Anorectal contractility under basal conditions and during rectal infusion of saline in ulcerative colitis.

Pressure activity in the rectum and anal canal was measured with a multilumen probe in 29 patients with ulcerative colitis (12 active, 11 quiescent, six studied during both phases) and 18 normal controls under resting conditions and during rectal infusion of saline. Resting motor activity was significantly decreased in patients with active colitis compared with quiescent colitis (p less than 0.005) and normal controls (p less than 0.001). Forty per cent of active colitics showed a featureless record compared with only one patient with quiescent colitis and one normal subject. The volume of saline infused before leakage occurred, and the total volume retained were significantly lower (p less than 0.001) in patients with active and quiescent colitis compared with normal controls. Rectal infusion of saline provoked regular rectal contractions, of significantly higher (p less than 0.05) amplitude in patients with active colitis, than in quiescent colitis or controls. These rectal contractions were associated with simultaneous anal relaxations. During saline infusion, peak and pressures were lower in patients with ulcerative colitis than in normal subjects, but there were no significant differences in relaxation pressures. In normal subjects, the rectal pressures remained below the anal pressures throughout the saline infusion. Peak rectal pressures exceeded the anal relaxation pressures during the last five minutes of saline infusion in patients with ulcerative colitis and throughout the infusion in those patients who complained of incontinence. Results suggest that although the resting rectal motor activity is diminished in patients with ulcerative colitis, luminal distension causes the inflamed rectum to generate abnormally strong contractions that may threaten continence.     

Anorectal sensitivity and responses to rectal distention in patients with ulcerative colitis

Anorectal function in ulcerative colitis was assessed by measuring pressures at multiple sites in the anus and rectum under basal conditions and during balloon distention of the rectum in 29 patients with ulcerative colitis (12 active, 11 quiescent, and 6 during both phases) and in 12 normal controls. Resting and squeeze sphincter pressures were similar in the three groups. The lowest rectal volume that could be perceived, the volume required to induce a desire to defecate, and the maximum tolerable rectal volume were all lower in patients with active colitis than in patients with quiescent colitis (p less than 0.001) and controls (p less than 0.001). The rectal volume required to cause a sustained anal relaxation was lower in patients with active colitis (p less than 0.05) than in controls. Both peak and steady state rectal pressures in response to rectal distention were significantly higher in patients with active colitis than in patients with quiescent colitis (p less than 0.05) and controls (p less than 0.02). Paired studies showed that during remission of disease there was a decrease in rectal sensitivity (p less than 0.05) and an increase in rectal compliance (p less than 0.05). These results suggest that the frequent and urgent defecation, i.e., the predominant feature of active colitis, is related to a hypersensitive and poorly compliant rectum, which, upon distention, is more reactive and is more likely to induce prolonged sphincter relaxation.     

Intramural extravasation of barium simulating carcinoma of the rectum

This report describes two patients found to have barium granuloma of the rectum. The lesions appeared as indurated, ulcerated rectal masses that resembled carcinoma on endoscopic examination. Deep mucosal biopsy results demonstrated no malignancy and barium sulfate crystals in tissue macrophages. Radiographs showed persistent soft-tissue barium in the rectum. Past reports of barium granuloma have described ulcerated or polypoid masses in the rectum and anus. Rectal intramural extravasation of barium occurs as a result of asymmetric enema balloon inflation and impaction of the enema tip against the rectal mucosa.     

Chronic ulcerative colitis

Summary Chronic ulcerative colitis has been observed in 220 patients at the Scott and White Clinic during the past 15 years. Our observations of the clinical features of the disease have been reviewed. The diarrhea associated with chronic ulcerative colitis tends to be chronic and recurrent and frequently occurs nocturally. Anorexia, weight loss, mild anxiety, tachycardia, fever, abdominal cramping, anemia, skin lesions, rectal complications, and joint involvement are the more common symptoms and signs. Important in the physical examination are auscultation and palpation of the abdomen and a careful digital examination of the rectum.The diagnosis of chronic ulcerative colitis is dependent upon sigmoidoscopic and roentgenologic examination of the rectum and colon. The characteristic sigmoidoscopic findings during various stages of the disease have been presented. Mucosal and luminal changes as observed radiologically have been depicted.The differential diagnosis has been discussed, and diseases occurring in association with chronic ulcerative colitis have been considered.     

