False positive GI bleed on Tc-99m RBC scintigraphy due to ileal varices

Tc-99m labeled RBC scintigraphy is commonly employed in the evaluation of acute gastrointestinal bleeding. On Tc-99m RBC studies gastrointestinal bleeding is seen as an initial focus of increased radiotracer activity that on subsequent images increases in intensity and changes position in a pattern that conforms to segments of bowel. We report a case of a patient with multiple episodes of hematochezia that presented with lower gastrointestinal hemorrhage. A Tc-99m labeled RBC scan was performed and the findings suggested a GI bleed. However, subsequent angiography revealed prominent ileal varices simulating an acute bleed. Although most varices fill promptly and should not be misinterpreted as a focus of hemorrhage, slow filling varices can simulate an acute bleed and lead to a false positive interpretation.

[Morphometric characteristics of the hemomicrocirculatory bed vessels in rat colon in large bowel obstruction and after its resolution]

The results are presented that describe the experimental study of colonic hemomicrocirculatory bed (HMCB) in intact rats, in animals 6 days after large bowel obstruction development that was modeled using the device created by the authors, and 1-15 days after its resolution. The most significant changes were observed in the capillaries and HMCB venular portion--capillary diameter was increased by 60-100%, while that of venules--by 73% as compared to those in control group. The degree of changes depended on the distance from the extraorgan bowel compression site. The dynamics of the normalization of morphometric parameters after colon obstruction resolution was demonstrated. It was found that the average arteriolar and venular diameters reached the initial level by day 5, while that of the capillaries by day 7 after colon obstruction resolution.

Early endothelial damage and increased colonic vascular permeability in the development of experimental ulcerative colitis in rats and mice

The role of endothelial damage and increased vascular permeability (VP) in the pathogenesis of ulcerative colitis (UC) has not been investigated. We examined using functional, morphologic, and molecular biologic studies whether and to what extent the endothelial barrier dysfunction precedes enhanced epithelial permeability (EP) and the development of mucosal lesions during the early stages of experimental UC. We showed that in rats with iodoacetamide (IA)-induced UC increased colonic VP occurs early (ie, 2.6-fold increase at 15 min, P<0.01) preceding changes in epithelial barrier permeability. EP was unchanged at 15 and 30 min after IA administration and was increased 1.9-fold at 1 h and 6.7-fold at 2 h (both P<0.001) after IA. In the dextran sodium sulfate-induced slowly developing UC, colonic VP was significantly increased in 2 days (P<0.05) and EP only in 4 days (P<0.05). Mucosal endothelial injury led to hypoxia (P<0.05) of colonic surface epithelial cells 30 min after IA administration that was associated with increased expressions of transcription factors hypoxia-inducible factor-1α and early growth response-1. Electron and light microscopy demonstrated areas of colonic mucosa with perivascular edema covered by intact layer of surface epithelial cells in both rat and mouse models of UC. This is the first demonstration in four models of UC that endothelial damage, increased colonic VP, perivascular edema, and epithelial hypoxia precede epithelial barrier dysfunction that is followed by erosions, ulceration, and inflammation in UC.

Transmural colonic ischemia: clinical features and computed tomography findings

Our purpose was to describe the computed tomography features of transmural colonic ischemia in correlation with clinical, laboratory and histopathological findings of 14 patients who underwent colectomy (9 female and 5 male; mean age, 68 years). Seven patients died (50%). Transmural necrosis involved the right colon in 10 patients (10/14, or 72%). Eleven patients showed thickened colonic wall (11/14, or 79%), 10 pneumatosis (10/14, or 71%), 5 gas in the portal venous system (5/14, or 36%), and 14 fat stranding (14/14, or 100%).

Intraoperative contrast-enhanced sonography of bowel blood flow: preliminary experience

OBJECTIVES

The potential to predict, and therefore avoid, anastomotic failure has eluded generations of colon and rectal surgeons to date. A reliable, reproducible method of assessing bowel blood flow therefore would be of enormous potential clinical relevance. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We present our study assessing the feasibility of using contrast-enhanced sonography to study bowel perfusion intraoperatively.

