Dilated Sigmoid Colon Research Articles

Massive sigmoid megacolon due to giant fecaloma: A case report of anal stricture

BackgroundA fecaloma is a mass of hardened feces in the colon or rectum, more solid than typical impacted feces, leading to severe intestinal distension. It predominantly affects elderly, frail individuals, children with anorectal deformities, and patients with conditions such as Chagas disease, Hirschsprung's disease, and spinal injuries. Case ReportWe report the case of a 34-year-old man with a history of anal imperforation and subsequent anal stricture, who presented with a massive megacolon due to a giant fecaloma. The patient experienced progressive abdominal distension, colicky pain, and an inability to pass stool for 15 days. Physical examination revealed a tender, distended abdomen and impacted feces in the rectum. Laboratory tests and imaging studies confirmed the diagnosis. An emergency laparotomy revealed a 30 × 30 cm dilated sigmoid colon filled with 15–25 kg of fecal material. The fecaloma was removed via enterectomy, and a Hartmann's procedure with colostomy was performed. Histopathological examination showed no evidence of malignancy. Post-operatively, the patient recovered well and was discharged in good condition. ConclusionThis case highlights the presentation and surgical management of a giant fecaloma causing megacolon. Prompt surgical intervention is critical in managing severe fecaloma to prevent life-threatening complications.

S2217 A Rare Case of Synchronous Double Volvulus of the Sigmoid Colon and Cecum

Introduction: Colonic volvulus is one of the leading causes of large bowel obstruction. Synchronous cecal and sigmoid volvulus is a rare presentation. Cecal volvulus and sigmoid volvulus have traditionally been thought of as separate clinical presentations with distinct clinical features, radiological findings, and treatment modalities. We focus on the classical radiological findings, uncharacteristic presentations, and definitive treatment to prevent recurrence, morbidity, and mortality. Case Description/Methods: A 67-year-old female with a past medical history of severe chronic constipation secondary to stercoral colitis presents to the emergency department complaining of abdominal pain for 5 days. Pain is diffuse, and associated with nausea and vomiting. The last colonoscopy performed 4 years ago, was normal. The patient was in immense pain and was not able to provide further information. On presentation, the patient was afebrile, BP 127/52, HR 73, RR 16 breaths/min. The abdomen was distended, and peritoneal sounds were auscultated in all quadrants but were worse in lower quadrants bilaterally. X-ray of the abdomen showed pneumoperitoneum and dilated bowel related to stercoral colitis. Subsequent CT abdomen showed small volume ascites, hollow perforated viscus, markedly distended cecum with peri-cecal inflammatory changes, and significant wall thickening with inflammation in the sigmoid colon secondary to concurrent cecal and sigmoid volvulus. The patient immediately underwent exploratory laparotomy, ileocecectomy with primary anastomosis, sigmoidectomy with primary anastomosis, and abdominal washout (Figure). Discussion: When evaluating acute abdomen, we propose consideration of synchronous large bowel volvulus is a rare and easily missed etiology of large bowel obstruction due to challenging radiological presentation. Even with detailed cross-sectional imaging like CT scan, it is possible to miss coexisting cecal volvulus due to massively enlarged sigmoid volvulus causing mass effect. The preferred treatment is total or subtotal colectomy with or without anastomosis on a case-to-case basis. This approach provides the advantage of avoiding the risk of recurrence and histopathological analysis to rule out underlying malignancy. Commonly, only one type of large bowel volvulus is found radiologically, it is advisable to pay attention to the possibility of coexisting cecal volvulus and a definitive diagnosis being made intraoperatively.Figure 1.: A. Chest X-ray showing gas under diaphragm; B. Volvulous with dilated caecum and Sigmoid colon on Abdominal X-ray; C. Scout film of the CT scan abdomen; D. Twisted Caecum with dilated sigmoid colon on axial film.

Dilated sigmoid colon with Chilaiditi's sign mimicking diaphragmatic hernia: A case report.

IntroductionChilaiditi's sign is a rare radiological presentation characterized by colonic interposition between the diaphragm and liver which is usually confused with conditions such as diaphragmatic hernia, pneumoperitoneum and subdiaphragmatic abscess.Case presentationWe report a case of 55 year old male presenting with abdominal pain since a year which was associated with abdominal fullness, loss of appetite and constipation. Further investigations showed us as a case of diaphragmatic hernia but intra operatively it was found to be Dilated sigmoid colon with Chilaiditi's sign.Clinical discussionIt is a rare incidental finding with major preponderance in male. The intestinal, hepatic and diaphragmatic causes predispose its pathology. Conservative management is the first line of treatment but the complicated abdominal pathologies are managed by various surgical intervention.ConclusionDilated sigmoid colon along with Chilaiditi's sign can sometime mimic as Diaphragmatic hernia which can make enormous difference in our pre and post-operative diagnosis. Chilaiditi's syndrome is a rare entity so early diagnosis is of utmost benefit.

Sigmoid volvulus; a rare complicated presentation of Hirschsprung's disease: A case report.

