Anal encirclement with polypropylene mesh for rectal prolapse and incontinence

Seventeen selected patients (mean age, 74 years)--14 with rectal prolapse and 3 with persisting anal incontinence after previous operations--underwent high anal encirclement with polypropylene mesh. There was no operative mortality. Prolapse recurred in 2 (15 percent) of the 13 patients followed up for 6 months or more (mean, 3.5 years). Three (27 percent) of the 11 patients with associated anal incontinence improved functionally, as did the three operated on for persisting incontinence, but only one patient regained normal continence. No breakage, cutting out, or infection related to the mesh was observed. Because of the risk of fecal impaction encountered in three of our patients, the procedure is not advocated for severely constipated patients. Despite the somewhat disappointing results regarding restoration of continence, we find this method useful in patients with rectal prolapse who are unfit for more extensive surgery, in controlling the prolapse to an acceptable degree.

[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.

Distal colonic impaction requiring laparotomy in an adult with cystic fibrosis

A sigmoid fecal impaction leading to colonic obstruction in an adult with cystic fibrosis was evacuated at laparotomy by manual compression of the inspissated stool through the rectum. In cystic fibrosis beyond infancy, constipation is a common management problem. Intestinal obstruction caused by inspissated stool in the terminal ileum and cecum has been well documented; however, distal colonic obstruction requiring operation has not been previously reported.

Unique urinary-fecal calculus after cystectomy and ureterosigmoidostomy

A 36-year-old m an had stage B1 bladder cancer-treated by cystectomy and ureterosigmoidostomy. Postoperatively, a urinary leak was managed successfully by transureteroureterostomy and temporary colostomy. In succeeding years a large calculus developed in the region where the bladder had been and it also involved the sigmoid colon. The huge stone was removed successfully. A nonabsorbable suture was found in the center of the stone. This is a unique complication of ureterosigmoidostomy.

[Congenital megacolon presented as fecaloma and urinary tract infection. Report of one case]

A 5-month old boy was admitted with urinary tract infection. While doing the voiding cystogram, the bladder was found to be pushed to the right side by a soft tissue mass. Through CT scan examination, the mass revealed to be a fecaloma. Through rectal suction biopsy and barium enema study for megacolon, it was proved to be a case of congenital megacolon. A pull-through operation for megacolon was carried out. He recovered quickly, and was discharged 10 days later. We make this report in order to discuss this rare presentation which may occur in congenital megacolon.

Diarrhea and fecal impaction in elderly long-stay patients

A retrospective screening of one year's duration was carried out on 245 permanently hospitalized geriatric patients to study the frequency and cases of periods of at least three days' diarrhea. Such periods were suffered by 65/245 patients and 32% had recurrencies. Fecal impaction was the most common cause of diarrhea (in 55%). Diarrhea was induced by laxatives in 20%. Gastrointestinal infections caused 5% of the diarrhea cases. Immobility and fecal incontinence were strongly associated with fecal impaction in cases of diarrhea. Urinary tract infections treated with antibiotics in the patients with fecal impaction and diarrhea almost were twice as frequent as in patients with other causes of diarrhea or patients with no diarrhea. This retrospective investigation emphasizes the importance of the recognition and proper treatment of constipation, especially in bedridden or chairbound elderly persons with fecal incontinence and diarrhea.

Hirschsprung's disease in adolescents. Misadventures in diagnosis and management

Three male adolescents, ages 13, 15, and 17 years, presented with complications of their Hirschsprung's disease, including acute enterocolitis with sepsis, chronic enterocolitis with anemia and leukocytosis, and severe fecal impaction. All had experienced delay in diagnosis resulting from either physician error in diagnosis or physician misinformation concerning the surgical treatment of the disease. These three patients illustrate some of the pitfalls in the diagnosis and surgical management of patients with Hirschsprung's disease. Misinformation concerning the surgical correction of this disease still exists, and these patients emphasize the necessity of continued, updated information in the diagnosis, management, and outcome of patients with Hirschsprung's disease.

Management of Hirschsprung's disease in adolescents

It is unusual for Hirschsprung's disease to go undiagnosed until late childhood. Adolescents presenting with Hirschsprung's disease offer unique challenges to the surgeon because of the massively dilated and hypertrophied colon that is invariably present. Five adolescents (four males and one female; ages, 11 1/2 to 16 1/4 years) with newly diagnosed Hirschsprung's disease were managed by slightly different methods between January 1981 and March 1987. Three patients had a "leveling" colostomy, followed by a Swenson procedure in two and a Duhamel procedure with a temporary diverting colostomy in one. One patient had a primary Duhamel procedure with a temporary diverting ileostomy. One patient had a primary Swenson procedure without diversion. Long-term results were uniformly excellent. Based on the experience with these patients the following principles of management emerge: 1) Avoid loop "leveling" colostomies because of their grotesque size and their tendency to retract or prolapse. 2) Rectal tube decompression can often adequately prepare a patient for a primary pull-through procedure. 3) When a diverting ostomy is required, it should be an ileostomy rather than a colostomy because its subsequent closure will not endanger the marginal artery, which if divided, could compromise the blood supply to the pulled-through colon. 4) The Swenson procedure, although difficult in adolescents, can be done with excellent long-term results. 5) Several applications of the stapling instrument are required in the Duhamel procedure to fully divide the septum between the aganglionic rectum anteriorly and the normal colon posteriorly.

