Absent Bowel Research Articles

Development of Encapsulating Peritoneal Sclerosis Following Bacterial Peritonitis in a Peritoneal Dialysis Patient

Encapsulating peritoneal sclerosis (EPS) isan uncommon and often fatal complication inpatients on peritoneal dialysis (PD) therapy. EPSis a clinical syndrome characterized by symp-toms of impaired intestinal motility, such asanorexia, nausea, vomiting, abdominal fullness,abdominalpain,absentbowelsounds,andconsti-pation.

Gastrointestinal symptoms in intensive care patients

Gastrointestinal (GI) problems are not uniformly assessed in intensive care unit (ICU) patients and respective data in available literature are insufficient. We aimed to describe the prevalence, risk factors and importance of different GI symptoms. We prospectively studied all patients hospitalized to the General ICU of Tartu University Hospital in 2004-2007. Of 1374 patients, 62 were excluded due to missing data. Seven hundred and seventy-five (59.1%) patients had at least one GI symptom at least during 1 day of their stay, while 475 (36.2%) suffered from more than one symptom. Absent or abnormal bowel sounds were documented in 542 patients (41.3%), vomiting/regurgitation in 501 (38.2%), high gastric aspirate volume in 298 (22.7%), diarrhoea in 184 (14.0%), bowel distension in 139 (10.6%) and GI bleeding in 97 (7.4%) patients during their ICU stay. Absent or abnormal bowel sounds and GI bleeding were associated with significantly higher mortality. The number of simultaneous GI symptoms was an independent risk factor for ICU mortality. The ICU length of stay and mortality of patients who had two or more GI symptoms simultaneously were significantly higher than in patients with a maximum of one GI symptom. GI symptoms occur frequently in ICU patients. Absence of bowel sounds and GI bleeding are associated with impaired outcome. Prevalence of GI symptoms at the first day in ICU predicts the mortality of the patients.

Non-occlusive colonic ischemia induced by verapamil ER overdose

Sir: Verapamil overdose can cause conduction disturbances and hypotension with cardiogenic shock [1], both of which can lead to ischemia. The colon is susceptible to ischemia because of the variable amount of collateral blood flow present, especially in arteriosclerotic patients [2, 3]. We report a case of colonic ischemia after verapamil overdose. A 60-year-old man with a history of hypertension, arteriosclerosis, aortofemoral bypass (with clamping of inferior mesenteric artery) 2 years ago and tobacco addiction was being treated with clopidogrel 75 mg/day and verapamil ER 240 mg/day. He came to the emergency department intoxicated after taking approximately 30 verapamil extended-release tablets and three clopidogrel tablets as a suicide attempt. His blood pressure was 72/38 mmHg, and his pulse rate was 52 beats/min. He was drowsy and had thready peripheral pulses. An electrocardiogram showed an atrioventricular block. A bottle of activated charcoal (50 g) was given and could be ingested by the patient. Despite the administration of intravenous fluids, calcium gluconate, and vasopressors, the patient’s blood pressure only marginally improved. He subsequently developed lower abdominal pain. Repeated examination showed abdominal distension with lower-quadrant guarding and absent bowel sounds. His leukocyte count was 22,000 cells/mm, and tomodensitometry of the abdomen showed a peritoneal effusion, a defect of opacification of the left colon with respect to opacification of celiac and superior mesenteric arteries (Fig. 1a, b). An exploratory laparotomy showed a gangrenous segment of the left colon; the rest of the colon and ileum was normal. He had a left hemicolectomy with a colostomy. Histolopathological evaluation showed a pronounced edema of the submucosa with the dilation of the submucosal vessels and several areas with necrotic ulcerations and intramural bleeding (Fig. 1c, d). There was no evidence of thromboembolic obstruction. He was hemodynamically stable during the remainder of his hospitalization and developed immediately acute respiratory distress syndrome. Finally, he left the ICU at day 30. Long-term verapamil use has also been reported as a cause of stercoral perforation of the sigmoid colon [4]. A previous case of caecal and

Severe acute pancreatitis with pseudocyst bleeding due to hepatitis E virus infection.

