A prospective randomized double blind trial comparing prednisolone and 4-aminosalicylic acid enemas in acute distal ulcerative colitis

A prospective double blind and randomized study was conducted to compare 4-aminosalicylic acid (4-ASA) and prednisolone-21-phosphate enemas in inducing remission in patients with acute distal ulcerative colitis. Patients with ulcerative colitis distal to the splenic flexure as assessed by flexible colonoscopy, barium enema and histology were included in the study. Of 40 consecutive patients, 20 were randomized to each of the two treatment groups. Clinical evaluation was done weekly; sigmoidoscopy and histology were performed at entry and at the end of 4 weeks. Therapy was discontinued in four patients treated with prednisolone enemas due to worsening of symptoms. The clinical improvement was significant in the remaining patients (P less than 0.001) and was similar in the two groups (P greater than 0.1). Sigmoidoscopic and histological improvement were better with 4-ASA than with prednisolone enemas. No adverse effects were observed in any of the patients treated. The present study suggests that 4-ASA is a safe and effective treatment for inducing remission in acute distal ulcerative colitis.     

Heterotopic gastric and pancreatic tissue in large bowel

Heterotopic gastric and pancreatic tissues rarely involves large bowel. We report the case of a 30-yr-old man who presented with lower gastrointestinal bleeding. The barium enema showed an ulcerated mass lesion at the splenic flexure. Colonoscopy revealed a polypoid ulcerated lesion at the splenic flexure. The resected specimen, on histological examination, showed a polypoid lesion lined by gastric mucosa. The base of the polyp also showed ectopic pancreatic tissue. The patient recovered completely after surgery.     

Colonic cancer in a patient with primary sclerosing cholangitis and long-standing ulcerative colitis

A 27-year-old woman with a 9-year history of ulcerative colitis involving the entire colon was admitted to our hospital in August 1992 because of bloody stools and left lower abdominal pain. She had been treated with sulfasalazine since 1983 and the colitis had been clinically quiescent or mild for 7 years. She had also been diagnosed as having primary sclerosing cholangitis (PSC) 4 years prior to this admission, based on the clinical, laboratory, and cholangiographic findings. A barium enema and colonoscopy showed an irregular mass obstructing the bowel lumen in the distal portion of the descending colon. Biopsy specimens taken from the mass revealed moderately differentiated adenocarcinoma, and a subtotal colectomy was performed. Histologic examination of the mass lesion showed moderately differentiated adenocarcinoma invading the pericolic adipose tissue. She is currently alive 3 years after surgery. PSC has recently been reported as a risk factor for colonic neoplasia in patients with longstanding ulcerative colitis. In Japan, however, colorectal cancer associated with PSC and ulcerative colitis has rarely been reported. The present case suggests that the risk of colonic cancer is higher in patients with ulcerative colitis and PSC than in patients with ulcerative colitis alone.     

Spread and distribution of 5-ASA colonic foam and 5-ASA enema in patients with ulcerative colitis

Rectal treatment with enemas, foams, and suppositories is the most efficient method of delivering an adequate quantity of locally active drugs to the distal colon. In a pilot study carried out by colonoscopy in four patients, it was observed that 4 g 5-ASA in 20 ml foam spread up or beyond the splenic flexure and more extensively than 2 g 5-ASA in 10 ml foam. Therefore we have undertaken a study in order to compare by scintigraphy the colonic distribution of 4 g 5-ASA foam versus 4 g 5-ASA in 100 ml liquid enemas in 10 patients with ulcerative colitis using a crossover randomized design. Both preparations were labeled with 100 MBq [^99mTc] sulfur colloid before administration. Anterior scans were taken at intervals for 4 hr. Activity, expressed as a percentage of total radioactivity, was measured in the rectum, sigmoid, descending, transverse, and ascending colon. Six patients had the same extent of spread with the two formulations; in three patients with foam and in one patient with enema a greater spread was observed. the foam reached the upper limit of disease in all cases, while enema failed in two cases. The maximum spread with foam was observed within 30 min in nine of 10 patients compared with seven of 10 after enema. Compared to enema, foam distributes more uniformly and seems to persist longer in the descending and sigmoid colon. The 5-ASA colonic foam shows some more favorable characteristics than enema for the local treatment of left-sided ulcerative colitis.This work was supported in part by Bracco S.p.A (Milan, Italy).Part of this study was presented at the 92th Annual Meeting of The American Gastrointestinal Association, May 18–24, 1991, in New Orleans, Louisiana.     