Restorative proctocolectomy for ulcerative colitis complicated by colorectal cancer

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is widely accepted as the procedure of choice for patients requiring surgery for chronic ulcerative colitis. The role of restorative proctocolectomy in the setting of chronic ulcerative colitis complicated by colorectal carcinoma is not clear. This study was undertaken to explore the clinical outcomes of chronic ulcerative colitis patients with coexisting colorectal carcinoma who underwent restorative proctocolectomy.METHODS: A total of 756 patients with chronic ulcerative colitis were followed prospectively after restorative proctocolectomy. Forty-five (5.9 percent) were found to have invasive carcinoma of the colon (n = 31) or rectum (n = 14). These patients were followed with special attention to cancer stage, adjuvant therapy, oncologic outcome, and functional results after restorative proctocolectomy.RESULTS: Twenty-one patients (45.6 percent) had staged surgery (colon, 14; rectum, 7). Twenty-seven patients received adjuvant chemotherapy (colon, 22; rectum, 5). Fourteen patients (51.8 percent) who received chemotherapy were not diverted during this treatment. Two node-positive rectal cancer patients had pelvic radiotherapy: one before restorative proctocolectomy and one after restorative proctocolectomy. Mean time to restoration of intestinal continuity among staged patients did not differ between cancer and noncancer patients. Six patients died of metastatic disease (colon, 3; rectum, 3). Five deaths occurred among patients with Stage III disease (colon, 3/13, 23.1 percent; rectum, 2/3, 66.7 percent). One patient with Stage I cancer at the time of restorative proctocolectomy died. Thirty-nine patients are alive without evidence of disease at a mean interval from surgery of 76.5 months. Thirty-six patients have functioning pelvic pouches. Bowel frequency, continence, and complication rates are similar among restorative proctocolectomy patients with and without cancer.CONCLUSIONS: Restorative proctocolectomy as a single or staged procedure is a viable therapeutic option for selected chronic ulcerative colitis patients with associated colorectal cancers. Prognosis seems to be related to cancer stage. Adjuvant chemotherapy can safely be given to nondiverted patients. Appropriate use of preoperative and postoperative radiotherapy for rectal cancer patients who are otherwise candidates for restorative proctocolectomy is unknown. Long-term functional results for cancer patients are similar to those seen in chronic ulcerative colitis patients without cancer.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Reprints are not available.     

Rectal perforation during barium enema

Perforation of the colon or rectum during the course of barium-enema examination is estimated to occur in approximately 500 patients annually in the United States. It has been over 30 years since the last collective review on this subject reported a prohibitively high mortality and morbidity. Since that time, much has been learned about the treatment of patients with peritonitis and bowel perforation, many new and more effective antibotics have become available, and the management of shock has become infinitely more sophisticated. A review of recently reported cases suggests that the mortality rate and possibly the early morbidity have fallen markedly. Late complications such as adhesive small-bowel obstruction and retroperitoneal fibrosis with ureteral stenosis are well described, but data on the incidence of these long-term sequelae are still not available.     

Assessment of anorectal function in selection of patients for ileorectal anastomosis in Crohn's colitis.

Anorectal function has been assessed in 53 patients with Crohn's disease by measurement of resting and squeeze anal canal pressures and the maximum volume tolerated during distension of a balloon in the rectum. Radiographs of the rectum from barium enema examination were also reviewed to assess rectal capacity. Thirty-three patients have had a colectomy and ileorectal anastomosis for Crohn's colitis of whom 13 now have a stoma because they either required a protectomy (n=9) or where closure of a loop ileostomy had not been possible (n=4) because of severe anorectal disease. The maximum tolerated volume was less than 150 ml in 12 of 13 patients who now have a stoma compared with none of the 20 patients who have a functioning anastomosis. Although the correlation between a radiological assessment of rectal capacity and the maximum tolerated volume was poor, a severely contracted rectum was associated with the need for a stoma in six of seven patients compared with only two of 13 patients who did not have radiological signs of a narrow rectum.     