Coincidence of acute pancreatitis caused by hepatitis E virus (HEV) infection is rare. We report a case of severe acute pancreatitis in the course of acute hepatitis E in a 35-year-old man who presented with jaundice for 1week. Serum was positive for IgM anti-HEV and negative for hepatitis A, B and C viruses. There was upper abdominal tenderness and fullness with absent bowel sounds. A diagnosis of acute pancreatitis was made and confirmed with elevated serum lipase 2,032U/L and amylase 1,287U/L. Twoweeks after admission he had an increase in abdominal pain associated with oliguria and hemodynamic instability. Serum creatinine had increased and hemoglobin had dropped along with metabolic acidosis. Ultrasound showed hemorrhage into the pseudocyst, which was confirmed by contrast-enhanced computed tomography scan (which also ruled any pseudoaneurysm as the cause of bleed). He was hemodialysed and transfused blood. However, he developed refractory hypotension and did not respond to inotropes. After a rapid downhill course, he did not survive. Hepatitis E virus infection was complicated with the development of acute pancreatitis, which was severe with multiorgan failure and had a fatal outcome.

Significance of Absent Bowel Perfusion in Patients with Necrotizing Enterocolitis

HomeRadioGraphicsVol. 28, No. 1 PreviousNext Letter to the EditorSignificance of Absent Bowel Perfusion in Patients with Necrotizing EnterocolitisAkshay Kumar SaxenaAkshay Kumar SaxenaAuthor AffiliationsDepartment of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160012, India, e-mail: [email protected]Akshay Kumar SaxenaPublished Online:Jan 1 2008https://doi.org/10.1148/radiographics.28.1.0280319MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 EpelmanM, Daneman A, Navarro OM, et al. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. RadioGraphics2007; 27: 285–305. Link, Google Scholar2 SilvaCT, Daneman A, Navarro OM, et al. Correlation of sonographic findings and outcome in necrotizing enterocolitis. Pediatr Radiol2007; 37: 274–282. Crossref, Medline, Google Scholar3 FaingoldR, Daneman A, Tomlinson G, et al. Necrotizing enterocolitis: assessment of bowel viability with color Doppler US. Radiology2005; 235: 587–594. Link, Google ScholarArticle HistoryPublished in print: Jan 2008 FiguresReferencesRelatedDetailsCited ByThe Journal of Maternal-Fetal & Neonatal Medicine, Vol. 24, No. 4Recommended Articles Contrast-enhanced US in Pediatric Patients: Overview of Bowel ApplicationsRadioGraphics2020Volume: 40Issue: 6pp. 1743-1762Extrapancreatic Advanced Endoscopic InterventionsRadioGraphics2022Volume: 42Issue: 2pp. 379-396Pediatric Liver Transplant: Techniques and ComplicationsRadioGraphics2017Volume: 37Issue: 6pp. 1612-1631CT of Penetrating Abdominopelvic TraumaRadioGraphics2021Volume: 41Issue: 4pp. 1064-1081Imaging Evaluation of Abdominopelvic Gunshot TraumaRadioGraphics2020Volume: 40Issue: 6pp. 1766-1788See More RSNA Education Exhibits Beyond Necrotizing Enterocolitis: Sonographic Findings on Uncommon Causes of Pneumatosis Intestinalis in the Neonatal and Pediatric Emergency ScenarioDigital Posters2020Contrast-Enhanced Ultrasound (CEUS) in Pediatric Patients: Overview of Bowel ApplicationsDigital Posters2019Practical Approach to Liver Transplant Complications in the Emergency Department - What a Radiologist Needs to Know!Digital Posters2020 RSNA Case Collection Necrotizing enterocolitisRSNA Case Collection2020Necrotizing enterocolitis RSNA Case Collection2020IntussusceptionRSNA Case Collection2020 Vol. 28, No. 1 Metrics Altmetric Score PDF download

Emphysematous Gastritis Due to Infection from a Non Gas-Producing Bacteria!