IntroductionSigmoid volvulus (SV) is a rare complication of Hirschsprung's disease (HD) with only 31 cases have been reported in the English literature. Although its diagnosis is challenging, unrecognized SV is a life-threatening condition requiring early recognition to decrease morbidity and mortality.Presentation of caseA 14-year-old male presented to our emergency department with massive abdominal distention. Plain erect abdominal X-ray showed massive colonic distention with multiple fluid levels. Colonoscopy failed to pass beyond 15 cm after entering dilated sigmoid loop. Open surgical exploration was done through a lower midline incision and revealed SV with massive distention of the entire colon. After detorsion, we found a markedly dilated sigmoid colon with an evident discrepancy at the lower sigmoid. Due to massive colonic dilatation, the decision was made for terminal ileostomy. Histopathological examination of biopsy from the narrow segment demonstrated aganglionosis and hypertrophic submucosal neural fibers confirming the diagnosis of HD.DiscussionSV is a rare serious complication of HD. Unrecognized SV is a serious life-threatening condition, so it should be considered in children with acute or recurrent abdominal pain, distension, constipation and vomiting as early recognition and management of volvulus is essential to decrease morbidity.ConclusionThe presented case highlights the possibility of SV as a rare complication of HD should be considered especially in children with a history of chronic constipation and abdominal distension who present with acute colonic distension and failure to decompress despite rectal washes.

An incarcerated internal hernia of the sigmoid colon through a defect in the broad ligament: A case report.

Introduction and importanceHernias through a defect of the broad ligament are rare, accounting for only 1.6–5% of internal herniations [1]. This report describes a rare case of sigmoid colon obstruction due to hernia through a defect of the broad ligament, which was diagnosed before surgery.Case presentationA 78-year-old multiparous woman presented with lower abdominal pain and nausea. Contrast-enhanced multi-detector CT (MDCT) demonstrated a dilated sigmoid colon and edematous mesentery of the sigmoid colon in the left Douglas' fossa, the uterus was compressed dorsally to the right and the left ovary was compressed ventrally. We diagnosed an internal broad ligament defect hernia with incarceration of the sigmoid colon, and performed emergency laparotomy. The necrotic sigmoid colon was resected and anastomosis was performed by the double stapling technique. The postoperative course was uneventful.Clinical discussionWe consider the treatment of hernia of sigmoid colon through a broad ligament defect.ConclusionWe recognize that there is a possibility that, in addition to the small intestine, proximally located organs may be incarcerated. In the case of the colon, we should choose the treatment method carefully according to whether or not the colon is expected to be necrotic.

Comments on ‘Ileosigmoid Knot’: Case Report

Dear Editor, I read with interest the case report paper by Nazir S 2020,1 who reported a young man with ileosigmoid knotting (ISK), who was diagnosed as an obstructive emergency and treated with emergency surgery. Although ISK is a very rare entity worldwide with a few hundred cases reported to date,2 it is endemic in eastern Anatolia, where I practice. I and my colleagues have 80 cases of experience with ISK over a 54-year period from June 1966 to date, which is one of the largest single-center ISK series over the world.3 Here, I would like to discuss some diagnostic and therapeutic details of ISK presented by the authors. Firstly, bowel gangrene, a catastrophic complication of ISK, develops in about two third of the patients with ISK and worsens the prognosis by doubling the mortality rate.4,5 Conversely, melanotic stool, as was presented in the authors’ case, is determined in anamnesis or digital rectal examination of about one fifth of the patients.6,7 Although fever, leukocytosis, abdominal guarding/tenderness, hypotension/shock, somnolence and acidosis suggest bowel gangrene, unfortunately, except for the melanotic stool, none of these indicators are pathognomonic for ISK. Secondly, although abdominal X-ray radiography generally demonstrates a dilated sigmoid colon in addition to multiple small intestinal air-fluid levels in ISK, computed tomography (CT) or magnetic resonance imaging (MRI) are highly diagnostic with 90% of diagnostic accuracy rate by showing enlarged sigmoid colon in addition to the mesenteric whirl sign, the last which is pathognomonic for volvulus.8,9 Following the usage of CT and MRI by 2000s, the diagnostic accuracy rate of ISK clearly increased. When CT or MRI is not used, the correct diagnosis of ISK is still less than 20%, and fortunately, misdiagnosis generally consists of abdominal emergency, which also requires emergency laparotomy, as was reported by the authors.3 Finally, if a stoma is needed in ISK cases with double segment bowel gangrene, the procedure is applied only for one segment, which demonstrates poor bowel conditions including significant edema, borderline ischemia or difference in proximal and distal bowel ends.5 Nevertheless, if possible, I always prefer and advise to perform a colostomy instead of an ileostomy, contrary to the authors’ practice. I congratulate the authors for their report and look forward to their reply.

WITHDRAWN: Hirschsprung disease masquerading as patent vitello-intestinal duct

Abstract Hirschsprung disease (HD) is usually presented early in the neonatal period with delayed or no passage of meconium up to 48 hours, with abdominal distension and bilious vomiting. A 3-month-old baby boy with a history of neonatal asphyxia presented a 2-week duration of umbilical redness and a foul-smelling greenish discharge. He was treated for omphalitis and was given oral antibiotics, but later developed feeding intolerance and abdominal distension with no bowel opening. The abdomen was grossly distended, tense with erythematous umbilicus, and a greenish discharge from the umbilical punctum. A plain abdominal radiography showed dilated bowels. With the impression of complicated patent vitello-intestinal duct, the baby was subjected for an emergency laparotomy. Intraoperatively, there was a grossly dilated and inflamed sigmoid colon with a 5 mm perforation on the sigmoid colon. It formed a direct communication to the umbilical defect, forming a colo-umbilical fistula. The perforation site was resected and brought out as a sigmoid colostomy. The resected perforation site showed an acute inflammation with the presence of ganglionic cells, histologically. Since HD is highly suspicious, a suction rectal biopsy was performed postoperatively and revealed typical features of HD. Subsequently, the patient underwent the Duhamel procedure; the stoma was brought down and anastomosed with the anal canal. Despite the typical presentation of HD, it can also present enterocolitis, and to some extent, a bowel perforation. In this case, we were fortunate that the bowel perforation formed a direct fistulation to the umbilicus, instead of free perforation inside the peritoneal cavity, causing peritonitis or a less favourable outcome.