Anorectal manometry in active and quiescent ulcerative colitis

Anorectal function was measured in 11 patients with active medically intractable ulcerative colitis, seven patients with quiescent ulcerative colitis, and 18 healthy subjects. The anal resting pressure, squeeze pressure, and ability to defecate a balloon were similar in all groups. Significantly lower rectal distention volumes were required for rectal sensation, critical volume, and to induce rectal contractility in patients with active disease compared to controls or patients with quiescent disease. Rectal compliance was significantly reduced in patients with active and quiescent disease. The increased rectal sensitivity and contractility in patients with active colitis appear to be related to active mucosal inflammation and ulceration. Episodes of mucosal inflammation may be responsible for chronic changes in the rectal wall resulting in fibrosis and decreased compliance in patients with quiescent disease. The frequency and urgency of defecation and the fecal incontinence may be due to a hypersensitive, hyperactive, and poorly compliant rectum.     

Barium granuloma of the rectum

Barium granuloma of the rectum is reviewed. Three additional patients are reported, one of whom had a concomitant rectal carcinoma. Barium granuloma of the rectum is a nonspecific ulcerative or polypoid lesion, the true nature of which may be recognized only after histopathologic examination. The age of the lesion is well correlated with microscopic findings. The acute phase occurs during the first week and, thereafter, a chronic inflammatory reaction with macrophages and foreign body giant cells ensues. The probable pathogenesis of rectal barium granuloma is laceration of the mucosa by the enema tip or proctoscope, or overdistension of the rectum by a Bardex balloon. Serial proctoscopic examination indicates apparent spontaneous healing of the lesion 3–6 weeks after biopsy.     

Rectal localized giant inflammatory polyposis with indeterminate colitis

Only two cases of rectal giant inflammatory polyposis with ulcerative colitis have been reported in the English literature and both concern children. This is the first report of a case of localized giant inflammatory polyposis of the rectum in an adult with indeterminate colitis. A 71-year-old man underwent sigmoidectomy due to stenosis of the sigmoid colon. Final histological diagnosis was indeterminate colitis. Three years following the first operation, a rectal tumor with giant polyposis was observed, and abdominoperineal resection was performed. Macroscopic and microscopic examination indicated a localized giant inflammatory polyposis of the rectum.     

Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm County

The long-term results of ileorectal anastomosis in patients with ulcerative colitis in Stockholm County over a 30-year period, 1955 to 1984, were investigated. During this time, 486 patients underwent colectomy and ileorectal anastomosis was performed in 60 of those patients (12 percent). A retrospective histologic examination of the slides of the operative specimens in the latter group revealed that nine patients had Crohn's disease. Of the 51 remaining patients with ulcerative colitis, the colectomy and ileorectal anastomosis was performed as an elective procedure in 44 cases (86 percent) and as a one-stage procedure in 48 patients (94 percent). Complications occurred in 7 of 43 patients (16 percent) undergoing an elective, one-stage procedure. There were two postoperative deaths (4 percent). There were 22 patients (43 percent) who had their ileorectal anastomosis in function at the time of follow-up, with a mean time of observation of 13 years. The cumulative probability of having the ileorectal anastomosis in function at 10 years was 51 percent. The causes of rectal excision were recurrent inflammation in the retained rectum (N=23), dysplasia (N=3), and postoperative complications (N=3). No rectal carcinoma occurred. Patients with preoperative mild rectal disease had a better outcome (ileorectal anastomosis in function at time of follow-up) compared with patients with moderate rectal disease (P <0.001). The functional outcome of ileorectal anastomosis was, if anything, better than what is stated in the literature following pelvic pouch procedure.Supported by grants from the Swedish Society of Medicine.     

Ulcerative colitis with relative sparing of the rectum

A series of 12 patients with relative sparing of the rectum in ulcerative colitis is analyzed. Half were recorded as having normal sigmoidoscopic appearance and, in every case, double-contrast barium enema showed an apparently normal rectum but an abnormal colon. Rectal biopsy showed changes compatible with ulcerative colitis in all cases, though in four, changes were slight. Thus, complete histologic sparing of the rectum was not observed. In four of six patients treated by colectomy and ileorectal anastomosis, inflammation of the retained rectum required medical or surgical treatment.     

