Voice changes: an initial manifestation of colonic perforation

The Close Relationship between Large Bowel and Heart: When a Colonic Perforation Mimics an Acute Myocardial Infarction

Colonoscopic perforation is a serious and potentially life-threatening complication of colonoscopy. Its incidence varies in frequency from 0.016% to 0.21% for diagnostic procedures, but may be seen in up to 5% of therapeutic colonoscopies. In case of extraperitoneal perforation, atypical signs and symptoms may develop. The aim of this report is to raise the awareness on the likelihood of rare clinical features of colonoscopic perforation. A 72-year-old male patient with a past medical history of myocardial infarction presented to the emergency department four hours after a screening colonoscopy with polypectomy, complaining of neck pain, retrosternal oppressive chest pain, dyspnea, and rhinolalia. Right chest wall and cervical subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and bilateral subdiaphragmatic free air were reported on the chest and abdominal X-rays. The patient was treated conservatively, with absolute bowel rest, total parental nutrition, and broad-spectrum intravenous antibiotics. Awareness of the potentially unusual clinical manifestations of retroperitoneal perforation following colonoscopy is crucial for the correct diagnosis and prompt management of colonoscopic perforation. Conservative treatment may be appropriate in patients with a properly prepared bowel, hemodynamic stability, and no evidence of peritonitis. Surgical treatment should be considered when abdominal or chest pain worsens, and when a systemic inflammatory response arises during the conservative treatment period.

Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema Caused by Colonoscopic Perforation: A Report of Two Cases

BACKGROUND

Although colonoscopy is generally a safe procedure, lethal complications can occur. Colonoscopic perforation is one of the most serious complications, and it can present with various clinical symptoms and signs. Aggravating abdominal pain and free air on simple radiography are representative clinical manifestations of colonoscopic perforation. However, unusual symptoms and signs, such as dyspnea and subcutaneous emphysema, which are less likely to be related with complicating colonoscopy, may obscure correct clinical diagnosis. We present two cases of pneumomediastinum, pneumothorax, and subcutaneous emphysema caused by colonoscopic perforation.

CASE REPORT

A 75-year-old woman and a 65-year-old man presented with dyspnea, and facial swelling and abdominal pain, respectively. In the first case, symptoms occurred during polypectomy, whereas they occurred after polypectomy in the second case. Chest radiograph and computed tomography scans revealed pneumomediastinum, pneumothorax, and subcutaneous emphysema in the neck. During both operations, an ascending colonic subserosa filled with air bubbles was observed, and laparoscopic right hemicolectomy was performed in the first case. In the second case, after mobilization of the right colon, retroperitoneal colonic perforation was identified and primary repair was performed. The postoperative course was uneventful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases show the unusual clinical manifestations of colonoscopic perforation, which depend on the mechanism of perforation. Awareness of these less typical manifestations is crucial for prompt diagnosis and management for an emergency physician.

The diagnosis and management of Sphincter of Oddi dysfunction: a systematic review

OBJECTIVES

Sphincter of Oddi dysfunction (SOD) is a benign pathological syndrome. The clinical manifestations may be a consequence of an anatomical stenosis or sphincter dysmotility. Manometry is invasive and has an associated morbidity. Non-invasive investigations have been evaluated to ameliorate risk but have unknown efficacy. The review aims to critically appraise current evidence for the diagnosis and management of SOD.

METHODS

A systematic review of articles containing relevant search terms was performed.

RESULTS

Manometry is the current gold standard in selecting which patients are likely to benefit from endoscopic sphincterotomy (ES). It can, however, be misleading. Several non-invasive investigations were identified. These have poor sensitivities and specificities compared to manometry. There is a paucity of data examining the investigation's specific ability to select patients for ES. Outcomes of ES for Type I SOD are favourable irrespective of manometry. Types II and III SOD may respond to an initial trial of medical therapy. Manometry may predict response to ES in Type II SOD, but not in Type III.

CONCLUSIONS

Non-invasive investigations currently lack sufficient sensitivities and specificities for routine use in diagnosing SOD. Type I SOD should be treated with ES without manometry. Manometry may be useful for Type II SOD. However, whilst data is lacking a therapeutic trial of Botox(TM) or trial stenting may bean alternative. Careful and thorough patient counselling is essential. Type III SOD is associated with high complications from manometry and poor outcomes from ES. Alternative diagnoses should be thoroughly sought and its management should be medical.