METHODS

We studied 8 patients (4 male and 4 female) with an age range of 52 to 81 years who underwent colorectal surgery (right hemicolectomies, n = 3; Hartmann procedure, n = 1; anterior resections, n = 2; and bowel resections with ileocolic anastomoses, n = 2). A 5-mL bolus of a sulfur hexafluoride contrast agent solution was injected before and after vascular ligation with simultaneous noncompression ultrasound scanning directly over the large bowel. The patients were followed clinically to assess for leaks. Contrast-enhanced sonographic time-intensity curves were generated for the time to peak and maximum amplitude.

RESULTS

Moderate interobserver agreement was shown for the time to peak (κ = 0.50) and maximum amplitude (κ = 0.42), and moderate intraobserver agreement was shown for the time to peak (κ= 0.53) and maximum amplitude (κ= 0.53). No significant differences were shown between the time to peak (P = .28) and maximum amplitude (P = .49) for the preligation and postligation scans.

CONCLUSIONS

To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We have shown the technique to be feasible with good intraobserver and interobserver agreement. Further work is ongoing to optimize the technique and assess its use in predicting anastomotic breakdown.

The effect of omega-3 fatty acid and ascorbic acid on healing of ischemic colon anastomoses

PURPOSE

Many systemic and local factors contribute to gastrointestinal tract anastomoses dehiscence, which is a serious and potentially fatal postoperative complication. The aim of this study was to evaluate the effects of omega-3 fatty acid and ascorbic acid on the healing of ischemic colon anastomosis.

PATIENTS AND METHODS

40 Wistar Albino rats weighing between 180 and 220 g were divided into four groups. Groups were assigned as follows; Group 1 (control): anastomosis and no treatment, Group 2: anastomosis plus ascorbic acid, Group 3: anastomosis plus omega-3 fatty acid, and Group 4: anastomosis plus ascorbic acid and omega-3 fatty acid. Colon anastomoses was were performed in all rats. All animals were sacrificed on the 5th postoperative day. Healing of the anastomoses was assessed by measuring the burst pressures (BP) and hydroxyproline levels.

RESULTS

No mortality was observed and perianastomotic abscesses were not noted in any rats. The BP was significantly higher in the ascorbic acid plus omega-3 fatty acid combination group than the other groups (p < 0.05). The hydroxyproline levels were significantly high in ascorbic acid plus omega-3 fatty acid combination group than the other groups (p < 0.05).

CONCLUSION

Dietary supplementation with omega-3 fatty acid and ascorbic acid improved colonic anastomoses healing. Ascorbic acid and omega-3 fatty acid enhance the colonic wound healing process by additive action.

[Estimation of postoperative morphological changes in the area of a potential formation of colorectal anastomosis in experiment]

In experiment on 50 white mongrel male rats there were investigated postoperative morphological changes in the area of a potential formation of colorectal anastomosis, occurring after total rectal mobilization performance. There was established, that rectal mobilization, even while securing a blood flow along the main vessels, causes nonreversible ischemic disorders in its wall. The investigation results witness the enhanced risk of the sutures insufficiency occurrence in low colorectal anastomoses and substantiate the expediency of application of prophylactic methods for this complication in a clinical practice.

Colonic ischaemia as a severe Shiga toxin/verotoxin producing Escherichia coli O104:H4 complication in a patient without haemolytic uraemic syndrome, Germany, June 2011

An increasing rate of infections with Shiga toxin/verotoxin-producing Escherichia coli (STEC/VTEC) O104:H4 has been observed in Germany since May 2011, with unusually high numbers of patients suffering from haemolytic uraemic syndrome (HUS). We report a STEC/VTEC O104:H4 case without HUS, presenting with colonic ischaemia demanding surgery. This atypical clinical presentation of STEC O104:H4 infection might indicate new severe complications associated with this uncommon strain, and highlights the importance of immediate interdisciplinary assessment of STEC/VTEC patients.