The "air enema" in acute colitis

The plain abdominal radiograph is an important investigation in acute colitis, but may fail to demonstrate the state of the colon owing to a lack of intracolonic gas. The extent of the colitis can be demonstrated by introducing air directly into the large bowel; the air also provides sufficient contrast to distinguish a granular from an ulcerated mucosa. The "air enema" may be used as an alternative to an unprepared barium enema. Its accuracy has been established by comparison with an unprepared barium enema in 10 patients with acute colitis.     

Colonic motility and transit in health and ulcerative colitis

Preprandial and postprandial colonic motility and transit (scintigraphy), with respect to the splenic flexure, were studied in 10 patients with ulcerative colitis and in 9 healthy subjects. The healthy subjects had a postprandial increase in intraluminal pressure that was significantly (P less than 0.03) greater in the descending colon than in other regions of the colon. In ulcerative colitis, the pressure was decreased in all regions compared with healthy subjects, with no significant pressure gradient among different regions. In normal subjects, transit was quiescent during fasting; eating stimulated both antegrade and retrograde transit. In ulcerative colitis, transit was variable before as well as after the meal. Both healthy subjects and patients with ulcerative colitis had more rapid emptying from the splenic flexure into the sigmoid than into the transverse colon. More frequent, low-amplitude, postprandial propagating contractions occurred in ulcerative colitis (P less than 0.05) than in healthy subjects. Propagating contractions were always antegrade and caused a rapid movement of the tracer into the sigmoid. In conclusion, ulcerative colitis is characterized by (a) decreased contractility, (b) increased low-amplitude propagating contractions, and (c) variable transit. These disturbances may accentuate the diarrhea in ulcerative colitis.     

Radiology in the current assessment of ulcerative colitis

Plain abdominal radiography in acute ulcerative colitis is essential to detect acute colonic complications, such as acute dilatation and free perforation. Sealed perforations may not be detected. Useful information can be gained as to the extent and severity of the mucosal lesions, but can be unreliable so that a contrast examination is required. The double contrast barium enema is more accurate than the single contrast study in revealing the early mucosal lesions of colitis. It is the examination of choice to show the extent and severity of disease, and is of considerable value in the differential diagnosis of colitis. In active colitis, the unprepared double contrast barium enema is recommended. The success of the examination relies on the absence of fecal residue adjacent to an active mucosa. The technique, uses, and limitations of this type of examination are described. In the long-term management of colitis, the role of radiology is to show the presence of extensive disease, which indicates an increased risk of malignancy. Lesions such as strictures or polyps may be found and are more likely to be benign than malignant, but confirmation often requires endoscopic biopsy. In the search for malignancy regular barium enema examination is not recommended, as this can only reveal an overt tumor, whereas premalignancy can be detected histologically from an endoscopic biopsy.     

Volvulus of the Splenic Flexure of the Colon

Volvulus of the splenic flexure is rare. Only 20 cases have been reported. Two additional patients are presented. Both had previous abdominal operations and were correctly diagnosed by barium enema. Resection and anastomosis in the two stages was performed in one patient and unwinding with fixation of the bowel in the other. The literature is reviewed and the pathogenesis discussed.     

Ischemic colitis of the cecum after renal transplantation masquerading as malignant disease

Fourteen years after kidney transplantation and following protracted rejection of the transplant, a patient developed abdominal pain, fever, and leukocytosis. Ultrasound demonstrated a pericolic abscess, and barium enema a deformity of the ascending colon suggesting malignant growth. Colonoscopy showed ulcerative and necrotic lesions of the cecum, and colonic carcinoma was suspected. At surgery, a granulomatous inflammatory reaction with fibrosis involving the kidney transplant and cecum was found. Histological examination revealed ulcerations secondary to ischemic colitis, but no malignancy. Thus, ischemic colitis should be ruled out in cases with a presumptive diagnosis of colonic malignancy at x-ray or endoscopy.     