Abdominal compartment syndrome due to extremely elongated sigmoid colon and rectum plus fecal impaction caused by disuse syndrome and diabetic neuropathy: a case report and review of the literature

BackgroundAbdominal compartment syndrome (ACS) is defined as a sustained raised level of intra-abdominal pressure more than 20 mmHg with or without abdominal perfusion pressure less than 60 mmHg and the development of new end-organ failure. Abdominal surgery, major trauma, volvulus, ileus, distended abdomen, fecal impaction, acute pancreatitis, liver dysfunction, sepsis, shock, obesity, and age have all been reported as risk factors. Herein, we report the severest known case of ACS due to extremely elongated sigmoid colon and rectum plus fecal impaction caused by disuse syndrome and diabetic neuropathy, together with a brief review of the literature.Case presentationA 48-year-old Asian man suffering from shock was transported by ambulance to our hospital. His medical history included hypoglycemic encephalopathy sequelae, disuse syndrome, type 2 diabetic neuropathy, and constipation. He recovered consciousness in the ambulance, and his physical examination as well as laboratory findings were normal. X-ray and dynamic computed tomography revealed a thickened gut wall, and an extremely dilated sigmoid colon and rectum filled with a massive amount of stool as well as gas, compressing other intra-abdominal organs. We diagnosed the patient with transient vasovagal syncope, together with ACS, due to extremely elongated sigmoid colon and rectum plus fecal impaction, caused by anorectal disturbance derived from disuse syndrome and diabetic neuropathy. We first repeated stool extraction for bowel decompression and he subsequently became symptom-free, after which we performed a colostomy on the 28th hospital day. The postoperative course was uncomplicated, and he was discharged on the 44th hospital day.ConclusionsClinicians need to keep ACS in mind as a differential diagnosis and perform careful and detailed examination when encountering patients presenting with symptoms or risk factors of ACS. In addition, they need to precisely diagnose ACS and perform optimal treatment without delay.

S3359 Adult Isolated Hypoganglionosis in the Anorectal Canal

INTRODUCTION: Hirschsprung's disease (HD) is a congenital bowel innervation disorder characterized by the absence of ganglion cells in myenteric and submucosal plexus in the distal. The term ‘‘Variant HD’’ has been used to describe a heterogeneous group of intestinal innervation disorders with clinical presentation that resembles HD despite the presence of ganglionic cells seen on rectal biopsy. Isolated hypoganglionosis is a rare entity that present with persistent bowel symptoms similar to those with classical HD, however has resected bowel histopathological findings of reduced number of nerve cells in the myenteric ganglia. CASE DESCRIPTION/METHODS: We present a case report of a 19-year-old male who was diagnosed with isolated hypoganglionosis following a long history of fecal impaction and constipation since childhood. Patient presented to our institution with complaints of distended abdomen at 19 years of age. CT imaging demonstrated a massively distended rectosigmoid colon filled with abundant fecal material (Figure 1). An abdominal series revealed stool scattered throughout his colon and a dilated, saccular appearing rectum. A water soluble contrast enema exhibited a short segment (approximately 8 cm) narrowing of bowel in the region of the rectum with dilated upstream sigmoid colon (Figure 2). The remainder of the visualized bowel including proximal sigmoid, descending, transverse, ascending colon and cecum were of normal caliber. This imaging pattern was compatible with Hirschsprung's disease. The patient then underwent a laparoscopic-assisted proctosigmoidectomy with a stapled end to end coloanal anastomosis and a diverting loop ileostomy. Though the surgical pathology demonstrated the presence of ganglion cells in the sigmoid colon and rectum, the anorectal canal showed presence of rare ganglion cells (Figure 3). On follow up, the patient underwent another water soluble contrast enema that confirmed an intact anastomosis and he subsequently underwent successful ileostomy closure two months later. One week after closure, the patient had recovered well, reporting daily bowel movements with good evacuation control and no fecal incontinence. DISCUSSION: To our knowledge, this is the first case of adult HD variant, isolated hypoganglionosis, with histology demonstrating hypoganglionosis in the anorectal canal and no evidence of agangliosis in the rectum and sigmoid colon. Following removal of the remnant hypoganglionic intestinal segment, our patient’s bowel motility significantly improved.Figure 1.: Routine CT abdomen and pelvis with intravenous and oral contrast was performed on admission with axial images and coronal reformations (A and B, respectively). These images demonstrated marked sigmoid colonic fecal loading and dilation (white arrows), compatible with a chronic obstructive process such as Hirschsprung's disease.Figure 2.: Water soluble enema study was performed. (A) This study showed a short segment (8 cm) narrowing of the distal rectum (solid white arrow) with upstream dilatation of the proximal rectum (dashed white arrow). (B) The AP view demonstrates massive upstream dilation of the rectum and sigmoid colon.Figure 3.: H&E stain of anorectal canal (A) and sigmoid rectal area (B). Arrows indicate ganglion cells, which were rare in the anorectal canal region. Inserts show the higher magnification of the circled area. Bar = 50 um.