Biliary and gallbladder dyskinesia

Gallbladder and biliary dyskinesia are conditions that are becoming increasingly recognized due to improved technology. They are motility disorders that affect the gallbladder and sphincter of Oddi (SO), respectively. Gallbladder dyskinesia presents with typical biliary pain in the absence of gallstones. Work-up includes laboratory tests and imaging to rule out gallstones. Further investigation leads to a functional radionuclide study to investigate gallbladder ejection fraction. An ejection fraction of less than 40% is considered abnormal, and patients should be referred for cholecystectomy. Symptom relief after the procedure has been seen in 94% to 98% of patients. The term sphincter of Oddi dysfunction (SOD) describes a collection of pain syndromes that are attributed to a motility disorder of the SO. SOD can be further subdivided into biliary and pancreatic SOD. Patients typically have had a prior cholecystectomy and present with episodic biliary pain. The initial work-up includes laboratory tests and imaging to rule out other structural causes of abdominal pain, such as retained gallstones. Imaging and laboratory studies further subdivide patients into types of SOD. SO manometry (SOM) is the gold standard for assessing biliary dyskinesia and can help stratify patients into one of two groups: SO stenosis versus SO dyskinesia. Those with stenosis (type I SOD) are the most likely to respond to treatment with endoscopic biliary sphincterotomy (EBS). As the vast majority of type I patients (>/= 90%) benefit from EBS, SOM is not necessary. Pancreatic SOD patients can be similarly divided into one of three groups. These patients present with recurrent bouts of abdominal pain and/or pancreatitis in the absence of gallstones or other structural abnormalities. Pancreatic sphincter manometry can help distinguish which patients would benefit from endoscopic pancreatic sphincterotomy. Recurrent stenosis of the opening after endoscopic treatment in these patients may necessitate a surgical (open) approach.

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique

BACKGROUND

Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients.

METHODS

Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated.

RESULTS

Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms.

CONCLUSIONS

The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.

Retroperitoneal, mediastinal, and subcutaneous emphysema, complicating colonoscopy and rectal polypectomy

Complications of flexible endoscopy-though still rare-are increasing in frequency lately as more invasive procedures are routinely performed. Perforation, hemorrhage, coagulation disorders, thrombophlebitis, and splenic rupture have all been reported to complicate colonoscopy and colorectal polypectomies. In this paper, we report on a case of retroperitoneal, mediastinal, and neck surgical emphysema, complicating colonoscopy and rectal polypectomy, presented initially as a change in the voice and facial swelling.

Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

BACKGROUND

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended.

AIMS

To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy.

METHODS

A systematic review of English language articles and abstracts containing relevant terms was performed.

RESULTS

Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation

Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.

Pancreas Divisum

We offer endoscopic therapy for pancreas divisum only in patients with acute recurrent pancreatitis or chronic pancreatitis, based on studies delineated in this article, which results in response rates of 80% and 50% respectively. We do not offer endoscopic therapy for patients with chronic abdominal pain in the absence of morphologic abnormalities in the pancreatic duct or parenchyma or normal laboratory study results. It has been our experience that the success rate for endoscopic cannulation and therapy directed at the minor papilla in patients with symptomatic pancreas divisum is improved when the procedure is performed with primary intent to treat in patients who have a pre-existing diagnosis of pancreas divisum, as opposed to patients who undergo diagnostic ERCP for idiopathic acute recurrent pancreatitis and are diagnosed with pancreas divisum during the procedure. We cannulate the minor papilla with ultratapered 3-F catheters and 0.018-in soft wires. It is our opinion that minor papilla sphincterotomy offers advantages over chronic stent therapy in treating patients with pancreas divisum. Although both techniques have proven efficacy, chronic stenting requires repeated procedures and results in a high incidence of stent-induced chronic duct changes, both of which can be avoided by performing a minor papillotomy. We use an ultratapered papillotome with a 20-mm monofilament cutting wire and typically use blended current. The papillotomy is extended to ablate the mucosal mound of the minor papilla typically in a 2-o'clock direction for a distance between 4 and 8 mm, depending on the patient's anatomy. Following minor papillotomy, we place temporary 5-F pancreatic duct stents to reduce the incidence of postprocedural pancreatitis, which has been demonstrated in pancreatic duct sphincterotomy of the major papilla. These stents usually migrate out after 24 to 72 hours following the procedure. We offer surgical sphincteroplasty to patients in whom minor papillotomy cannot be performed or whose disease relapses after successful endoscopic therapy.

An unusual cause of 'pain in the neck'

Images

Sphincter of Oddi dysfunction

Evidence continues to accumulate indicating that sphincter of Oddi dysfunction may give rise to cholestasis, pancreatitis, or upper abdominal pain syndromes. Diagnosis of such dysfunction may be inferred from noninvasive tests or more precisely defined by manometric studies. Both the biliary and pancreatic sphincters are commonly involved. If medical therapy is ineffective, sphincter ablation via endoscopy or laparotomy should be considered for highly symptomatic patients. Complication rates of invasive techniques remain relatively high and risk:benefit ratio should be carefully considered. Future research as to etiology, more defined pathophysiology, more accurate noninvasive evaluation, and optimal therapies are awaited.