Antibiotic treatment with ampicillin accelerates the healing of colonic damage impaired by aspirin and coxib in the experimental colitis. Importance of intestinal bacteria, colonic microcirculation and proinflammatory cytokines

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for their anti-inflammatory, analgesic and antipyretic effects, however their use is associated with the broad spectrum of side effects observed in human as well as the experimental animals. Despite damaging activity of NSAIDs in upper gastrointestinal (GI) tract, these drugs exert deleterious influence in lower GI tract, including colon. The role of GI microflora in the pathogenesis of NSAIDs-induced experimental colonic damage is not completely understood. The aim of this study was 1) to evaluate the relative importance of the GI microflora on the experimental colonic damage in the presence of caused by NSAID, and 2) to assess the efficacy of antibiotic treatment with ampicillin on the process of healing of colitis. We compared the effect of vehicle, ASA applied 40 mg/kg intragastrically (i.g.) or the selective cyclooxygenase (COX)-2 inhibitor, celecoxib (25 mg/kg i.g.) without or with ampicillin treatment (800 mg/kg i.g.) administered throughout the period of 10 days, on the intensity of TNBS-induced colitis in rats. The severity of colonic damage, the alterations in the colonic blood flow (CBF) and myeloperoxidase (MPO) activity, the mucosal expression of TNF-α, IL-1β, COX-2, VEGF and iNOS and the plasma concentration of TNF-α and IL-1β were assessed. In all rats, the faeces samples as well as those from the colonic mucosa, blood, liver and spleen underwent microbiological evaluation for intestinal bacterial species including Escherichia coli and Enterococcus spp. The administration of TNBS resulted in macroscopic and microscopic lesions accompanied by the significant fall in the CBF, an increase in tissue weight and 4-5-fold rise in the MPO activity and a significant increase in the plasma IL-1β and TNF-α levels. ASA or celecoxib significantly increased the area of colonic lesions, enhanced MPO activity and caused the marked increase in colonic tissue weight and plasma IL-1β and TNF-α levels, as well as an overexpression of mRNA for IL-1β and TNF-α, COX-2, VEGF and iNOS in the colonic tissue. ASA and coxib also resulted also in a significant increase of E. coli counts in the stool at day 3 and day 10 day of the observation compared with the intact rats. Moreover, E. coli translocation from the colon to the blood and extraintestinal organs such as liver and spleen in the group of rats treated without or with ASA and coxib. E. coli was the most common bacteria isolated from these organs. Treatment with ampicillin significantly attenuated the ASA- or celecoxib-induced increase in plasma levels of IL-1β and TNF-α and suppressed the mucosal mRNA expression for IL-1β and TNF-β, COX-2, iNOS and VEGF in the colonic mucosa. Ampicillin administration caused a significant fall in the number of E. coli in the faeces at day 3 and day 10 of observation in ASA- and coxib-treated rats with colitis. Antibiotic therapy markedly reduced bacterial translocation to the colonic tissue and the extraintestinal organs such as the liver and spleen. We conclude that administration of ASA and to lesser extent of celecoxib, delays the healing of experimental colitis and enhances the alterations in colonic blood flow, proinflammatory markers such as IL-1β, TNF-α, COX-2, iNOS and VEGF and increased intestinal mucosal permeability resulting in the intestinal bacterial translocation to the blood, spleen and liver. Antibiotic treatment with ampicillin is effective in the diminishing of the severity of colonic damage, counteracts both the NSAID-induced fall in colonic microcirculation and bacterial E.coli translocation to the extraintestinal organs.

[Objective intraoperative estimation of state of the intestinal transplant prepared for placing into the perineum in experiment]

The work is devoted to experimental investigation and practical application of the objective intraoperative diagnosis method for the intestinal transplant state estimation, which is prepared for descendence to perineum, using modified pulsoximetric data analyser in environment of experimental modelling of abdominoanal rectal resection, resulting in determination of objective indices of the intestinal transplant vital capacity. The method of operative intervention in experiment on laboratory animals is adduced. The expediency of application of modified pulsoximetric data analyser in colorectal surgery was established.