FigurePurpose: Emphysematous gastritis is a rare condition in which gas collects within the stomach wall secondary to infection by gas-producing bacteria. We report the case of 25 year old female with neurofibromatosis who developed diffuse abdominal pain and distension after C-section. There was no history of alcohol or substance abuse, ingestion of corrosive substances or NSAIDs. Patient was febrile, tachycardic, and tachypneic and appeared toxic. Abdomen was markedly distended and tender with absent bowel sounds. Blood work showed WBC count of 25,000 with 91% neutrophils. CT of the abdomen showed gastric pneumatosis along the entire greater curvature and biliary tree, diffuse dilatation of the stomach, small bowel and large bowel. EGD showed diffuse severe mucosal abnormality with congestion, discoloration, granularity, texture change, decreased vascular pattern and ulceration on the posterior wall and greater curvature of the stomach. Gastric biopsy revealed transmural necrosis and streptococcus viridans and stomatococcus were isolated. Patient was started on clindamycin and piperacillin/tazobactam as well as IV hydration and TPN from the first day. Patient improved with the above measures and was discharged home after 10 days of hospital stay. Follow up CT scan and EGD showed resolution of the previous findings. It is important to differentiate emphysematous gastritis from gastric emphysema as early institution of antibiotic therapy covering anaerobes and gram negative bacilli, along with IV hydration and institution of nutrition is the mainstay of treatment. The stomach is a very uncommon site of involvement, due to abundant blood supply, acidity and efficient mucosal barrier. Currently, CT is the best imaging study for diagnosis of emphysematous gastritis. Surgery is avoided during the acute phase of infection due to friability of the gastric mucosa.[figure1][figure2]Figure

Neonatal gastric perforation following inadvertent connection of oxygen to the nasogastric feeding tube

An 3-day-old baby, who was being treated for probable sepsis, developed acute abdominal distension. On examination he was pale, and had tachycardia and tachypnoea and cold, dusky extremities. He responded...

Ileosigmoid knotting: A report of two cases

Background: Ileosigmoid knotting (ISK) is a rare cause of acute intestinal obstruction with high morbidity and mortality. The diagnosis is rarely made preoperatively because of its infrequency and the variations in presentation. Aim: To report two cases managed by the author, which will hopefully increase awareness of this condition. Case Reports: The first was a 51-year-old man who presented with a sudden onset of colicky lower abdominal pain, which later became generalized. His pulse rate was 100 beats/minute while his blood pressure was 80/60 mmHg.There was mild abdominal distension with absent bowel sounds. The second was a 50-year-old man with a sudden onset of generalized colicky abdominal pain, abdominal distension and vomiting. His pulse rate was 120 beats/minute and the blood pressure 80/50 mmHg. His bowel sounds were markedly reduced. They were resuscitated accordingly. In both patients, exploratory laparotomy revealed a copious amount of sero-sanguinous fluid in the peritoneal cavity with ileosigmoid knotting, and extensive gangrene involving the distal ileum and the sigmoid colon. In the first patient, the caecum was involved in the knot and therefore also gangrenous. Each of them had a sigmoid colectomy with a right hemicocetomy. The first patient died of adult respiratory distress syndrome while the other had an uneventful recovery. In the patient who died, surgery was done on the third day of onset of symptoms. Conclusion: A high index of suspicion, aggressive resuscitation, and prompt surgical intervention are indispensable for a successful outcome. Port Harcourt Medical Journal Vol. 1 (3) 2007: pp. 197-200

Prothrombin 20210 G/A Defect as a Cause of Mesenteric Venous Infarction: Report of a Case

