A case of an absent diseased appendix in an incompletely rotated gut

A case of an absent diseased appendix in an incompletely rotated gut in a 35-year-old farmer along with its management and review of literature is presented here.

Perirectal abscess, colic, and dyschezia in a horse

A quarter horse gelding with intermittent colic was diagnosed with a perirectal abscess and dyschezia. Rectal ultrasonography identified a multiloculated, fluid-filled mass. A perirectal abscess was diagnosed when the mass ruptured and drained into the rectum. The abscess was treated successfully with warm soapy water enemas and trimethoprim and sulfamethoxazole.

[Delirium due to urinary retention: confusing for both the patient and the doctor]

A delirium due to urinary retention confuses both patient and physician. Three patients presented with delirium and/or physical deterioration had a bladder retention. A man aged 82 had delirium and an acute renal failure due to a urinary retention with an enlarged prostate gland. A woman aged 81 had a delirium and a bladder retention due to an atonic bladder. A man aged 71 showed cognitive deterioration and a bladder retention due to a backbone-fracture and faecal impaction. In the elderly it is very important to include urinary retention in differential diagnosis because its presentation can be atypical.

Barium impaction as a cause of small bowel obstruction in an infant with cystic fibrosis

Small bowel obstruction in children with cystic fibrosis due to the impaction of barium is an unusual occurrence. This is the report of an 8.5-month-old black male who had an upper GI series on the day of discharge from the hospital, and returned the next day with a distal small bowel obstruction due to a barium impaction.

Severe juvenile chronic constipation

Constipation in the paediatric population is common and encompasses a spectrum of organic and functional pathology which differ from that of the adult population. Recently an expert group published a comprehensive system of classification of childhood functional gastrointestinal disorders that may have useful clinical application. We present the case of an adolescent schoolgirl with severe constipation with extreme anorectal, urological and neurological sequelae who displayed inappropriate behavioral response to her condition. The patient appeared inappropriately unmotivated and undisturbed by the severity of her constipation. This abnormal psychological habituation and adaptation to an abnormal bowel habit perpetuated the constipation. In addition, we examined the role of recent advances in anorectal investigation techniques and treatment in the context of the recent guidelines issued by the American Gastroenterological Association

[Hirschsprung disease in the adult. Report of a case]

OBJECTIVE

To describe a case of Hirschsprung's disease (HD) in an adult patient.

BACKGROUND

HD is diagnosed in the newborn in 80 to 90% of cases. HD is rare in the adult, and usually affects an ultrashort segment of the bowel.

CASE REPORT

A 49-year-old woman with a history of constipation since birth is involved. She was submitted to an abdominal laparotomy because of fecal impaction. A colostomy was performed. The diagnosis of HD affecting, the descending colon was established with manometry and histopathology. She underwent surgery, and a proctectomy and left hemicolectomy with colo-anal anastomosis was performed.

CONCLUSION

Adult HD is an infrequently diagnosed entity that must be suspected in a patient with chronic, intractable constipation from infancy, evidence of megacolon, and typical manometric and histopathologic features. The short and ultrashort-segment disease are more often found in older children and adults. The differential diagnosis includes idiopathic megarectum, functional constipation, and colonic pseudo-obstruction.

[Adult Hirschsprung's disease with mental retardation and microcephaly]