Adrenomedulline improves ischemic left colonic anastomotic healing in an experimental rodent model

BACKGROUND

Leakage from colonic anastomosis is a major complication causing increased mortality and morbidity. Ischemia is a well-known cause of this event. This study was designed to investigate the effects of adrenomedullin on the healing of ischemic colon anastomosis in a rat model.

METHODS

Standardized left colon resection 3 cm above the peritoneal reflection and colonic anastomosis were performed in 40 Wistar rats that were divided into four groups. To mimic ischemia, the mesocolon was ligated 2 cm from either side of the anastomosis in all of the groups. The control groups (1 and 2) received no further treatment. The experimental groups (3 and 4) received adrenomedullin treatment. Adrenomedullin therapy was started in the perioperative period in group 3 and 4 rats (the therapeutic groups). Group 1 and group 3 rats were sacrificed on postoperative day 3. Group 2 and group 4 rats were sacrificed on postoperative day 7. After careful relaparotomy, bursting pressure, hydroxyproline, malondialdehyde, interleukin 6, nitric oxide, vascular endothelial growth factor, and tumor necrosis factor alpha levels were measured. Histopathological characteristics of the anastomosis were analyzed.

RESULTS

The group 3 animals had a significantly higher bursting pressure than group 1 (p<0.05). Hydroxyproline levels in group 1 were significantly lower than in group 3 (p<0.05). The mean bursting pressure was significantly different between group 2 and group 4 (p<0.05). Hydroxyproline levels in groups 3 and 4 were significantly increased by adrenomedullin therapy relative to the control groups (p<0.05). When all groups were compared, malondialdehyde and nitric oxide were significantly lower in the control groups (p<0.05). When vascular endothelial growth factor levels were compared, no statistically significant difference between groups was observed. Interleukin 6 and tumor necrosis factor alpha were significantly decreased by adrenomedullin therapy (p<0.05). The healing parameters and inflammatory changes (e.g., granulocytic cell infiltration, necrosis, and exudate) were significantly different among all groups (p<0.05).

CONCLUSION

Adrenomedullin had positive effects on histopathologic anastomotic healing in this experimental model of ischemic colon anastomosis.

[Endoscopic assessment of large bowel and safety of bowel preparation and sedoanalgesia in patients with advanced liver cirrhosis]

INTRODUCTION

In patients with advanced liver cirrhosis endoscopic images of large bowel are still poorly recognized in comparison with upper digestive tract. At present, the colonoscopy is examination routinely performed during qualification to liver transplantation. The purpose of this study was to retrospectively analyze colonoscopic reports and to assess a safety of all procedures realized before and during colonoscopy.

MATERIAL AND METHODS

The study included 46 patients with liver cirrhosis (males 54.4%, females 45.6%) at age of 18-66 years, hospitalized between 2007-2009 for qualification to liver transplantation. Colonoscopy was done in short general sedation, and standard bowel preparation involved 256 g of polyethylene glycol dissolved in 4 liters of fluid given to the patient one day before colonoscopy.

RESULTS

In 26.1% of patients no pathology was found on colonoscopy. Anal/rectal varices were found in 41.3% of patients, lesions classified as portal colopathy in 13% of patients and sigmoid diverticula in 8.7% of patients. In 17 (37%) of patients colonoscopy disclosed 46 polyps in large bowel (38 polyps in 12 patients were retrieved for histopathological examination). In 4 (8.7%) patients polyps were hyperplastic, in 6 (about 13%) tubular adenomas of low grade dysplasia and in 2 (4.35%) tubulo-villous adenomas of low grade dysplasia. Tubulo-villous adenomas were found only in patients with alcoholic cirrhosis. Colonoscopy did not worsen the general clinical state of any patient, however, as compared with compensated cirrhotics, the patients with ascites and/or peripheral edema showed features of water retention (larger body mass changes -0.50 +1.21 kg vs 0.23 +1.38 kg; p < 0.05). After colonoscopy a significant increase of body temperature by 0.23 +0.30 degrees C; p < 0.001 was noted, while examination had no significant effect on serum creatinine level and white blood cell number.