Congenital positional anomalies of the colon: radiographic diagnosis and clinical implications. II. Abnormalities of fixation

Defective fixation during embryologic development is responsible for a variety of segmental colonic malpositions seen during barium enema examinations. A review of the normal development process of fixation is presented, together with the most common and significant aberrations. On the right side clinical entities such as axial torsion, cecal bascule, retrocolic sigmoid, and pericolic bands are discussed and illustrated. On the left side, the configuration and clinical implications of the malposition of the splenic flexure are analyzed. It is pointed out that reversed configurations of the splenic flexure associated with failure of fixation of the entire descending colon may occur as an isolated congenital abnormality and may not necessarily be associated with renal anomalies. The characteristic radiographic appearance of the persistent descending mesocolon and its potential for complications is in addition emphasized. Familiarization with the radiographic appearance and clinical implications of these common abnormalities is essential in the daily interpretation of barium enema examinations.     

Necrosis of the colon secondary to pancreatitis

Summary This case is the sixth report of colonic necrosis developing secondary to acute pancreatitis. In the previous cases there was no roentgen evidence of colonic inflammation or necrosis prior to surgery or autopsy. The initial radiographic findings in this 56-year-old woman consisted of a diffuse transverse colitis on both abdominal films and a hypaque enema. Subsequent radiographs revealed evidence of a pancreatic abscess and changes consistent with necrosis in the splenic flexure. A contrast enema is recommended in all patients suspected of having colonic manifestations of pancreatitis.Dr. Thompson is a Picker Scholar, James Picker Foundation.     

Barium granuloma of the sigmoid colon

Barium granuloma (BG) is an unusual complication of barium enema that occurs due to the intravasation of barium into the colonic wall as a result of mucosal injury from an enema tip, overinflation of the rectal balloon, or intrinsic disease such as ulcerative colitis. We report a case of BG from a barium enema performed within 24 h after a proctoscopic biopsy. It was detected 5 years later when the patient developed persistent low back pain.     

Quantitative distribution of radiolabeled 5-Aminosalicylic acid enemas in patients with left-sided ulcerative colitis

Rectally administered suspensions of 5-aminosalicylic acid (5-ASA) are topically effective in treating left-sided ulcerative colitis. The extent to which the contents of these enemas are distributed to inflamed mucosal linings has not previously been determined. This study was undertaken to validate a technique for labeling 5-ASA with^99mTc and to quantitate the distribution of [^99mTc]5-ASA in eight patients with left-sided ulcerative colitis. Eight patients underwent three colonic scintigraphic exams within five days, receiving a 60-ml radiolabeled 5-ASA enema into the unprepared rectum for each study, with sequential anterior abdominal images obtained for 4 hr. Activity within the rectum, sigmoid, descending, transverse, and ascending colon was quantitated. Over 50% of the labeled enema had advanced beyond the rectum in five of eight patients and in six of eight patients by 30 min and 60 min, respectively. The distribution of [^99mTc]5-ASA was quantitatively reproducible when repeated in the same patient on different days, despite apparent visual differences. By 2 hr, the amount of the enema present within the rectum decreased significantly (P<0.05) compared to the initial distribution. The amount of enema present within the descending colon was increased significantly at 0.5 hr (P< 0.05) and at 2 hr (P< 0.01). There were no significant changes in the distribution from initial values for the sigmoid, transverse, or ascending colon at any time. In each of these cases the spread of the enema to or beyond the extent of disease was documented. In patients with left-sided ulcerative colitis, small volume [^99mTc]5-ASA enemas reliably reach the area of inflammation.Supported by a grant from Reid-Rowell, Inc.     