A 50-year-old man with abdominal pain, nausea, and vomiting presented at our emergency department. Physical examination revealed diffuse abdominal tenderness and absent bowel sounds. Computed tomography showed partial portal vein thrombosis extending to the right portal vein and the superior mesenteric vein, perfusion defects in the liver, and nonopacified intestinal segment after contrast injection. An emergency laparotomy was performed. The wall of the distal jejunum was edematous, congested, and a 10-cm jejunal segment was necrotic. A partial intestinal resection and a primary anastomosis were performed. Screening for thrombophilia revealed a heterozygote 20210 G/A mutation of the prothrombin gene. Anticoagulation was initiated. Computed tomography 45 days after surgery showed a complete dissolution of the thrombi and cavernous transformation in the main portal vein. His subsequent clinical course was uneventful. Mesenteric venous thrombosis which causes an intestinal infarction is rare, and also difficult to diagnose. However, a prothrombin 20210 defect should be considered in the differential diagnosis of patients with unexplained thrombosis.

Correlation of sonographic findings and outcome in necrotizing enterocolitis

There is little in the literature regarding the use of gray-scale and Doppler sonography of the bowel in necrotizing enterocolitis (NEC) and how findings depicted by this modality might assist in predicting outcome and influence management. To correlate sonographic findings with outcome in NEC. This was a retrospective analysis of clinical and abdominal ultrasonography (AUS) findings in NEC from January 2003 to December 2005. AUS findings were evaluated for portal venous gas, free gas, peritoneal fluid, bowel wall thickness, echogenicity, perfusion and intramural gas. Patients were categorized into two groups, according to their outcome. A total of 40 infants were identified who had AUS for NEC prior to any surgical intervention. Group A comprised 18 neonates treated medically and recovered fully, and group B comprised 22 neonates who required surgery or died. Free gas (six patients) and focal fluid collections (three patients) were only found in group B. Increased bowel wall echogenicity, absent bowel perfusion, portal venous gas, bowel wall thinning, bowel wall thickening, free fluid with echoes and intramural gas were seen in both groups, but more frequently in group B. Anechoic free fluid was seen more frequently in group A. Increased bowel perfusion was seen equally in both groups. An adverse outcome was associated with the sonographic findings of free gas, focal fluid collections or three or more of the following: increased bowel wall echogenicity, absent bowel perfusion, portal venous gas, bowel wall thinning, bowel wall thickening, free fluid with echoes and intramural gas. Sonographic findings are useful in predicting outcome and therefore might help guide management.

Clinical profile and risk factors for perforation of acute appendicitis in children

To describe the clinical profile and determine the risk factors associated with perforation of appendix in children under 13 years of age. A retrospective review of charts of children admitted for appendicitis between the year 1999 to 2000. Department of Paediatrics and Child Health, Tikur Anbessa Specialised Hospital, Addis Ababa University, Addis Ababa, Ethiopia. A total of 147 children under the age of 13 years admitted for acute appendicitis. A total of 147 cases were analysed. The mean age was 9.3 years and appendicitis occurred more commonly among males. Factors independently found to be predictors of perforation by univariate analysis were: age <10 years, duration of illness for over 24 hours, history of treatment elsewhere before arrival to TAH, generalised abdominal tenderness, rebound tenderness and/or rigidity, hypoactive and/or absent bowel sound, RLQ mass, leukocytosis with neutrophilia and presence of complications. However, none of these was retained as significant factors in the multiple logistic regression analysis. There are many factors that are associated with perforation but there is no single factor that independently predicted perforation of appendicitis. Delay in intervention due to late presentation to hospital is an important preventable factor.