Histologic Changes in Defunctioned Rectums in Patients With Inflammatory Bowel Disease

PURPOSE: Inflammation occurs in defunctioned rectums in patients without inflammatory bowel disease. Defunctioned rectums in patients with inflammatory bowel disease have additional histopathologic changes that can cause diagnostic confusion. The aim of this study was to ascertain whether histologic changes in defunctioned rectums had any association with original pathologic diagnosis in the colectomy specimen, duration of defunctionalization, or occurrence of Crohn's disease-like complications during follow-up. METHODS: In this retrospective study, we reviewed the patient records and reexamined histologically the defunctioned rectums and original colectomy specimens of 84 consecutive patients encountered between 1983 and 1986. RESULTS: All excised rectal specimens had ulcers and erosions, usually with prominent mucosal lymphoid aggregates, often with mucosal atrophy, diffuse mucin depletion, and marked mucosal architectural distortion. Transmural lymphoid aggregates were identified in 56 patients (67 percent) and were graded as moderate or marked in 35 (42 percent). Ten rectal specimens contained nonnecrotizing granulomas. The original pathologic diagnoses from the colectomy specimens were as follows: ulcerative colitis (n = 22), Crohn's disease (n = 19), indeterminate colitis (n = 41), adenocarcinoma (n = 1), and diverticular disease (n = 1). Only mild histologic changes were observed in rectal specimens from patients with diverticular disease and adenocarcinoma, and granulomas were identified more frequently in Crohn's disease patients. Otherwise, no feature in the defunctioned rectum was associated with the original diagnosis or duration of defunctionalization. Sixteen patients (19 percent) had late surgical complications suggestive of Crohn's disease (abscess, fistula, or subsequent biopsy specimen containing nonnecrotizing granulomas) after a median follow-up of 4.8 years. Five were patients categorized as having Crohn's disease with colectomy specimen, nine had indeterminate colitis, and two had ulcerative colitis. No histologic feature in the defunctioned rectum was associated with Crohn's disease-like complications. CONCLUSIONS: Granulomas in a defunctioned rectum were associated with an original diagnosis of Crohn's disease. Transmural lymphoid aggregates were common in defunctioned rectums in patients with inflammatory bowel disease and did not indicate Crohn's disease. Other histologic changes developed independently of diagnosis and duration of defunctionalization.     

Cavernous Hemangiomas of the Rectum: Report of three cases

Cavernous hemangioma of the rectum are uncommon benign vascular lesions. Misdiagnosis often occurs because of lack of awareness of classic clinical features. Endoscopy, plain x-ray abdomen, barium enema, and selective angiography are useful means of investigation for accurate diagnosis. Three cases of rectal haemangioma are presented that were earlier misdiagnosed as ulcerative colitis.     

Barium granuloma of the rectum

Summary and Conclusions Clinical and experimental evidence indicates that barium sulfate causes minimal foreign-body reaction and generally is well tolerated when injected into the lungs, peritoneal cavity, and subcutaneous and retroperitoneal tissues. That this is also true when it is injected accidentally into the wall of the rectum during administration of barium enemas is revealed by a review of the 15 cases reported in medical literature and our two cases. Depending on the degree of bacterial contamination, host resistance, and the site and mechanics of injection, barium introduced into the wall of the rectum may present as perianal or retrorectal abscesses which require drainage, or as ulcerated or nonulcerated tumors of the rectal wall. In the latter instances, only biopsy is required for diagnosis, and this is well tolerated. Attempts to eliminate the barium from the tissues by surgical means are futile and unnecessary. Barium granuloma of the rectum can be avoided by care and diligence while introducing tubes into the rectum prior to administration of barium enemas, by avoiding excessive pressure in the rectum when a balloon is used, and by avoiding administration of barium enemas soon after biopsy of the rectal mucosa. Read at the meeting of the New England Proctologic Society, Framingham, Massachusetts, April 6, 1968.     

Air insufflation: a useful adjunct to the single contrast barium enema for the evaluation of the rectum

We examined whether insufflation of a small volume of air after a single-contrast barium enema would improve evaluation of the rectum. Eighty patients presenting for barium enema by single-contrast technique underwent examination of the colon including spot films with fluoroscopy and palpation during introduction of the barium and filled overhead views, using standard apparatus and technique. The examination was completed by draining barium from the rectum only, following which air in the barium enema bag was squeezed back into the rectum and three views of the rectum obtained (lateral, left posterior oblique, and frontal). Two reviewers then chose the best image of the rectum from each study with relevance to luminal distention and visibility of surface detail of the rectum. Following air insufflation, improved surface detail visualization was recognized by both reviewers in 69 (86%) patients and by one reviewer in 10 (12%) patients, a statistically significant observation (P < 0.0001). There was a trend towards improved rectal distention, recognized by both reviewers in 37 (46%) patients and by one reviewer in 18 cases (22%). In 25 (31%) patients neither reviewer recognized any improvement in rectal distention. Rectal abnormalities were identified in nine cases; there were two large carcinomas, two radiation strictures, two rectal fistulae, two small rectal polyps (5 and 7 mm), and one case of prolapsing rectal mucosa. All rectal abnormalities were visible on the air insufflation views. In the two cases of suspected rectal polyp and one of the cases of rectal fistula, the findings were not visible on the initial barium filled views. A normal rectum was observed in 71 cases. Follow-up of these 71 patients found no later evidence of any rectal abnormalities. Improved filling of the proximal colon following air insufflation was observed in 12 (15%) patients, an additional and unexpected benefit of this maneuver. Air insufflation is a simple addition to the SCBE study that improves visualization of the rectum.     