CONCLUSIONS

Liver cirrhosis may predispose to certain diseases of the large bowel, including portal colopathy and adenomatous polyps. Procedures accomplished before and during colonoscopy seem to be safe for cirrhotic patients, however, in decompensated cirrhosis exists a tendency to further water retention.

[The ileal and colic microcirculation by the thrombosis and thromboembolism of mesenterial arteries]

Quantitative and functional parameters of regional intestinal blood circulation were intraoperatively investigated with the use of laser Doppler flowmetry. The first group consisted of patients with necrotized parts of the intestine, while the second (control) group consisted of flowmetry data from intact intestine. Such indexes, as basal circulation, variation coefficient, blood oxygen perfusion saturation index, maximal perfusion amplitude of endothelial, neurogenic and myogenic oscillations in the intestinal volume, were showed to be valuable for the intestinal viability assessment. Thus, the method of the intraoperative laser Doppler flowmetry can be useful for determining the volume of intestinal resection.

Result of esophageal reconstruction using supercharged interposition colon in corrosive and Boehave's injury: Thammasat University Hospital experience

Seven esophageal reconstructions with interposition colon in severe suicide corrosive ingestion and Boehave's injury at Thammasat University Hospital were presented. Vascular enhancement (as called "supercharge") were done. Only one patient had micro-leakage at pharyngeal anastomosis with healed by conservative treatment and no late anastomotic stricture. The operation need more time and general surgeon skill but better comparison outcome.

CONCLUSION

Using supercharged interposition colon in adult esophageal reconstruction in corrosive and Boehave's injury was benefit in lower the incidence of anastomotic leakage and late anastomotic stricture. Just a longer operative time and vascular anatomizes skill were need.

[Clinicomorphological characteristics of colonic circulatory changes in children with organic and functional colostasis]

Acute colonic perfusion impairments (thrombosis, infarction, and ischemia) have evident clinical manifestations and are reasonably well described in the literature. At the same time, the problems of chronic peripheral circulatory disorder in the large bowel and the impact of the disorder on its motility are inadequately considered. By summarizing the data available in the literature and their findings, the authors consider the etiology and pathogenesis of organic and functional colostasis in the context of changes in the colonic angioarchitectonics.

Hyperbaric oxygen on the healing of ischemic colonic anastomosis--an experimental study in rats

The aim of the present study was to evaluate the effect of hyperbaric oxygen therapy (HBO2) on the healing process of ischemic colonic anastomoses in rats. Forty Wistar rats were divided into four groups: control (Group I), control and HBO2 (Group II), ischemia (Group III), ischemia and HBO2 (Group IV). Ischemia was achieved by clamping four centimeters of the colonic arcade. On the eighth therapy day, the anastomotic region was removed for quantification of hydroxyproline and immunohistochemical determination of metalloproteinases 1 and 9 (MMP1, MMP9). The immunohistochemical studies showed significantly larger metalloproteinase-labeled areas in Group IV compared with Group III for both MMP1 and MMP9 (p < 0.01). This finding points to a higher remodeling activity of the anastomoses in this experimental group. Additionally, animals subjected to hyperbaric oxygen therapy showed both a reduction in interstitial edema and an increase in hydroxyproline concentrations [at the anastomotic site]. Therefore, we conclude that HBO2 is indeed beneficial in anastomotic ischemia.

Diagnosis and treatment of abdominal angina

Abdominal angina refers to abdominal pain in which perfusion to digestive tissues has been compromised, usually due to mesenteric atherosclerosis. Pathology can progress to necrosis of vital viscera, sepsis, or even death. Practitioners need to be aware of this serious medical condition, especially in the ever-growing elderly population.

["Arteriosclerotic" aneurysm of the abdominal aorta]

We present a patient with an aortic aneurysm and the epidemiology, etiology, screening, symptoms and therapeutic options of abdominal aortic aneurysms are discussed. A widening of the abdominal aorta >3 cm is termed aortic aneurysm. As patients with aortic aneurysm are mostly oligosymptomatic until rupture occurs and an estimated 30,000 patients annually die from ruptured aortic aneurysm in the US a screening of the population at greatest risk (smokers, familial predisposition) is recommended. Screening is best done by ultrasound. Noninvasive therapy is limited to antiplatelet therapy and optimal adjustment of risk factors. For definitive treatment endovascular aortic repair (EVAR) is considered an established alternative to open surgery with lower 30 days mortality but higher reintervention rate.