A Preterm Female Who Has a Distended Abdomen and Absent Bowel Sounds

### Prenatal History: ### Birth History and Presentation: The infant was delivered by repeat cesarean section. Amniotic fluid was meconium-stained. After delivery, the infant was intubated, and meconium was suctioned from the trachea. Apgar scores were 5 and 8 at 1 and 5 minutes respectively. She was transported to the neonatal intensive care unit while intubated. The patient edematous at birth. Surfactant was administered through the endotracheal tube. The patient’s abdomen was distended, and an abdominal radiograph was obtained, with findings similar to the abdominal radiographs shown on the previous page and below. An orogastric tube was placed for suctioning. Paracentesis was performed, with drainage of brown fluid. A surgical drain …

Necrotizing Enterocolitis With Hepatic Portal Venous Gas And Pneumatosis Intestinalis In A Patient With AIDS

A 43-year-old man was admitted in our hospital because of severe Pneumocystis jerovecii pneumonia [formerly called Pneumocystis Carinii Pneumonia (PCP)]. During his stay in Intensive care unit, he developed vomiting, abdominal distension and absent bowel sounds. On abdominal radiograph, hepatic portal venous gas (HPVG) and pneumatosis intestinalis of the small and large intestine were present. HPVG caused by necrotizing enterocolitis was diagnosed, and an emergency laparotomy was thus performed that showed necrosis of the small and large bowel. Bowel resection was done. The patient is alive as of two years after operation. The prognosis of necrotizing enterocolitis accompanied by HPVG and pneumatosis intestinalis is extremely poor. The presence of HPVG suggests the occurrence of a serious lesion in the abdominal cavity. Therefore, appropriate treatment should be performed immediately.

Richter's hernia after colonoscopy: a rare complication

A 53-year-oldman presented to a private GI practice with moderate, diffuse abdominal pain and vomiting a day after diagnostic colonoscopy for recurrent diarrhea. Endoscopic findings were normal, and no biopsy specimen was taken. Previous colonoscopies and an upper-GI endoscopy, both with biopsies, and a lactose breath test were all normal. Apart from antidepressants and loperamide on demand, no other medication was prescribed. His medical history revealed grade II internal hemorrhoids, arterial hypertension, and chronic back pain. On examination, he had a slightly tender abdomen, with absent bowel sounds. Upper-GI endoscopy showed a fluidfilled stomach but no obstruction. We suspected a postinterventional paralytic bowel; therefore, the patient was managed conservatively, but without clinical improvement. An abdominal radiograph showed air-fluid levels of the small bowel (Fig. 1), and a CTshowed an abrupt change in diameter of the terminal ileum 15 cm proximal to the ileocecal valve, within reach of a colonoscope. The patient at that time was clinically well. To determine the nature of the obstruction (i.e., extrinsic compression, intussusception, stricture, intraluminal mass, inflammation), colonoscopy was repeated. No pathology could be detected at the suspicious site. Because of increasing signs of mechanical ileus, laparoscopy was performed. An incarcerated Richter’s hernia lateral to the enlarged right internal inguinal ringwas found (Figs. 2 and 3). It involved the terminal ileum, 30 cm proximal to the ileocecal valve. After reduction of the vital bowel, the hernia was closed by preperitoneal mesh repair. The patient made an uneventful recovery.

A retrospective review of 89 stab wounds to the abdomen and chest.

This study compared the admission findings in 89 stab victims with the subsequent severity of their injury. The majority of patients were young males who arrived at hospital after 2300 h on a Friday, Saturday or Sunday and had consumed alcohol prior to admission. The presence of "clinical shock" or absent bowel sounds was invariably associated with significant injury. However, 64 of the 89 patients in this study had a normal blood pressure and audible bowel sounds at the time of admission. Thirty of the 64 patients had also suffered significant injury, which frequently was a perforated viscus. A diagnostic laparotomy should be readily performed in such patients in view of the high incidence of occult injury. Experienced anaesthetic support is necessary to ensure a low mortality from the actual laparotomy.

Risk factors for mortality due to shigellosis: a case-control study among severely-malnourished children in Bangladesh.