Endoscopic dilation of rectal strictures

PURPOSE: This study was performed to prospectively evaluate results of endoscopic balloon dilation of strictures of the rectum. METHODS: Eighteen patients with symptoms of rectal strictures at endoscopy or barium enema were treated on 49 occasions with balloon dilation during sigmoidoscopy. RESULTS: Twelve patients were completely satisfied with relief of their symptoms after treatment. Two patients considered the results as poor, and four patients were not subject to follow-up evaluation. One patient had a perforation during the dilation procedure but was completely relieved at follow-up examination. CONCLUSIONS: Endoscopic balloon dilation of strictures in the rectum is a safe method. The method is simple and can be performed on an outpatient basis. The technique shows good results even in narrow strictures.     

Allergic proctitis, a clinical and immunopathological entity.

Patients with isolated ulcerative proctitis form a heterogeneous group. Some may develop ulcerative colitis, others have a limited, benign disease. Twelve patients with isolated proctitis with a mean course of seven years were studied. All patients had a typical clinical picture consisting of a mild and intermittent course of the disease with the presenting symptom of rectal blood loss. At endoscopic examination the inflammatory process was limited to the rectal and distal sigmoid colonic mucosa with a clear upper border beyond which the mucosa of the sigmoid colon was normal. Histologically the mucosal biopsy specimens of the affected rectum resembled those of ulcerative colitis. However, in contrast with proctitis on the base of ulcerative colitis or Crohn's disease, immunoperoxidase staining revealed a markedly increased number of IgE containing cells in the lamina propria of rectal mucosa biopsies. As an IgE-mediated immune mechanism was considered to play a role in this type of proctitis, eight of the 12 patients were treated with oral administration of disodium cromoglycate (DSCG). All patients were improved by the drug. The remaining four patients with mild proctitis did not require treatment. We concluded that, in patients with isolated proctitis on clinical and immunopathological criteria, a group can be separated which responds to DSCG, a condition for which we suggest the name 'allergic proctitis'.     

Colonoscopy in the differential diagnosis of colonic strictures

Colonoscopy was performed on ten patients who had colonic strictures demonstrated by barium-enema examination. In all cases the diagnosis of carcinoma had been considered, but it was confirmed by colonoscopic examination, cytology, and biopsies in only two patients. Five patients were shown to have benign inflammatory strictures due to ischemic colitis, ulcerative colitis, Crohn's disease, irradiation colitis, or postoperative strictures. The remaining three patients were shown to have no intrinsic lesion. These eight patients were thereby spared further diagnostic procedures, and even unnecessary laparotomy.     

The fate of the rectal stump after subtotal colectomy for ulcerative colitis

In a retrospective review of 311 patients having subtotal colectomy for ulcerative colitis, information on the fate of the rectal stump was obtained in 288. Proctectomy was performed in 159 patients (55 percent); for persistent proctitis in 118 (41 percent), cancer prophylaxis in 37 (13 percent), and cancer in four (1.4 percent). One hundred twenty-two patients (42 percent) had ileorectal anastomoses. Eighty-four of these (69 percent) retained a functioning ileorectal anastomosis at the time of follow-up or death, one to 22 years later, and an additional six patients (5 percent) had a satisfactory ileorectal anastomosis for five to 14 years before proctectomy. Cancer developed in the rectal stump in nine patients (3.1 percent), underscoring the need for either proctectomy (total or mucosal) or long-term surveillance of the retained rectum. However, subtotal colectomy, by permitting ileorectal anastomosis or other sphincter-preserving surgery at a later date, does have a definite place in many patients requiring surgery for ulcerative colitis. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.