Hirschsprung's disease occurs rarely and sporadically in adult, involving males. In cases, which are manifested perinatally, the so called Hirschsprung-associated congenital anomalies (mainly central nervous system, urogenital and cardiovascular) may present (2-21%), which have not observed in adult. Mental retardation and Hirschsprung's disease more frequently are associated with Down syndrome (5-10%). The discoveries of molecular genetics in the last 4-5-years through the examination of transgenic ("knockout") mice, proved the basic role the mutation of 4 genes: the RET (receptor tyrosin kinase), a proto-oncogene, coding its ligand, the glial cell-line derived neutrophic factor (GDNF), the gene of the endothelin-B receptor (ENDRB) and the gene one of its ligand, the endothelin-3 (EDN3), in the pathogenesis of Hirschsprung's disease. In our case, the short segment Hirschsprung's disease caused respiratory and cardiac failure, which was recognized by autopsy. Besides, the severe mental retardation, the role of the long term use of antipsychotic medicines comes up in the prolongation and masking of the symptoms. The accompanied mental retardation and microcephalia in early childhood are known, which are associated anomalies with Hirschsprung's disease. In cases of Hirschsprung diseases at adults, no other associated congenital anomalies has been published. The mental retardation in Down-syndrome, in association with Hirschsprung's disease (and presumable in our case, too) is supposed to be the consequence of the mutation in the gene of GDNF. In this case, we observed, that the so called short segment H-d was accompanied at a 33 years old men patient with mental retardation (who was originated from a gypsy ethnic minority), because of it the connection of the nurses and the patient was disturbed and the main symptom of the H-d (chronic obstipation) remained hidden. The mechanic ileus was going on behind the scenes, and in addition to the cardiac failure caused the death of the patient. Practical conclusion of the case is that, Hirschsprung's disease should be suspected in all adult patients, who had severe obstipation persisting since childhood, especially in males.

Functional bowel disorders in the geriatric patient: constipation, fecal impaction, and fecal incontinence

Functional bowel disorders, including constipation, fecal impaction, and fecal incontinence, are common gastrointestinal diseases in the elderly and a major source of morbidity. Often the etiology is multifactorial. Evaluation should investigate presenting symptoms and important historical clues. An appropriate workup, including radiological studies, endoscopy, and physiological testing should be individualized. Therapy should be directed against relieving the major complaint and treating the underlying pathophysiological mechanism.

Long-term results and functional outcome after Ripstein rectopexy

PURPOSE

The aim of this study was to evaluate operative mortality, morbidity, and functional results after Ripstein rectopexy for rectal prolapse and internal rectal intussusception.

METHODS

Sixty-nine patients with rectal prolapse and 43 with internal rectal intussusception were included. All patient records were studied and complications registered. Long-term follow-up was possible in 105 patients and performed by clinical examination and standardized interview, telephone interview, or patient records. Seventy-six patients were prospectively evaluated, comparing bowel function before and after rectopexy.

RESULTS

There was no operative mortality. Operative morbidity was 33 percent, and most complications were minor. Severe early complications included one large-bowel obstruction and one transient ureteric stenosis. Median time of follow-up was seven years in patients with rectal prolapse and 5.4 years in patients with internal rectal intussusception. Late complications included two rectovaginal fistulas and one lethal sigmoid fecaloma. Five patients underwent subtotal colectomy for severe constipation. There was one recurrent prolapse (1.6 percent). Functional evaluation showed that incontinence improved (P = 0.049), whereas the number of bowel movements per week decreased (P < 0.001). Frequency of emptying difficulties did not change significantly in patients with rectal prolapse but increased in patients with internal rectal intussusception (P = 0.038).

CONCLUSION

Ripstein rectopexy can be performed with low mortality and recurrence rate, but with a high early complication rate. There were also some serious late complications. Continence was improved, although increased constipation was a problem in some patients, especially among those with internal rectal intussusception.

Fecal impaction: a review

TOPIC

Fecal impaction, a review of the literature.

PURPOSE

To review the definition, diagnosis, causes, signs and symptoms, and treatment of fecal impaction.

SOURCES

Published literature.

CONCLUSIONS

While a great deal has been published on fecal impaction, there is limited research. Clarification of when constipation changes to impaction is ambiguous. Causes of fecal impaction are multiple, and people can be affected at all ages. Signs and symptoms of and problems associated with fecal impaction are varied. Research-based treatment of fecal impaction is very limited, and nonresearch based treatment varies. There is a need for additional research to clarify terminology, diagnosis, and interventions.

Movicol in treatment of constipation and faecal impaction

To resolve severe constipation or faecal impaction requires the induction of a large increase in faecal water content that hitherto has only been achieved with enemas. A novel iso-osmotic laxative has been shown to achieve a similar effect from oral dosing.