[Meconium ileus equivalent]

Meconium ileus equivalent (MIE) can be defined as a clinical manifestation in cystic fibrosis (CF) patients caused by acute intestinal obstruction by putty-like faecal material in the cecum or terminal ileum. A broader definition includes a more chronic condition in CF patients with abdominal pain and a coecal mass which may eventually pass spontaneously. The condition occurs only in CF patients with exocrine pancreatic insufficiency (EPI). It has not been seen in other CF patients nor in non-CF patients with EPI. The frequency of these symptoms has been reported as 2.4%-25%. Pathophysiologically, MIE is probably caused by a combination of EPI, increased intestinal transit time, and abnormal intestinal mucus. The treatment should primarily be non-operative. Specific treatment with N-acetylcysteine, administrated orally and/or as an enema is recommended. Enemas with the water soluble contrast medium, meglucamine diatrizoate (Gastrografin), provide an alternative form for treatment and can also serve diagnostic purposes. It is important that the physician is familiar with this disease entity and the appropriate treatment with the above mentioned drugs. Non-operative treatment is often effective, and dangerous complications following surgery can thus be avoided.

Constipation and fecal impaction in the long-term care patient

Constipation is a significant problem in the long-term care patient. There is a high prevalence of both primary and secondary causes of constipation in this population. Common primary causes include deficient dietary fiber, deficient fluid intake, and immobility. Common secondary causes include carcinoma, constipating medications, and neurologic and endocrine diseases. Moreover, complications of constipation such as fecal impaction, fecal incontinence, stercoral ulceration, and obstruction can be catastrophic in the debilitated elderly patient. Many cases of constipation can be treated by supplementing dietary fiber and fluid intake, with attention to nonmedical forms of intervention. In some patients, therapies such as bulk-forming agents, emollients, and periodic enemas may be necessary. In addition, there are some newer therapies available. Chronic stimulant laxative therapy should be reserved for patients with certain conditions that warrant their use.

Acute hypomagnesaemia complicating the treatment of meconium ileus equivalent in cystic fibrosis

Meconium ileus equivalent (MIE) is a common and often recurrent complication in adolescent and adult patients with cystic fibrosis (CF). MIE is characterized by partial or complete bowel obstruction, resulting from abnormally viscid mucofaeculant material in the terminal ileum and right colon. Patients present with recurrent abdominal pain, intestinal obstruction, and/or a palpable faecal mass. Conventional treatment consists of the oral and rectal administration of the mucolytic agent N-acetylcysteine, and hypertonic solutions of sodium diatrizoate. We describe the occurrence of acute decreases in plasma magnesium in all of seven patients treated with this regimen with marked hypomagnesaemia (less than 0.70 mmol/l) in four of the seven patients. No changes in plasma sodium, potassium, or calcium were observed.

Colonic impaction in guinea pigs fed a chemically defined diet: a case report

Pathogen-free female Hartley guinea pigs were divided into four diet groups to determine optimal nitrogen requirements for growth, pregnancy and lactation. Three chemically defined test diets varying in total nitrogen were compared with commercial guinea pig feed. Within 13 days, 24 of 78 animals from the three test diet groups died or required euthanasia. Affected guinea pigs were depressed, lost weight and had distended abdomens. Distension, impaction and, in most cases, rupture of the spiral of the ascending colon and subsequent peritonitis were observed at necropsy. Husbandry changes which resulted in a decreased incidence of impactions included increased acclimatization time on commercial feed post-shipping, decreased animal density per cage and cessation of water medication with oxytetracycline.

The geriatric implications of fecal impaction

Fecal impactions are a common problem in debilitated elderly people and may present as a life-threatening event. The atypical presentations of fecal impactions are not well-recognized, and the incidence, morbidity and mortality of fecal impactions in the elderly are largely unknown. Elderly debilitated people have reduced organ system reserve. An acute illness may worsen underlying chronic diseases. Fecal impactions may upset the fragile homeostasis of an elderly debilitated person. The signs and symptoms of fecal impaction may not be manifested in the gastrointestinal system; rather, the patient may present with circulatory, cardiac or respiratory symptoms. If the diagnosis of fecal impaction is unrecognized and untreated, signs and symptoms may progress, leading to death. The causes, mechanisms, appropriate history, physical examination, diagnostic techniques, therapy and prevention of fecal impactions in elderly people are presented.

Retained stool as a guide to the site of severe rectal bleeding

Despite improvements in diagnostic techniques including the use of radionuclide imaging, locating the site of severe rectal bleeding is not always possible. We present two patients in whom a survey film of the abdomen showed a dense accumulation of stool in the transverse colon. Subsequent evaluation confirmed that the source of rectal bleeding was distal to this area. Accordingly, the presence of a fecal impaction in the colon strongly suggests that the site of active bleeding lies more distally. In these circumstances, diagnostic measures should be directed to the segment of the colon distal to the impaction.

Pathogenesis and pharmacologic management of pseudo-obstruction of the bowel in pheochromocytoma

Metastatic malignant pheochromocytoma can be a disease of long duration and though poorly responsive to both radiation therapy and chemotherapy, pharmacologic management of its myriad manifestations can be very effective. Hypertension is the most recognized feature of this disease, but gastrointestinal manifestations can, on rare occasions, be just as serious and life threatening. We present two patients with metastatic pheochromocytoma who developed pseudo-obstruction, and discuss the pathopharmacology and treatment of this syndrome.