumours or for inflammatory bowel disease. Severe squamous dysplasia or carcinoma in situ were found in 13 of 16 anal canals harbouring variants of squamous carcinoma but not in others. The lesions were mainly or totally located to the anal transitional zone (ATZ) in 11 cases and only in 2 cases exclusively to the squamous zone below the dentate line. Dysplastic areas separate from the tumour were found in 6 of the 13 cases. Junctional melanocytic activity and atypical melanocytic hyperplasia located in the ATZ as well as the squamous zone were present in 1 of 3 cases of malignant melanoma. The findings underline the close relationship between dysplasia and invasive carcinoma in the anal canal. Further they support the concept that basaloid, mucoepidermoid and some ordinary squamous carcinomas arise in the ATZ, and that this may also be the point of origin for malignant melanoma. A search for precancerous changes for anal canal tumours should therefore include the whole ATZ, i.e. in some cases up to 2 cm above the dentate line and it should be borne in mind that the lesions may be spotty.

Ogilvie's syndrome associated with herpes zoster infection

Acute colonic pseudo-obstruction that occurs in the setting of an underlying medical condition is known as Ogilvie's syndrome. The etiology of Ogilvie's syndrome is unknown, and associated medical illnesses are varied and often extra-abdominal. While herpes zoster infection has been reported to cause constipation and hypomotility, the association with massive colonic distention has not so far been described. We present a patient with Ogilvie's syndrome in the setting of herpes zoster infection. There was no evidence of other active illnesses, and the patient has continued to do well since the resolution of the zoster. We believe that this is the first reported association of Ogilvie's syndrome and herpes zoster infection.

Nonoperative management of acute idiopathic colonic pseudo-obstruction (Ogilvie's syndrome)

In a four-year experience (35 episodes in 27 patients) with the use of medical and colonoscopic therapy for acute idiopathic colonic pseudo-obstruction, we have found that initial conservative measures followed by flexible colonoscopy in nonresponders are effective and safe. Contrary to previous reports, an initial nonoperative approach including colonscopy is frequently successful and the outcome with this approach is not adversely affected even in the few patients who eventually require surgical decompression.

[Ogilvie's syndrome--a case report and review]

Ogilvie's syndrome is caused from functional obstruction of the colon without mechanical stenosis and also termed as pseudo-obstruction of the colon. This disease is seen in patient who has other causative distress. The pathogenesis of this rare entity is unknown but it is suspected that there may be an underlying autonomic disturbance which causes non-mechanical obstruction of the colon. Most of the case reports on Ogilvie's syndrome have appeared in European and North American journals but are extremely rare in Japan. Some cases which have been categorized "spastic ileus" may be included in this syndrome. We recently experienced a patient with cerebral infarction who developed non-mechanical obstruction of the colon. This patient was treated successfully with an exploratory laparotomy and sigmoidostomy. It is considered that early diagnosis is an essential part of the initial management of this syndrome. Conservative treatment is indicated for most of the patients but a definitive surgical therapy is occasionally necessary.

Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie's syndrome). Report of 22 cases and review of the literature

This report has described a series of 22 patients who underwent colonoscopic decompression for acute pseudoobstruction of the colon and summarizes those cases previously reported in the literature. Twenty of the 22 patients (91 percent) were successfully treated by decompression initially. Fifteen patients (68 percent) were cured with the initial procedure, and 4 patients (18 percent) experienced recurrence. Overall, in 17 patients (77 percent), the pseudoobstruction resolved completely with colonoscopic decompression. Three patients (14 percent) underwent operation because of cecal dilatation refractory to colonoscopic decompression, and in one patient (4.5 percent), the colonic dilatation resolved spontaneously after a failed colonoscopy. Complications resulted in the death of one patient (4.5 percent). Our data are similar to those in the literature and indicate that colonoscopic decompression is a safe and efficacious first line of treatment for acute pseudoobstruction of the colon.