Cecal impaction due to dysautonomia in a llama (Lama glama)

A llama (Lama glama) died after 1 wk of obstipation, lethargy, and rolling. Necropsy showed that the stomach and small intestine were distended with gas and fluid. The cecum was impacted with dry contents and the colon was empty. No gross lesions were found in the wall of the gastrointestinal tract or other organs. Histologic changes consisted of chromatolysis of neurons of autonomic ganglia, enteric plexi, and the accessory cuneate nucleus, consistent with lesions associated with dysautonomia in other domestic animals.

Retained fecalith after laparoscopic appendectomy

An intraabdominal abscess developed from a retained fecalith following laparoscopic appendectomy. We discuss the prevention and management of retained fecaliths in light of the numerous reports of retained gallstones.

Atypical presentation of Clostridium difficile colitis in patients with cystic fibrosis

OBJECTIVE

This report describes the unusual presentation of Clostridium difficile colitis in five patients with cystic fibrosis and the role of CT in first suggesting the correct diagnosis in this group of patients. Because of the absence of watery diarrhea and the presence of abdominal bloating and decreased stooling, cystic fibrosis patients with C. difficile colitis will be treated for stool impaction, meconium ileus equivalent, or distal intestinal obstruction syndrome. CT of the abdomen, performed in these five patients because of their lack of improvement after standard therapy for stool impaction, showed an extensive pancolitis later confirmed to be caused by C. difficile infection.

CONCLUSION

In patients with cystic fibrosis, imaging findings of a pancolitis should raise the possibility of C. difficile colitis despite the lack of watery diarrhea. Anticlostridial treatment can be initiated before bacteriologic confirmation is obtained.

How to resolve stool retention in a child. Underwear soiling is not a behavior problem

Many parents do not realize their child has stool retention when they bring him or her for an office visit. Some complaints that may be a tip-off and should prompt questioning about stool frequency and underwear soiling are vague abdominal pain, urinary incontinence, and stools so large they plug the toilet. A rectal examination is usually adequate to confirm the diagnosis. Management begins with educating parents that leaking of liquid stool around impaction and onto underwear is completely involuntary, so the child should never be scolded or embarrassed. Stool retention may begin because of unpleasant or unavailable toilet facilities, constipation, or painful elimination and often becomes self-perpetuating. Impaction must be removed immediately; magnesium citrate solution is usually effective. To allow the rectum to return to its normal size, which can take an extended time, stool must be kept soft and movable with administration of mineral oil and appropriate dietary choices (eg, fruit, juice, fiber). Recurrence is common, so ongoing measures and follow-up are important.

Gravel impaction in a 2-year-old Morgan gelding

An unusual case of impaction colic caused by the ingestion of large quantities of gravel. The clinical presentation, surgical findings, and outcome are described.

Highly effective new oral therapy for faecal impaction

We reasoned that relief of faecal impaction could be achieved if a bolus of polyethylene glycol/electrolyte solution was delivered to the caecum over a few hours. Thus, 16 patients with faecal impaction (duration of constipation 5-23 days) were treated in an open study with up to three daily treatments of one litre of polyethylene glycol/electrolyte solution daily, taken orally over 4-6 hours. Complete resolution of impaction, strictly defined, was obtained in 13 patients, and significant improvement in the other three. Only one patient was faecally incontinent and the only side-effect was an increase in borborygmi. Polyethylene glycol/electrolyte solution, given as a treatment dose of one litre daily for up to three days, is a highly effective and acceptable oral therapy for faecal impaction.

Evaluation and treatment of constipation and fecal impaction in adults

Constipation is a common complaint that physicians encounter. Understanding the patient's definition of constipation and focusing the history and physical examination provide clues to the underlying cause. Initially, an empiric treatment trial is recommended. For patients with warning symptoms or those in whom treatment fails, a limited diagnostic work-up is suggested. Tests of physiologic function are reserved for patients whose condition is refractory to therapy. Fecal impaction can be considered extreme constipation. The pathophysiologic features of fecal impaction are discussed, and recommendations are provided for treatment and prevention.