The Twisted Colon: A Review of Sigmoid Volvulus

In sigmoid volvulus (SV), the sigmoid colon wraps around itself and its mesentery. Sigmoid volvulus accounts for 2% to 50% of all colonic obstructions and has an interesting geographic dispersion. SV generally affects adults, and it is more common in males. The etiology of sigmoid volvulus is multifactorial and controversial; the main symptoms are abdominal pain, distention, and constipation, while the main signs are abdominal distention and tenderness. Routine laboratory findings are not pathognomonic: Plain abdominal X-ray radiographs show a dilated sigmoid colon and multiple small or large intestinal air-fluid levels, and abdominal CT and MRI demonstrate a whirled sigmoid mesentery. Flexible endoscopy shows a spiral sphincter-like twist of the mucosa. The diagnosis of sigmoid volvulus is established by clinical, radiological, endoscopic, and sometimes operative findings. Although flexible endoscopic detorsion is advocated as the primary treatment choice, emergency surgery is required for patients who present with peritonitis, bowel gangrene, or perforation or for patients whose non-operative treatment is unsuccessful. Although emergency surgery includes various non-definative or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful nonoperative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.
 Journal of Surgical Sciences (2019) Vol. 23(2): 90-94

A Case of Sigmoid Volvulus in Pregnancy: A Rare Emergency in Pregnancy

Background Sigmoid volvulus (SV) in pregnancy is a very rare entity, which can be associated with extremely high rates of mortality and morbidity for both mother and fetus. Care Report A 22-year-old female patient with a first pregnancy with a gestational age of 27 weeks was referred to the Omolbanin hospital, Mashhad, Iran, and presented with generalized pain, abdominal swelling, and abnormal bowel movements from a week ago. Intestinal loops with thick wall and fluid content decreased with decrease in peristalsis was seen in abdominal and pelvic ultrasound. In addition, abdominal and pelvic X-ray examination showed enlarged bowel with bent inner tube view. Due to severe abdominal pain and available evidence, she underwent laparotomy for suspected intestinal obstruction. A dilated sigmoid colon rotated about two times around its mesentery was seen adjacent to the pregnant uterus. The sigmoid was detorted and was fixed to the pelvic floor through its mesentery. The patient was discharged 4 days after surgery in good general condition, and her baby was born at 38 weeks of gestation by natural vaginal delivery. Conclusion Sigmoid volvulus during pregnancy is a rare complication. Its timely diagnosis will prevent intestinal gangrene and reduce maternal and fetal damage.

2140 Management of Recurrent Sigmoid Volvulus Using Dual Endoscopic Modalities of Sigmoidopexy and Percutaneous Colostomy Placement

INTRODUCTION: Sigmoid volvulus (SV) occurs when the colon twists about its mesentery which can compromise vascular perfusion leading to ischemia. Mortality rate (MR) is up to 60%, requiring emergent endoscopic (ES) detorsion via flexible sigmoidoscopy (FS) with placement of a rectal tube. Recurrence is high, ultimately requiring surgical management. The mean age of presentation is 70 with high likelihood of multiple comorbidities, resulting in high surgical risk. We present a case of ES therapy of recurrent SV. CASE DESCRIPTION/METHODS: 88-year-old man with colon cancer status post left hemicolectomy (LH), coronary artery disease on antiplatelet agents, atrial fibrillation on anticoagulation, congestive heart failure, and chronic pulmonary disease, presented with abdominal pain, distention and obstipation for two days. The patient had a history of three episodes of SV requiring ES detorsion since LH. Abdominal x-ray revealed a markedly dilated sigmoid colon. Emergent FS was performed with insertion of a 36 French (Fr) catheter resulting in decompression. Computed tomography (CT) was unrevealing for other pathology. Colonoscopy showed a severely redundant, tortuous and dilated colon without other abnormalities. Subsequently, ES sigmoidopexy was performed under fluoroscopy to minimize looping and confirm SV detorsion. Six T-fasteners (TF) were placed cephalocaudally, 5-10 cm apart, with the first TF upstream to proximal region of twisting and the sixth TF downstream to distal region of twisting. A 16 Fr percutaneous endoscopic colostomy (PEC) tube was then inserted as a decompression valve. The tube was affixed to the abdominal wall with two additional TFs inserted adjacent to the third TF to create a triangle within the region of previously dilated lumen. The eight TFs and PEC tube were tightened to abdominal wall, and the tube was connected to a Foley drainage bag. Follow up CT scan confirmed resolution of SV. The patient improved clinically and was discharged home after having formed bowel movements. DISCUSSION: Due to high MR, a high index of suspicion for SV is necessary in elderly patients presenting with abdominal distention. Although several case series exist describing ES sigmoidopexy and laparoscopically-assisted PEC tube insertion, to our knowledge this is the only described case of definitive ES therapy using both surgical and ES techniques. While additional cases are required to assess safety and efficacy, this technique may be an addition to the ES armamentarium in managing SV.

