Burkitt’s Lymphoma Presenting as Ileocaecal Intussusception in Systemic Lupus Erythematosus

Patients with systemic lupus erythematosus (SLE) are reported to have an increased risk of malignancy, especially lymphoproliferative disorders. We decribe the occurrence of ileocaecal intussusception secondary to Burkitt’s lymphoma in a patient with SLE. A 23-year-old woman, who had been diagnosed with SLE 2 years ago, developed intermittent abdominal pain with a palpable mass. Computed tomography and a double-contrast barium enema showed a lobulated mass with intussusception at the ileocaecal junction. Right hemicolectomy and splenectomy was performed after histopathological examinations on colonoscopic biopsy revealed Burkitt’s lymphoma. Fourteen months after chemotherapy, there is no evidence of recurrence of the Burkitt’s lymphoma. When a patient with SLE has abdominal complaints, besides serositis, lupus enteritis such as peptic ulcer disease, mesenteric vasculitis with or without complications and pancreatitis, we have to consider intussusception secondary to gastrointestinal lymphoma as one of the differential diagnoses. Therefore, we should thoroughly investigate patients with SLE presenting with abdominal pain and not simply consider it a feature of lupus enteritis until other causes have been ruled out. Received: 14 September 1998 / Accepted: 21 December 1998     

提高对结肠脾曲综合征的认识、诊断及治疗

结肠脾曲综合征指结肠脾曲处的弯曲部积聚过多气体或粪便引起腹胀、腹痛及顽固性不全结肠梗阻的一种综合征。发病原因尚不清楚,多数学者认为与先天性结肠固定点异常有关。最常用的检查方法是X线钡剂灌肠大肠造影。治疗以彻底的近段、次全及全结肠切除术最为合理,且效果亦最理想。充分的术前准备是手术成功的关键措施之一。     

Amebic perforation of the colon

Conclusions Complications of amebiasis should be taken into consideration in all acute abdominal disorders which occur during or after severe attacks of diarrhea, dysentery or dysenterylike syndromes. In view of the grave consequences, all diagnostic resources should be exhausted before performing a laparotomy. In patients with acute abdominal syndromes, there is less risk in proctosigmoidoscopic examination than in exploratory laparotomy, despite the seriousness of the condition. Besides providing extremely valuable macroscopic data, proctosigmoidoscopy makes it possible to take samples for examination. This may provide a quick diagnosis and thereby avoid the loss of time required for stool tests, which are a most essential factor. Specific treatment with emetine should be begun as soon as the diagnosis is made. In cases of doubt, emetine should be administered as a therapeutic test which serves the same purpose as preparation for possible surgery. Since so few guarantees are provided by surgical treatment, the fewer operative and exploratory procedures employed, the better. Surgical results are improved, as in the case of abscess of the liver, if previous antiamebic treatment has been administered. Read at the Congreso Nacional de Proctología, Mexico City, Mexico, May 13 to 15, 1963.     

原发性门静脉、肠系膜静脉广泛血栓伴发小肠梗阻1例治疗体会

肠系膜静脉血栓(mesenteric venous thrombosis,MVT)缺乏特异性的临床症状及体征,病情复杂,难于早期准确诊断,易误诊误治。对于有可疑诱发因素导致的无法用其他疾病解释的腹痛、腹胀、恶心、呕吐,需要考虑到MVT的可能,行腹部增强CT可明确诊断,给予积极的抗凝溶栓治疗,预防肠坏死、休克、多脏器功能衰竭等严重并发症,改善患者预后。及时跟踪患者病情,对于可能出现的并发症,应给予高度重视。     

Perineal Colostomy with Appendicostomy as an Alternative for an Abdominal Colostomy: Symptoms,Functional Status,Quality of Life,and Perceived Health

Purpose Abdominoperineal rectum resection with perineal colostomy and appendicostomy for antegrade continence enema has been developed as an alternative for abdominal colostomy or total anal reconstruction in patients with low rectal cancer. This present study was designed to compare symptoms, functional status, quality of life, and perceived health after perineal colostomy and appendicostomy with that after abdominal colostomy. Methods Twenty-seven patients, 14 with abdominal colostomy and 13 with perineal colostomy and appendicostomy, were included. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR38 were used to investigate functional status and symptoms. Quality of life was measured by using a Linear Analog Scale and the Satisfaction with Life Scale. Self-perceived health was assessed by using a Linear Analog Scale. Results Patients with perineal colostomy and appendicostomy were younger and more frequently female. They experienced better physical functioning (93.3 vs. 73.3 P = 0.048), a slightly better role functioning (100 vs. 83.3 not significant), body image (77.8 vs. 66.7 not significant), and sexual functioning (33.3 vs. 0; not significant) than patients with abdominal colostomy. Stoma-related problems were substantial in patients with abdominal colostomy (38.1) and very limited in patients with an appendicostomy (8.7). Fecal loss did not occur one hour or more after antegrade continence enema in 11 patients with perineal colostomy and was limited in the others. Quality of life and self-perceived health were comparably good in both groups. Conclusions Perineal colostomy with appendicostomy for antegrade continence enema is a valid and acceptable alternative for a permanent abdominal colostomy in selected patients, with a comparable functional and quality of life outcome. Reprints are not available.     