To determine the risk factors for death of severely-malnourished Bangladeshi children with shigellosis, a case-control study was conducted at the Clinical Research and Service Centre of ICDDR,B: Centre for Health and Population Research in Dhaka, Bangladesh. One hundred severely-malnourished children (weight-for-age <60% of median of the National Center for Health Statistics), with a positive stool culture for Shigella dysenteriae type 1 or S. flexneri, who died during hospitalization, were compared with another 100 similar children (weight-for-age <60% and with S. dysenteriae type 1 or S. flexneri-associated infection) discharged alive. Children aged less than four years were admitted during December 1993-January 1999. The median age of the cases who died or recovered was 9 months and 12 months respectively. Bronchopneumonia, abdominal distension, absent or sluggish bowel sound, clinical anaemia, altered consciousness, hypothermia, clinical sepsis, low or imperceptible pulse, dehydration, hypoglycaemia, high creatinine, and hyperkalaemia were all significantly more frequent in cases than in controls. In multivariate regression analysis, altered consciousness (odds ratio [OR]=2.6, 95% confidence interval [CI] 1.0-6.8), hypoglycaemia (blood glucose <3 mmol/L (OR=7.8, 95% CI 2.9-19.6), hypothermia (temperature <36 degrees C) (OR=5.7, 95% CI 1.5-22.1), and bronchopneumonia (OR=2.5, 95% CI 1.1-5.5) were identified as significant risk factors for mortality. Severely-malnourished children with shigellosis having hypoglycaemia, hypothermia, altered consciousness and/or bronchopneumonia were at high risk of death. Based on the findings, the study recommends that early diagnosis of shigellosis in severely-malnourished children and assertive therapy for proper management to prevent development of hypothermia, hypoglycaemia, bronchopneumonia, or altered consciousness and its immediate treatment are likely to reduce Shigella-related mortality in severely-malnourished children.

Acute Paraspinal Compartment Syndrome

Acute compartment syndrome is the condition of raised pressure within an enclosed compartment, such that the perfusion and the function of the tissues within are compromised, resulting in ischemia and eventually necrosis. Although, in theory, it can occur in any compartment, it is most commonly seen in the lower limb. We describe a rare case of acute compartment syndrome in the paraspinal muscles that responded well to surgical decompression. Our patient was informed that data concerning this case would be submitted for publication. Athirty-five-year-old man on the third day of a skiing holiday presented to the emergency department because of severe, unrelenting pain in the right lumbosacral paraspinal area, radiating across the abdomen to the groin. The pain had been present for four hours and had begun spontaneously with no history of trauma. In retrospect, the patient had experienced similar but milder pains during previous ski trips and during long-distance running. There was associated numbness in the right lumbosacral area. Positive findings on physical examination were bilateral paraspinal muscle rigidity associated with swelling, marked tenderness, and loss of the lumbar lordosis. There was dense loss of sensation in the paraspinal area to the midaxillary line and altered sensation extending anteriorly to the midline. Reduced abdominal muscle tone on the right side, resulting in asymmetry, was also noted. Active movement of the spine was minimal and exacerbated the pain. The patient had mild tenderness of the abdomen with absent bowel sounds. The initial differential diagnosis included a renal stone, a herniated disc, discitis, and a retroperitoneal abnormality. A urine specimen was dark in appearance, and analysis revealed 3+ myoglobinuria. Blood chemistry studies showed elevation of aspartate aminotransferase (804 IU/L; …

Enteral nutritional management in trauma patients blenderized feeds versus immunosupplemented feeds

As patients with head injury and polytrauma have an increased basal metabolic rate and catabolism their nutritional requirements substantially increase. At the same time they have an obtunded sensorium and are unable to accept orally for a prolonged period of time. These patients should receive optimum nutritional support after 48 hours of injury to prevent multiple organ failure and sepsis. We studied the effect of blenderized versus immunosupplemented feeds. Patients in the age group of 20–35 years were selected and randomly divided into two groups of twenty five patients each. Energy requirements were calculated by the Harris-Benedict Equation. Protein requiret was calculated so as to have a C/N ration of 90:1. Control group received blenderized enteral feeds whereas study group received added immunonutrients for a period of two weeks. Enteral feeding was started within 48 hours of injury and the patient’s full nutritional requirements were reached by day four. Patients were assessed by maintaining daily nutrient intake record, serum albumin level and nitrogen balance on the admission and discharge, I.C.U. stay and length of stay. Patients were studied till discharge. Patients with diabetes, intraabdominal injury and absent bowel sound were excluded. P value was calculated by paired t test. Results showed that study group had significant increase In the nitrogen balance at discharge [<0.05] reduced ICU stay and Iength of stay as compared to control group but control group also showed a positive balance [<0.05], which was cost effective. We conclude that giving early enteral nutrition with a C:N ratio of 90:1 helps in better outcome. Immunonutrients supplementation certainly helps in increased nitrogen retention and reduces length of ICU stay.