Spontaneous detorsion of sigmoid volvulus in a toddler: A timely Abdominal X-ray that clinched the diagnosis and a review of the role of radiology

Introduction: Sigmoid volvulus is extremely rare in children and the spontaneous detorsion is even more rarely encountered by clinicians. If it is undiagnosed on first presentation because of spontaneous detorsion, it could recur with severe complications like bowel wall gangrene, perforation and peritonitis which requires emergency Laparotomy with attendant higher mortality. Case Report: An acutely ill looking eighteen months toddler presented with a two day history of sudden onset of abdominal distension without associated pain. There were no obvious risk factors or previous history of similar episode. The abnormal findings on physical examination were mild pallor, abdominal distension and reduced bowel sounds. All his vital signs were stable. The urgent abdominal X-ray carried out soon after presentation, revealed the classical “Coffee bean sign” of the displaced dilated sigmoid colon. He was admitted, placed on intravenous fluid and nil per oral, and booked for Laparotomy. In about five to six hours while waiting for the surgery, his bowel opened to flatus and later to faeces with subsequent reduction in abdominal girth and normalized bowel sounds. Conclusion: Sigmoid Volvulus occurs in children and spontaneous untwisting is a reality. If the abdominal X-ray was done after the passage of flatus, the diagnosis would have been missed. We recommend that patients should have an abdominal X-ray immediately they present with sudden onset of abdominal distension to increase the chances of demonstrating the radiological features of sigmoid volvulus in order to offer an elective surgery to prevent recurrence, complications and reduce mortality.

Desmosis Coli − a Case Report and Review of The Literature

Desmosis coli is a rare pathology presenting as slow transit constipation. In this case we would like to discuss the presentation and management of desmosis coli. A 14-month-old female hailing from western India with a history of chronic constipation presented with acute massive abdominal distension and vomiting. At laparotomy, a hugely dilated transverse and sigmoid colon with a transition zone at the lower sigmoid was found. A transverse stoma was done after taking multiple seromuscular biopsies. The patient underwent re-exploration on day 14 because of the non-functioning of the stoma and a fixed bowel loop. The histopathology report was suggestive of normal ganglion cells. Unfortunately, the stoma continued not to function. A dye study showed dye in the colon after 24 hours ruling out any anatomical obstruction. Histopathology slides were reviewed multiple times and reported lack of connective tissue of the colonic wall leading to the diagnosis of desmosis coli. The patient was started on gradual feeds and pro-kinetics and over the next 2 weeks the stoma started functioning slowly. Desmosis coli is a rare cause of constipation which should be suspected in cases where aganglionosis has been ruled out and the constipation is refractory to conventional therapy.

直腸を病変の首座とする急性大腸偽性閉塞症による壊死型虚血性腸炎の1例(A case of gangrenous ischemic colitis caused by acute colonic pseudo–obstruction of the rectum)