Evolution of surgery for large-intestinal obstruction

Summary Since the early 1930s, it has been possible to distinguish clinically small- and large-intestinal obstructions. The hazard of perforation of the cecum in instances of complete colonic obstruction with great distention is today recognized by all abdominal surgeons. Decompression by transverse colostomy has been the operation of choice in this clinic. In this surgeon's judgment, primary resection is rarely justified. The patient deserves to be treated like a drowning man, dragged to shore. It is not the proper time for a swimming lesson. The time may not be far off when the mortality rate associated with management of the acutely obstructed colon may approach minimal levels. The hospital mortality rate for decompression and subsequent resection of the colon for malignancy in this clinic over the 12-year interval 1942–1953 was 6.1 per cent; for cecal and sigmoidal volvulus, approximately 10 per cent. In 1943, this surgeon reported 61 primary consecutive colonic resections (unobstructed) with one death, a mortality rate of 1.6 per cent. These operations were performed over a two-year interval, all by the closed method of intestinal anastomosis, an enema being the only preoperative preparation.¹⁸ It is regrattable that this precise and nice method of anastomosis, effective and safe, has gone out of style. Presented at Principles of Colon and Rectal Surgery Annual Continuing Medical Education, University of Minnesota, Minneapolis, Minnesota, November 12, 1976.     

Aerophagia and Intestinal Gas

Opinion statement Aerophagia refers to a rather rare disorder that may occur in both children and adults that features repetitive air swallowing and belching and that may result in abdominal distention. There are few, if any, controlled studies to guide therapy, which remains largely supportive but may include behavioral therapy and psychotherapy. Bloating, distention, and other gas-related symptoms are common in functional gastrointestinal disorders, including the irritable bowel syndrome; their pathophysiology remains, for the most part, poorly understood. Two separate phenomena need to be distinguished in these disorders: gas production and gas perception. Thus, whereas gas production, which relates most closely to flatus emissions, is probably within the normal range in most patients with irritable bowel syndrome, gas transport or transit through the gut may be impaired and may lead to the retention of gas within segments of the gut. Visceral hypersensitivity, a common phenomenon in all functional disorders, may exacerbate the sensation of distention and contribute to other “gas-related” symptoms. Few controlled studies have addressed any of these issues. Although, on an empiric basis, dietary therapy may be partially effective in some situations, there is at present no data to support the use of any form of pharmacologic, endoscopic, or surgical therapy for any of these symptoms.     

Long-Term Functional Assessment of Antegrade Colonic Enema for Combined Incontinence and Constipation Using a Modified Marsh and Kiff Technique

Purpose Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation. Methods Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles’ operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H₂-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap. Results During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P < 0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P < 0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6–40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux. Conclusions Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy. Presented in part as a poster at the meeting of the EACP and ECCP, Bologna, Italy, September 15 to 17, 2005. Reprints are not available.     

Repetitive rectal painful distention induces rectal hypersensitivity in patients with irritable bowel syndrome

Background A reduced rectal perceptual threshold has been reported in patients with irritable bowel syndrome (IBS), but this phenomenon may be induced by a comorbid psychological state. We evaluated the rectal pain threshold at baseline and after conditioning (repetitive rectal painful distention: RRD) in patients with IBS or functional abdominal pain syndrome (FAPS), which is an abdominal pain disorder, and in healthy controls, and determined whether rectal hypersensitivity is a reliable marker for IBS. Methods The rectal sensory threshold was assessed by a barostat. First, a ramp distention of 40 ml/min was induced, and the threshold of pain and the maximum tolerable pressure (mmHg) were measured. Next, RRD (phasic distentions of 60-s duration separated by 30-s intervals) was given with a tracking method until the subjects had complained of pain six times. Finally, ramp distention was induced again, and the same parameters were measured. The normal value was defined by calculating the 95% confidence intervals of controls. Results Five or six of the seven IBS patients showed a reduced rectal pain threshold or maximum tolerable pressure, respectively, at baseline. In all patients with IBS, both thresholds were reduced after RRD load, but they were reduced in none of the patients with FAPS. RRD significantly reduced both thresholds in the IBS group (P < 0.05), but it had no effect in the control or FAPS groups. Conclusions Rectal hypersensitivity induced by RRD may be a reliable marker for IBS. Conditioning-induced visceral hypersensitivity may play a pathophysiologic role in IBS.     