[Replantation of IMA and accessory right RA during infrarenal AAA repair and a current view on indications for IMA replanting]

INTRODUCTION

Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair is a measure which might prevent development of colon ischemia under certain circumstances. These circumstances and patients who would benefit from this procedure are not well defined.

CASE REPORT

64-year old man underwent an elective operation on infrarenal AAA at our institution in December 2009. From preoperative CT angiography we knew about the accessory right renal artery branching directly from AAA and bilateral occlusion of hypogastric arteries. We performed open resection of AAA with implantation of a bifurcated graft. Proximal anastomosis was situated below renal arteries, distal anastomoses were bilaterally constructed on external illiac arteries. The accessory right renal artery was anastomosed into the right limb of the graft and IMA was replanted into the body of the graft. Postoperative recovery of the patient was uneventful. His follow-ups 3 and 6 months after the operation have been showing good clinical state of the patient, absence of abdominal complaints and normal levels of urea and creatinine. CT angiography which was performed 3 months after the operation discovered an occlusion of the reimplanted IMA, but patent replanted accessory right renal artery.

DISCUSSION

Assessment of collateral circulation of large intestine during infrarenal AAA repair is influenced by many preoperative and intraoperative factors. Most surgeons judge the adequacy of the collateral circulation by IMA backbleeding combined with inspection of sigmoid colon after restoring aortic flow. There have been numerous attempts to replace this subjective approach with more objective methods like intraoperative colon mucosal saturation measurement, laser Doppler flowmetry, IMA stump pressures, photophletyzmographic technique. Even though these methods describe conditions when a collateral circulation of rectosigmoid is inadequate after IMA ligature, they are unable to fully eliminate the occurrence of colon ischemia because of its multifactorial nature. Solving the problem of collateral circulation of the large intestine represents only a part of the obstacle presented by colon ischemia after infrarenal AAA repair.

CONCLUSION

IMA replantation during infrarenal AAA repair does not fully prevent an occurance of colon ischemia. On the other side, this moneuver does not increase perioperative morbidity, nor prolongs an operation significantly. Our policy is to replant IMA whenever we thing the circulation of large intestine is under threat or in borderline situations.

[Prophylaxis of sutures insufficiency of the large bowel anastomoses]

The results of surgical treatment of 202 patients, for the large bowel surgical diseases, were analyzed. Basing on the analysis of the sutures insufficiency causes in the large bowel anastomoses, which have had occurred in 95 patients of control group, there were elaborated a new methods of the large bowel anastomoses formation and prophylaxis of their sutures insufficiency development in 107 patients (main group), permitting to lower the sutures insufficiency causes in the large bowel anastomoses from 13.2 to 5.6%.

A case of phlebosclerotic colitis with involvement of the entire colon

Phlebosclerotic colitis is a rare type of ischemic colitis caused by obstruction of the veins in the intestinal wall and adjacent mesentery, and is most commonly seen in the ascending colon. We report a 56-year-old woman presenting with intermittent abdominal pain and diarrhea for three years. She had a liver abscess and two episodes of pancreatitis during this time and experienced progressive body weight loss. Initial radiologic findings showed multiple tortuous threadlike calcifications in the region of the right side of the colon and transverse colon on plain abdominal radiographs and computed tomography images. A colonoscopy demonstrated brownish-black pigmentation on the right side of the colon with scattered hyperemic patches. The more distal along the colon, the more normal the color of the bowel appeared. Follow-up studies revealed calcifications not only alongside the colonic and mesenteric veins, but also extending into the superior and inferior mesenteric veins. These findings have not been reported previously. As noted in our patient, this disease entity may not be confined to the tributaries of the superior mesenteric vein. The entire colon may be involved in advanced disease.