STERCORAL PERFORATION OF THE SIGMOID COLON

Stercoral perforation of the sigmoid colon is a rare event resulting in severe peritonitis and is associated with a high mortality rate. Since 1894 fewer than 90 cases have been reported in the medical literature, and a MEDLINE search revealed only 48 articles on this topic over the last 3 5-year time period. We present five cases of stercoral perforation of the sigmoid colon observed in a 350-bed community hospital over an eight-year period. All our patients underwent urgent surgical procedures including peritoneal lavage, resection of as much colon as possible, along with Hartmann closure and colostomy. Histology showed the perforations to be distinctly different from a diverticular perforation. Three of our patients died shortly after their initial presentation while our fourth patient had delayed mortality undoubtedly related to this illness. Our experience with this disease leads us to the following conclusions: (1) Patients with severe obstipation and absent bowel movements for over one week are at particular risk. (2) The severity of the abdominal pain in the absence of initial overt radiological signs of perforation may be an important clue to the diagnosis (3) The initial physical examination may not show peritoneal signs (4) Rectal examination frequently shows no stool because the impaction is above the rectosigmoid junction and (5) Absent stool in the rectal ampullae may cause physicians to underestimate the significance of the patient's problem and contribute to a false sense of security in the face of an impending perforation. We believe stercoral perforation of the sigmoid colon is an underreported entity and we urge our colleagues to report more cases of this illness.Table: Patient Characteristics

Prevalence of autonomic signs and symptoms in antimuscarinic drug poisonings

Classically described antimuscarinic poisoning signs and symptoms include mydriasis, decreased secretions, ileus, urinary retention, hyperthermia, tachycardia, and altered mental status. These features may be used clinically to assist in the diagnosis of patients with unknown poisonings. We sought to analyze the prevalence of antimuscarinic physical examination findings in evaluating patients presenting with acute poisoning from antimuscarinic agents. We conducted a retrospective, medical record review at two urban tertiary care teaching hospitals. The study population consisted of patients presenting to the Emergency Department with a diagnosis of acute poisoning secondary to medications with known antimuscarinic side effects during a 78-month period between January 1994 and July 2001. Cases were excluded for incomplete medical records or unreliable histories of ingestion, and when concomitant ethanol intoxication was present on laboratory analysis. Clinical information obtained from each patient included vital signs, pupillary size, electrocardiogram abnormalities, the presence of mucous membrane and axillary secretions, initial urine output after bladder catheterization, quality of bowel sounds, mental status changes, the occurrence of seizures and coma, need for orotracheal intubation, and time required for clinical resolution. Diagnostic and therapeutic information including laboratory tests, administration of sodium bicarbonate, and usage of physostigmine was also collected. We identified a total of 345 cases, 213 of which met inclusion criteria. Of these cases, the most common documented findings included decreased secretions in 75.1%, tachycardia in 68.1%, confusion in 49.3%, drowsiness in 48.2%, and hypoactive or absent bowel sounds in 44.6%. Combining signs and symptoms to predict this toxic syndrome was not very reliable. Tachycardia, decreased oral or axillary secretions, and mydriasis proved to be the most predictive trio of clinical signs, but were found in only 28.2% of cases. At least one of these three signs was documented in 94% of our patients. The combination of tachycardia and decreased secretions was the most common pair of findings, recorded in 55.4% of cases. We conclude that the clinical presentation of antimuscarinic syndrome is variable.