影响TACE术治疗HCC患者恶心呕吐的非化疗因素分析

目的 研究影响肝细胞癌（HCC）患者肝动脉化疗栓塞术（TACE）术后发生恶心呕吐的非化疗因素。方法 随机选取我院2014~2016年诊治的360例确诊为HCC患者,记录所有HCC患者的性别、年龄、体质指数（BMI）、肝区疼痛、肿瘤质地、大小、是否发生转移、手术次数、是否发热、发热持续时间、腹部有无肿胀、注射碘化油的量等,并采用Logistic回归分析逐一分析以上所有因素与HCC患者TACE术后发生恶心呕吐的关系。根据恶心程度语言描述分级和主诉疼痛程度分级法进行评价。结果 在360例HCC患者中,发生2级恶心58例（16.11%）,1级恶心83例（23.06%）,0级恶心219例（60.83%）;在大部分HCC患者中,其年龄越大,发生恶心呕吐的程度越轻（r=-0.303,P<0.05）;疼痛和腹胀程度越严重,发生恶心呕吐的程度越重（r=0.299,r=0.497,P<0.05）;疼痛时间越长,恶心呕吐程度越重（r=-0.203,P<0.05）;Logistic回归分析结果显示,高龄是HCC患者TACE术后恶心呕吐的保护因素,而长时间的腹痛和腹胀是TACE术后恶心呕吐的危险因素;根据结构方程模型的分析结果显示,恶心呕吐与腹部疼痛和腹胀程度呈现出直接的正向效应（β=0.39,β=0.69,P<0.01）,年龄与腹胀也呈现出正向效应（β=0.02,P<0.01）,而年龄与腹疼程度呈现出负向效应（β=-0.02,P<0.01）。结论 引起HCC患者TACE术后恶心呕吐的发生是与多种不同因素共同作用引起的,其中与年龄、腹痛和腹胀程度关系最为密切,其中高龄是HCC患者TACE术后恶心呕吐发生的保护因素,而长时间的腹痛和腹胀是TACE术后恶心呕吐发生的危险因素。     

Acute abdomen as the first presentation of pseudomembranous colitis.

Acute abdomen was the presenting manifestation of pseudomembranous colitis in six men who had previously been treated with antibiotics and presented with abdominal distention, pain, fever, and leukocytosis with absent or mild diarrhea. Plain abdominal radiographs revealed megacolon in two, combined small and large bowel dilation in three, with one of them showing volvuluslike pattern, and isolated small bowel ileus in one. Emergency colonoscopy was performed successfully in all patients and revealed pseudomembranes in five and nonspecific colitis in one. All patients had positive latex test results for Clostridium difficile, and two tested positive for cytotoxicity. All patients were treated with IV metronidazole, resulting in resolution of symptoms and abdominal findings. In addition, two patients underwent colonoscopic decompression with improvement. Endoscopically, complete resolution of the pseudomembranes occurred at 4 weeks in all cases. No patient had a recurrence. It is concluded that (a) pseudomembranous colitis may present as abdominal distention mimicking small bowel ileus. Ogilvie's syndrome, volvulus, or ischemia; (b) in such cases, emergency colonoscopy is safe and useful for diagnosis and therapeutic decompression and may obviate the need for surgery; and (c) treatment with IV metronidazole is effective. Colitis due to C. difficile should be considered in the differential diagnosis of acute abdomen in patients previously treated with antibiotics.     

The role of surgery in the treatment of instussusception in celiac disease.

Small bowel intussusceptions comprise fewer than 10% of all pediatric patients with intussusceptions and most of them are secondary to another pathology. In this report, we discuss the role of surgery in the treatment of intussusception in celiac disease. A 13-month-old girl was admitted with a three day history of progressive abdominal distention and vomiting of bile. There were air-fluid levels on supine abdominal X-ray and ultrasonographic examination demonstrated an intussusception. At surgery, two separate small bowel intussusceptions were encountered. The postoperative course was uneventful. Due to a history of frequent diarrhea and mild abdominal distention developing after the age of seven months, further studies for celiac disease were initiated. Antigliadin and antiendomysium antibodies were found to be strongly positive. Celiac disease was also confirmed by endoscopic small bowel biopsy. Children who present with chronic or transient intestinal obstruction should also be evaluated for underlying celiac disease. Nevertheless, the surgical decision should be based upon clinical observation in this group of patients.     