Course and prognosis after colectomy and ileostomy for inflammatory bowel disease in childhood and adolescence

The clinical course of 32 pediatric patients with inflammatory bowel disease (ulcerative colitis--18, Crohn's disease--14) after colectomy and ileostomy was investigated. Specific indications for surgery were: ulcerative colitis (severe colitis--50%, chronic disease--50%); Crohn's disease (fistulae--28%, severe colitis--28%, chronic disease--21%, hemorrhage--14%, growth failure--7%). Proctectomy was performed at the time of colectomy in 72% of patients with ulcerative colitis and in 64% of those with Crohn's disease. Major post-operative complications (stomal dysfunction without documented recurrent disease, obstruction, abscess, bleeding) were observed in 60% of all patients regardless of diagnosis. Histologically documented recurrent disease developed in 42% of the patients with Crohn's disease (mean follow-up: 5 yr) despite removal of all affected bowel. Ileal disease at the time of surgery appeared to be a poor prognostic factor. Sexual activity was either improved or unchanged in sexually active patients. Impotence was not observed in any of the male patients. Despite complications and recurrent disease, the majority (75%) of patients viewed colectomy and ileostomy as improving the quality of their life.

[The Ogilvie syndrome. Review of literature and report of 2 cases]

Two cases of pseudo-obstruction of the colon (Ogilvie's syndrome) are presented. Increasing abdominal distension and the pain suggested surgical treatment for both patients. The operation showed in the first case a marked dilatation of the transverse colon and sigmoid, in the second the dilatation of the ascending and transverse colon, without any distal obstruction. Enterotomy was performed only in the first case, as the diameter of the colon was more then 10 cm. The authors, by review of the literature and their own experience, propose a critical revision of the syndrome, discussing the physiopathology of the rising disease.

[Neonatal necrotizing enterocolitis (author's transl)]

Authors present analysis of 31 cases of necrotizing enterocolitis, which where treated medically as well surgically. Etiology is discussed and perinatal accidents are considered. An analysis of symptomatology and radiological study is made, both being deciding factors as to whether a surgical intervention is necessary. Medical treatment is commented as well as surgical and technical aspects. Mortality is sensibly diminished due to a better knowledge of the illness and to a closer cooperation between neonatologist and surgeon. It is important to point out sequelae which appeared in patients treated medically with intestinal stenosis localized in the colon.

[Cecum perforation, complication of an acute idiopathic dilatation of the colon, or Ogilvie's syndrome. Practical interest of various pathogenic data. Apropos of one case]

The authors report a new case of caecal perforation complicating acute dilatation of the colon without organic obstruction (Ogilvie's syndrome). They recall the two characteristics of this syndrome : abdominal distension due to colonic ileus, without any organic cause, and the constant coexistence of an associated pathological condition (traumatic, post-operative, infective, cardio-vascular, respiratory or neurological). The major complication is caecal perforation, announced by a clinical and radiological preperforative syndrome. The pathogenesis of Ogilvie's syndrome remains mysterious. Two facts are worth attention : the role of the sympathetic nerve in intestinal paralysis and the direct intervention of an extra-intestinal pathological factor in the onset of this syndrome. Hence two therapeutic consequences : the favourable effect of splanchnic infiltrations on intestinal motility, and the parallel course of acute colonic dilatation and the extra-intestinal disease.

[Functional disorders of distal colon in children (author's transl)]

Functional disorders of the distal part of the colon in neonates and infants should be diagnosed by X-ray investigations (defecograms), double-suction biopsies (Erlanger children suction biopsy apparatus), anorectal and sigmoidal manometry and coloscopic functional investigations. 90% of all disorders of the distal colon can be diagnosed by manometric studies, in 40% X-ray investigations will lead to an exact diagnosis, in 12% double suction biopsies and in 10% coloscopic investigations establish the right diagnosis. The double suction biopsy is important for the exclusion of aganglionosis. Either a conservative or a surgical treatment is necessary, depending on the primary lesion. Wash outs, sphinctertraining, toilet training are necessary in cases of prolonged constipation following sigmaresection with restmegacolon, in cases of rectal inertia syndrom, and in cases of overflow incontinence. A pressure reducing operation (a sphincteromyotomy) is indicated in ultrashort aganglionic segments, in special cases of elongated sigma, in cases of prolonged constipation after sigma resection and with disturbed reflex mechanism, in cases of sphincter inhibition syndrome, and in children with paradox reflex mechanism. A resection is indicated in Hirschsprung disease, mechanical obstruction of the bowel, very large and severe cases of sigma elongatum and in cases of overflow-incontinence.

Colitis cystica profunda

Colitis cystica profunda is a benign disease characterized by variably sized mucin-filled cysts beneath the muscularis mucosae. The clinocpathologic features of five patients are described. The accumulated evidence suggests that awareness of this entity both by clinicians and pathologists with help differentiate it from carcinoma and decrease the need for radical surgery.