急性大腸偽性閉塞症（acute colonic pseudo–obstruction: ACPO）は，明らかな閉塞機転や炎症性腸疾患などがないにもかかわらず急激な腸管拡張を来す疾患で，穿孔により手術を要することがあるが，腸管壊死を来すことは少ないとされる。今回我々は，直腸におけるACPOによる壊死型虚血性腸炎の1例を経験したので報告する。症例は93歳の男性，前日からの腹部膨満感と下腹部痛を主訴に搬送されてきた。患者は毎日排便がみられていたが，直腸内には大量の便が充満しS状結腸まで著しく拡張していた。腹部造影CTでは直腸壁は造影されており閉塞機転もみられなかったため，ACPOを考慮して可及的に便の摘出を行ったが，数時間後にショック状態に陥り緊急手術を必要とした。組織所見では壊死型虚血性腸炎を呈していたが明らかな血管閉塞はみられず，ACPOにより貯留した便が粘膜の圧迫壊死を来した原因と思われた。これまでACPOの多くは，S状結腸までの左半結腸に病変の首座を有し，横行結腸や上行結腸などの腹腔内の腸管が拡張する比較的予後の良い疾患とされていたが，直腸におけるACPOでは，周囲を骨組織に囲まれた骨盤腔内の腸管が拡張するため，腸管内圧の上昇から腸管の圧迫壊死を来しやすいものと思われ，より早期からの腸管減圧介入と厳重な経過観察が必要と考えられた。 Acute colonic pseudo–obstruction (ACPO) causes abrupt intestinal dilation, although intestinal obstruction and toxic megacolon are absent. Although ACPO rarely causes ischemic necrosis, we report a case of gangrenous ischemic colitis in the rectum due to ACPO. A 93–year–old male presented with abdominal distension and lower abdominal pain. He had daily bowel movements; however, we found large amounts of fecal matter in his rectum and a markedly dilated sigmoid colon. Contrast–enhanced abdominal CT showed well–enhanced rectal wall and no intestinal obstruction, but a few hours later he needed emergency surgery because of septic shock. Although histological findings indicated gangrenous ischemic colitis, vascular occlusion was absent; therefore, we suspected compression necrosis of mucosa due to ACPO. Most ACPO cases have a fair prognosis if the dilation is localized between the ascending and the sigmoid colon and remains within the abdominal cavity. However, because ACPO in the rectum causes intestinal dilation within the narrow pelvic cavity, increased intraenteric pressure may result in compression necrosis of the intestinal tract and worsen the condition, as was observed in this case. We believe that prompt bowel decompression and subsequent observation of patient progress are necessary for cases of ACPO with the dilation within the pelvic cavity. ACPOは非閉塞性に急激な腸管拡張を来す疾患であり，多くは保存的加療にて改善するものの，時に腸管虚血や穿孔により外科的加療が必要になる 1, 2, 3。発症からの時間経過や拡張した腸管径などを参考に治療方針が決定されるが，何らかの基礎疾患を有する症例や高齢者などの場合は，時に自覚症状や理学所見に乏しいことがある。今回我々は高齢者のACPO患者において，比較的早期に診断し得たが，その後，急激に全身状態が悪化し最終的には救命できなかった症例を経験した。病変の首座が直腸であるACPO症例は稀と考えられたため報告する。 患 者：93歳の男性 主 訴：下腹部痛，腹部膨満感 既往歴：高血圧，陳旧性脳梗塞，前立腺癌 内服薬：トラマドール塩酸塩，メロキシカム，エメプラゾール，タムスロシン塩酸塩，イルベサルタン/トリクロルメチアジド，ビカルタミド，バイアスピリン 現病歴：前夜からの下腹部痛と腹部膨満感にて発症し，自力での排便がみられたが症状の改善に乏しいため当院救急搬送となった。 来院時現症：意識は清明で自力歩行も可能であった。血圧97/59mmHg，脈拍85/分，整。体温36.2度，呼吸数23/分，SpO2 95%。理学所見上，下腹部は軽度膨隆しており，同部位の持続的な自発痛と圧痛を認めるものの筋性防御はみられず腸蠕動音は聴取された。直腸診では明らかな肛門狭窄や腫瘤性病変を認めず，黄色泥状便の貯留を認めた。 来院時血液検査所見：WBC 7,100/μL，Hb 11.6g/dL，BUN 39.1mg/dL，Cre 1.31mg/dLであったが，それ以外にはとくに異常所見を認めなかった。動脈血液ガス分析（室内空気）ではpH 7.359，PCO2 32.4mmHg，PO2 76.6mmHg，HCO3– 19.4mmol/L，BE –4.2mmol/L，乳酸5.4mmol/Lであり，腹部症状に伴う脱水から末梢循環不全と軽度の腎機能障害を来したものと判断した。 来院時画像検査所見：腹部レントゲンでは直腸からS状結腸にかけての腸管ガス貯留を認めた。腹部単純CT検査（Fig. 1）では直腸粘膜の軽度肥厚と直腸内の大量の便貯留，直腸からS状結腸までの最大径8.5cmに及ぶ著しい拡張を認めたが，明らかな狭窄部位は認めなかった。腹部造影CT検査でも，腸管粘膜の明らかな造影不良域や血管の途絶や閉塞を認めなかった。 Plain abdominal CT showed fecal matter filling the rectum but no stenosis from the rectum to the anal sphincter (arrow). 来院後経過：搬送直前にも排便はみられていたが，下腹部の膨隆および持続痛は直腸内の大量の便貯留が原因と判断し，可能な範囲で摘便を行うも症状の改善には至らず，さらなる排便コントロールを目的に入院とした。 入院後経過：入院後，輸液負荷による脱水の補正と緩下剤の内服や摘便を行うも，入院3時間後にショック状態に陥り急速輸液負荷と昇圧剤の投与を開始した（Fig. 2）。腹部造影CT再検では直腸壁内の嚢胞気腫像の出現と腹水の増量を認めたため，腸管壊死を疑って入院7時間後に緊急開腹術を施行した。 