A case of Budd–Chiari syndrome with Behcet’s disease and oral contraceptive usage

We present a case of Budd–Chiari syndrome (BCS) having two risk factors, Behcet’s disease (BD) and oral contraceptive (OC) usage. A 33-year-old woman with BD was admitted to the Emergency Unit with nausea, vomiting, abdominal pain, abdominal distention, and confusion started 12 days ago before admission. Since the patient was in a shock state, she was taken to the Intensive Care Unit (ICU) with the suspicion of abdomen-originated sepsis. Abdominal ultrasound showed massive hepatosplenomegaly and moderate ascites. Abdominal MRI revealed an inferior vena cava (IVC) obstruction starting above the renal veins and diffuse thrombosis of the right and medial hepatic veins. An extensive thrombosis of the IVC and the hepatic veins (BCS) which led to shock was diagnosed. In addition to BD, the unnotified OC usage for a year by the patient without her doctor’s knowledge was recognized as possible precipitating factor of BCS. Pulse methylprenisolone was started for three consecutive days to treat active BD-induced vasculitis. IVC digital subtraction angiography (DSA) showed occlusion of the IVC below the hepatic veins with extensive collateral circulation originating at the occlusion level suggesting that obliteration had a subacute or chronic course. Since intralesional thrombolytic therapy failed, the patient was transferred to a liver transplantation center. While waiting for an appropriate donor, the patient died due to hepatic failure. Since BCS is mortal and deemed multi-factorial, every patient with a thrombotic risk factor such as BD should be questioned for other possible causes of thrombosis.     

Survival after colonic perforation during barium-enema examination

Four of five patients survived perforation of the colon incidental to barium-enema examination, while the other survived without sequela of infection until hemiplegia and pneumonia supervened two and 36 days, respectively, postoperatively. It is postulated that adequate intravenous fluids, early operation, with complete cleansing by antibiotic irrigation and mechanical debridement of the abdominal cavity, along with excision of the perforated segment of bowel with establishment of an end colostomy or ileostomy and distal mucous fistula, if possible, are keys to survival in these patients. Triple antibiotics, using ampicillin, gentamicin, and clindamycin, or metronidazole, should be administered in all patients as soon as the diagnosis is made, and continued postoperatively as indicated until there is no evidence of infection. An intraluminal intestinal tube, for stichless plication of the small bowel, may be helpful in some patients. A stomacone should be used for a barium enema through a colostomy stoma. Care should be exercised in performing barium contrast studies in patients with inflammatory bowel disease.     

Computed tomography colonography in 2014: An update on technique and indications

Twenty years after its introduction,computed tomographic colonography(CTC)has reached its maturity,and it can reasonably be considered the best radiological diagnostic test for imaging colorectal cancer(CRC)and polyps.This examination technique is less invasive than colonoscopy(CS),easy to perform,and standardized.Reduced bowel preparation and colonic distention using carbon dioxide favor patient compliance.Widespread implementation of a new image reconstruction algorithm has minimized radiation exposure,and the use of dedicated software with enhanced views has enabled easier image interpretation.Integration in the routine workflow of a computer-aided detection algorithm reduces perceptual errors,particularly for small polyps.Consolidated evidence from the literature shows that the diagnostic performances for the detection of CRC and large polyps in symptomatic and asymptomatic individuals are similar to CS and are largely superior to barium enema,the latter of which should be strongly discouraged.Favorable data regarding CTC performance open the possibility for many different indications,some of which are already supported by evidence-based data:incomplete,failed,or unfeasible CS;symptomatic,elderly,and frail patients;and investigation of diverticular disease.Other indications are still being debated and,thus,are recommended only if CS is unfeasible:the use of CTC in CRC screening and in surveillance after surgery for CRC or polypectomy.In order for CTC to be used appropriately,contraindications such as acute abdominal conditions(diverticulitis or the acute phase of inflammatory bowel diseases)and surveillance in patients with a long-standing history of ulcerative colitis or Crohn’s disease and in those with hereditary colonic syndromes should not be overlooked.This will maximize the benefits of the technique and minimize potential sources of frustration or disappointment for both referring clinicians and patients.     