Splenic flexure colonic volvulus: a pediatric case report

Volvulus of the colon is an unusual cause of intestinal obstruction in the pediatric population. Splenic flexure colonic volvulus is the most uncommon site in children. We report a case of splenic flexure volvulus (SFV) in a 21-month-old boy with underlying cerebral palsy and epilepsy. He experienced abdominal distension, bilious vomiting and absence of bowel movement for 2 days. Abdominal radiography showed a proximal distended colon and a "coffee bean sign" at the left upper quadrant. Barium enema revealed a "bird beak sign" at the splenic flexure, which confirmed the diagnosis of SFV. Detorsion of SFV occurred while undergoing exploratory laparotomy. He received regular follow-up in the subsequent 3 years without recurrence.     

Medical management of ulcerative proctitis, proctosigmoiditis, and left-sided colitis.

Ulcerative colitis distal to the splenic flexure includes disease confined to the rectum (proctitis), rectosigmoid (proctosigmoiditis or distal colitis), or extending to the descending colon or splenic flexure (left-sided colitis). These subtypes represent up to 60% to 80% of newly presenting cases of ulcerative colitis. Although these conditions are defined by the extent of colon that is affected, they also share the characteristic of being amenable to topical therapy. In general, the course of disease is milder and symptoms are less severe than in patients with more extensive colonic involvement. Nonetheless, symptoms may significantly impair patients' health-related quality of life. Treatment options include the oral and/or rectal 5-aminosalicylate (5-ASA) preparations. Rectal therapy delivering higher concentrations of active medication (5-ASA or glucocorticoids) directly to the inflamed mucosa while minimizing systemic absorption provides a highly effective and safe treatment. Oral glucocorticoids are indicated in patients who are resistant to or intolerant of 5-ASA therapy. Immunomodulators have an important role in individuals with glucocorticoid dependent or glucocorticoid refractory disease. This article reviews the clinical diagnosis and current medical management of ulcerative proctitis, proctosigmoiditis, and left-sided ulcerative colitis, including patients resistant to conventional medical therapy.     

Intussusception up to splenic flexure by cecal carcinoma in an adult: report of a case

A 73-year-old woman was admitted because of constipation and appetite loss. She was diagnosed as having intussusception caused by a colonic tumor, based on the results of physical examination and imaging such as ultrasonography, computed tomography and barium enema. Operation revealed that right colon from the cecum up to the hepatic flexure of the ascending colon was not fixed to the retroperitoneum, and a circular cecal carcinoma was invaginated to the splenic flexure of the transverse colon. We experienced a rare case of ileocolic intussusception up to the splenic flexure by a cecal carcinoma with mesenterium ileo-colicum commune in an adult.     

Gold colitis induced by auranofin treatment of rheumatoid arthritis: case report and review of the literature.

A case of ulcerative colitis occurred during treatment of rheumatoid arthritis with the new oral gold preparation auranofin after a cumulative dose of 2160 mg. A barium enema showed loss of mucosal pattern and a rectal biopsy disclosed deep erosions, mucosal inflammation, and crypt abscesses. Precipitates of gold were seen in the periglandular stroma. On electron microscopy the gold deposits seemed to be identical to granules described in gold nephropathy. As the extrapolated serum gold level was within the normal range at the onset of the complication, the morphological findings suggested a local toxicity of the drug. The patient recovered within 14 days of withdrawal of auranofin and the start of therapy with sulphasalazine and steroids. A review of the published work shows that the previously reported mortality in gold colitis of 40% has decreased in recent years. The causes of this decrease may be both the earlier diagnosis of gold colitis and the improved intensive care of its severe complications.     

Acute colorectal ischaemia after anaphylactoid shock.

A 29 year old woman is reported with bloody diarrhoea three hours after developing anaphylactoid shock. Sigmoidoscopy, barium enema, and histology showed rectal and colonic ischaemia to the splenic flexure. Recovery was complete. There was no history of vascular disease but the patient was taking an oral contraceptive. Thirty one other cases of spontaneous ischaemic proctitis are reviewed.     

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.     

Perforation of the rectum and sigmoid colon during barium-enema examination

Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque^®), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.