Changes in systolic blood pressure (sBP: continuous line), heart rate (HR: dashed line), arterial pH (pH: dotted line), and serum lactate (Lac: dashed spaced line) from admission to death. TAZ/PIPC: tazobactam and piperacillin 手術所見：開腹したところ混濁した悪臭を伴う腹水を認め，明らかな腸管穿孔は認めなかったが，直腸からS状結腸にかけての連続した壊死腸管を認めた（Fig. 3）。手術は壊死腸管を切除し，人工肛門造設術を施行した。切除標本で，直腸の漿膜面の色調は比較的良好で血流は保たれていたが，粘膜面の壊死は全周性かつ連続的にみられた。 Surgical findings indicated continuous bowel necrosis from the sigmoid colon to the rectum. 病理組織所見：粘膜面はほぼ完全に凝固壊死し，粘膜下層には強い浮腫とうっ血を認めたが，固有筋層の平滑筋には壊死が少なかった。虚血による腸管壊死の所見であったが，明らかな動脈内の血栓や塞栓は認めなかった（Fig. 4）ため，腸管内圧の亢進に伴う虚血壊死と診断した。 Histological findings indicated necrosis of the mucosa and loss of microvilli and extreme vascular congestion and edema in the submucosa, but virtually no necrosis in the muscularis propria. 術後経過：術後，集中治療室にて人工呼吸器管理下に，輸液負荷と昇圧剤の併用による循環管理，抗菌薬投与を行ったが，敗血症性ショックから多臓器障害を来し入院24時間後に永眠された。 ACPOはOgilvie症候群とも呼ばれ，1948年にOgilvieにより初めて報告された急激に発症する腸管の異常拡張を特徴とした疾患 1であり，腸管内に明らかな機械的閉塞がないにもかかわらず，腸管内容が停滞し腸閉塞症状を呈する。同様の状態を呈する疾患に中毒性巨大結腸症が挙げられるが，前者では何らかの器質的疾患や病態によって生じた交感神経系と副交感神経の不均衡が主病態とされる一方で，後者では炎症性腸疾患などにおいて炎症細胞から産生された一酸化窒素による平滑筋弛緩作用が主病態 4とされており，後者の診断基準や臨床経過は本症例には該当しなかった。 医学中央雑誌にて「Ogilvie症候群」もしくは「急性大腸偽性閉塞症」をKey Wordに検索すると，本邦では1984年以降，2015年までに自験例を含めて51例が報告されている。その多くは腹部手術後など入院治療中に発症しており，高血圧や脳梗塞など本症例と同じ既往歴を有する報告もみられたが，ACPOとの因果関係は不明である。また，本症例は数年来，前立腺癌の内服加療中であったが，これまでに副作用や同様の腹部症状の訴えはなく，腫瘍マーカーも基準値内で手術歴や放射線治療歴もなかった。過去の骨盤部CTと比較しても前立腺のサイズや肛門周囲組織に変化はみられなかったことなどから，服用薬剤や前立腺癌とACPOの関連性は低いと考えた。 本症例はこれまでに便秘の既往もなく，搬送直前まで自力排便がみられていたことから，大量の便貯留はACPOに伴うものと考えられた。ACPOの治療では速やかな腸管減圧が必要とされるものの，腸蠕動や排便がみられるため，腸管径が10cm以下の症例や強い腹痛を認めない症例では，発症後48–72時間は保存的加療が第一選択とされている 5。本症例での最大直腸径は8.5cmで発症24時間以内であったこと，腹痛も自制内であったことなどから保存的加療の適応と判断したが，極めて短時間のうちに全身状態が悪化し，病理診断にて壊死型虚血性腸炎と診断された。 壊死型を含めて虚血性腸炎の発症には，血圧低下や動脈硬化，微小血管攣縮などの血管側因子と，便秘やガス貯留による腸管内圧亢進などの腸管側因子が相互に関連している 6, 7。本症例における血管側因子として，来院時からの低血圧とその後に用いた昇圧薬による腸管の低灌流状態の関与も考慮され，非閉塞性腸間膜虚血（non–occlusive mesenteric ischemia: NOMI）との鑑別が必要であった。NOMIは心不全や循環血液量減少性ショックなどによる腸管の低灌流状態に起こる腸間膜動脈の攣縮が主病態であり，病変部位も上腸間膜動脈に多いとされる 8, 9。腸間膜の血管攣縮がランダムに起こるため，虚血部位は非連続性に斑状に発生する点が虚血性腸炎との重要な鑑別点 10とされ，手術所見や病理所見などからも本症例はNOMIには合致しない。低血圧や入院後の昇圧薬使用などの血管側因子の関与よりは， 腸管側因子として直腸内の大量の便塊による腸管内圧亢進が壊死型虚血性腸炎の発症に大きく関与したものと考えられる。 壊死型虚血性腸炎は致命率が高いことから早期診断が重要とされ，加瀬ら 11は早期診断における入院時のSIRS（systemic inflammatory response syndrome）スコアとSIRS持続期間の有用性を述べている。本症例では，入院時にSIRSの診断基準は1項目しか該当せず持続期間も短時間であったが，臨床所見などに乏しく，手術適応の判断が遅れた可能性は否めない。ACPOの多くは保存的加療にて軽快する比較的予後の良い疾患とされ，保存的加療に反応がないものや腸管径が10–12cm以上で6日間以上続くものは，腸管虚血や穿孔の危険性が高く外科治療の適応 5とされる。本邦の症例においても多くは初期に保存的治療が選択されており，緊急手術となっている症例の多くはACPOとしての手術適応ではなく，異常腸管拡張から腸管壊死や腹膜炎が疑われて開腹手術となり，手術所見とあわせて閉塞起点がないことからACPOの診断に至ったものが多かった。 これまでACPOの多くはS状結腸や横行結腸など周囲を比較的柔らかい組織に囲まれた腸管に発症するため，ある一定以上に腸管径が拡張するまでは合併症は起こりにくく，保存的加療が選択され手術適応に至るまでに時間的な猶予があった。ところが，ACPOでは少ない 3とされる直腸に発症した症例 12では，病変の首座が周囲を硬い骨性成分で囲まれた骨盤腔内にあるため直腸内圧が上昇しやすく，より早期に壊死型虚血性腸炎などを合併する可能性がある。本邦の報告例では，直腸に病変を認めたものは51例中6例（11.8%）とやはり少なく，多くはS状結腸などの他部位の腸管拡張が直腸に及んだ症例であった（Table 1）。またACPOから壊死型虚血性腸炎に至ったのは3例のみ 13であり，直腸に病変の主座を有し壊死型虚血性腸炎に至った症例は自検例のみであった。ACPOとは異なるが，巨大直腸を来す疾患において，腸管減圧などの治療的介入を要する腸管径は6.5cm以上とする文献 14もあり，自検例が8.5cmの拡張であったことを鑑みても，直腸病変ではより早期からの積極的な腸管減圧を考慮するべきである。 本症例は，術前の血液培養および術中の腹水培養はともに陰性であったが，手術所見や輸液抵抗性のショックなどの術後経過から，敗血症性ショックと診断した。エンドトキシン吸着療法などの血液浄化療法は，家族の強い希望もあり施行しなかった。高齢であるがゆえの所見の乏しさと，壊死型虚血性腸炎の早期診断・手術適応決定の難しさを痛感させられた1例であり，重篤な合併症の一つとして念頭におくべきである。 直腸におけるACPOによる壊死型虚血性腸炎の1例を経験した。直腸を病変の首座とする症例は，骨盤腔との関連で容易に内圧が上昇し壊死型虚血性腸炎へ進展する可能性があり，腸管減圧などの早期介入を要すると思われた。 本論文における利益相反は存在しない。