The remaining colon after radical surgery for colorectal cancer

This study investigates the possible gain and limitation by performing colonoscopy and double-contrast enema immediately after, and every six months after, radical surgery for colorectal cancer. It was possible to perform a complete colonoscopy within three months of surgery in 80 per cent of the 239 patients and at the follow-up time in 90 per cent. Incompleteness was related to insufficient bowel preparation, narrow anastomosis, and long transverse colon. Five patients had synchronous cancers, and 64 had adenomas at the time of surgery. The risk of recurrent adenomas in the latter was higher (17/64) than in those without adenomas (15/175). The adenomas were located above the rectum in 57 of 80 patients who had polypectomy. Four patients with metachronous cancer and one of five patients with local recurrence had another radical operation, while this was possible in none of 40 patients with recurrence diagnosed by other means than colonoscopy and enema. Radical colorectal surgery should be followed by colonoscopy and double-contrast enema, but how often and for how long remains to be established.     

Management and prevention of fecal impaction

Fecal impactions occur in both sexes at any age but are particularly concentrated in children, in the institutionalized or impaired elderly, and in patients with certain psychiatric disorders or medical conditions that predispose to obstipation. The clinical consequences may be disabling and occasionally life threatening. Clinical manifestations include fecal incontinence, abdominal distention and pain, anorexia, weight loss, intestinal obstruction, and stercoral ulceration with bleeding or colonic perforation. Diagnosis begins with recognition of possible fecal impaction and confirmation by digital examination or abdominal radiography. Management consists of disimpaction, colon evacuation, and a maintenance bowel program to prevent recurrent impactions.     

Management of functional abdominal pain

Opinion statement The diagnosis of functional abdominal pain should be made based on the Rome II symptom criteria with only limited testing to exclude other disease. During physical examination the clinician may look for evidence of pain behavior which would be supportive of the diagnosis. Reassurance and proper education regarding the clinical entity of functional abdominal pain is critical for successful treatment and good patient satisfaction. Education should include validation that symptoms are real, and that other individuals experience similar symptoms. No further treatment may be required for those with mild symptoms. For patients with more severe symptoms, a long-term management plan of either pharmacological or psychological treatments is warranted. This will require a commitment by both the patient and the physician to engage in a partnership with active involvement and responsibility by both individuals. The goal of treatment—to decrease pain and increase function over time, not to cure the disorder— should be explained. Strong consideration should be made for the use of an antidepressant to treat analgesic effects. Tricyclic antidepressants are the mainstay of therapy for functional pain disorders. The analgesic effect is generally quicker in onset and occurs at a lower dose than their effect on mood. To maximize patient compliance, patients should be told the rationale behind their use, warned of the potential side effects, and reassured that many of the side effects will disappear with time. Choice of an antidepressant should be based on the presence of concomitant symptoms (eg, depression), cost, and physician familiarity with specific agents. All patients with functional abdominal pain should be screened for underlying psychiatric disturbance as an untreated mood disorder will adversely affect response to treatment. If a concurrent mood disorder is found, it should be treated by either using a higher dose of the tricyclic antidepressant or by adding another antidepressant agent. Psychological interventions such as cognitive behavioral therapy may be important as adjuvant therapy or as an alternative to treatment with antidepressants for those patients who find antidepressants ineffective or are intolerant to them. Narcotics and benzodiazepines should not be used to treat chronic abdominal pain due to the high risk of physical and psychological dependence.     

Perforation of a gastric ulcer in a premature infant exposed to cold

Summary The sixth newborn and second premature infant to have survived perforation of a gastric ulcer has been reported.Cold is implicated as an additional stress of possible significance in the formation of peptic ulcers. Hypothermic infants with other signs or symptoms of neonatal cold injury (lethargy, redness of skin, edema, sclerema) should be observed especially carefully for evidence of an ulcer.Refusal of feedings, even mild abdominal distention, or vomiting should alert one to the possible indication for abdominal films, as early surgical intervention is essential to the salvage of newborns with this condition.Presented at the Seventh Annual Symposium of Air Force Internists and Allied Specialists at the Wilford Hall USAF Hospital, Lackland AFB, Tex., on Feb. 7, 1964.The author wishes to express his appreciation for the editorial assistance of Dr. John H. Githens, Dr. John J. Boehm, and Dr. William E. Hathaway.     

Intestinal Gas

Opinion statement The most common symptoms associated with intestinal gas are excessive eructation, flatulence, and abdominal bloating and distention. Unfortunately, few therapies have been shown to be effective in treating these symptoms. Excessive eructation can be treated by decreasing excessive air swallowing. Bloating and gaseous distension can improve in some patients by avoiding foods containing partially digested or absorbed polysaccharides, by taking replacement enzymes (such as alfa-galactosidase or lactase), or by taking antibiotics directed toward altering the colonic flora. Activated charcoal or prokinetic agents (such as tegaserod and metoclopramide) also can be effective options in some patients. For noxious odor associated with flatus, bismuth subsalicylate or the charcoal cushion may improve patients’ symptoms.