Relation between mast cells concentration and serotonin expression in chagasic megacolon development.

Chagas' disease is still reaching about 10million people in the world. In South America, one of the most severe forms of this disease is the megacolon, characterized by severe constipation, dilated sigmoid colon and rectum and severe malnutrition. Previous data suggested that mast cells and serotonin (5-hydroxytryptamine [5-HT]) expression could be involved in intestinal homeostasis control, avoiding the chagasic megacolon development. The aim at this study was to characterize the presence of mast cells and expression of serotonin in chagasic patients with and without megacolon and evaluate the relation between mast cells, serotonin and megacolon development. Our results demonstrated that patients without megacolon feature a large amount of serotonin and few mast cells, while patients with megacolon feature low serotonin expression and a lot of mast cells. We believe that serotonin may be involved in the inflammatory process control, triggered by mast cells, and the presence of this substance in large quantities of the intestine could represent a mechanism of megacolon prevention.

S状結腸捻転症を繰り返した内臓逆位症の1例

An 81-year-old man who had been diagnosed as having situs inversus totalis and had suffered from repeated episodes of sigmoid volvulus was admitted with a history of right upper quadrant abdominal pain. Physical examination showed no evidence of peritoneal irritation. A plain radiograph of the abdomen showed a markedly dilated sigmoid colon with an inverted U-shaped appearance. Abdominal CT showed situs inversus totalis, no free air, no ascites, and a whorled appearance of the sigmoid mesentery, with dilated bowel loops. Based on these findings, the patient was diagnosed as having recurrence of sigmoid volvulus. Colonoscopy performed for repositioning showed converging mucosa signifying the distal point of the torsional obstruction, and a dilated section of the bowel with gas and feces proximal to the obstruction in the sigmoid colon. After endoscopic decompression, colonoscopy showed no evidence of mucosal ischemia. We treated this case successfully as we would have a case of sigmoid volvulus without situs inversus.

Surgical Management of Functional Constipation: Preliminary Report of a New Approach Using a Laparoscopic Sigmoid Resection Combined with a Malone Appendicostomy.

Introduction Functional constipation is a common problem in children. It usually can be managed with laxatives but a small subset of patients develop intolerable cramps and need to be temporarily treated with enemas. The senior author has previously reported: 1) open sigmoid resection as a surgical option, but this did not sufficiently reduce the laxative need, then 2) a transanal approach (with resection of rectosigmoid), but this led to a high rate of soiling due to extensive stretching of the anal canal and loss of the rectal reservoir. The understanding of these procedures' results has led us to use a laparoscopic sigmoid ± left colonic resection with a Malone appendicostomy for these patients, to decrease the laxative requirements, temporarily treat with antegrade flushes, and to reduce postoperative soiling. Methods A single-institution retrospective review (3/2014-9/2015) included patients who failed our laxative protocol, and therefore were considered surgical candidates. Patients with anorectal malformation (ARM), Hirschsprung disease, spina bifida, tethered cord, trisomy 21, cerebral palsy, mitochondrial disease, prior colon resection at other facilities, or those that did not participate in our laxative program were excluded. Demographics, duration of symptoms, prior treatments, postoperative complications, and postoperative bowel regimens were evaluated. Results A total of 6 patients (3 males; median age of 12.5 years) presented with soiling related to constipation and intolerance to laxatives. Four patients failed preoperative cecostomy (done prior to referral to us). An average of 4.7 medication treatments were previously tried. In all, 4 patients had required in-patient disimpactions. Duration of symptoms was 7.5 years (median). The median senna dose was 30 mg (range, 15-150 mg), and all patients had intolerable symptoms or failed to empty their colon, which we considered a failed laxative trial. All had contrast enemas that demonstrated a dilated and/or redundant sigmoid colon, and colonic manometry was abnormal in 4. All patients underwent laparoscopic sigmoid and left colon resection, or only sigmoid resection (a low anterior resection). Two patients had postoperative colitis treated with oral antibiotics. The median follow-up was 52 days (range, 8-304 days). Five patients are on antegrade enemas with plans to convert to laxatives at 6 months, 1 is taking laxatives alone at a 33% lower dosage. Five of six are completely clean, 1 soils occasionally and their daily flush is being adjusted. Conclusion Only a minority of patients with functional constipation are medically unmanageable. This preliminary report shows that laparoscopic colon resection combined with antegrade flushes is an effective surgical technique to treat that group. A laparoscopic approach, guided by contrast enema and colonic manometry, allows for a defined resection of the abnormal segment of colon with the advantages of minimally invasive surgery including allowing for an extensive rectal resection (an improvement over open sigmoid resection) and avoidance of overstretching of the anal canal and removal of the rectal reservoir (an improvement over the transanal approach). Having antegrade access is useful to manage soiling and avoiding cramping from laxatives in the early postoperative period. Although our series is small, we believe that long-term most patients can avoid antegrade flushes and be on no, or a dramatically reduced, laxative dose.

Rare Case of Sigmoid Volvulus Following Single Balloon Enteroscopy

Introduction: Single balloon enteroscopy (SBE) has revolutionized visualization of the small bowel. Common complications include perforation, abdominal pain, and mucosal tears. In this case report, we describe sigmoid volvulus (SV) presenting 48 hours after SBE. Clinical Case: A 69 year-old man received an outpatient SBE for evaluation of small bowel polyps. The procedure lasted 29 minutes and 71 liters of CO2 were used. No therapeutic intervention was performed. Forty-eight hours after discharge, the patient noted severe left lower quadrant pain. His past history was significant for irritable bowel syndrome - diarrhea predominant, appendicitis s/p appendectomy, and inguinal hernia repair. Physical exam showed a soft, distended abdomen with hyperactive bowel sounds and no peritoneal signs. Rectal exam had normal anal sphincter tone without masses. A CT scan revealed a dilated sigmoid colon to 12 cm due to SV. Laboratory values revealed white count of 8.0, creatinine of 0.71, and lactate of 2.7. Flexible sigmoidoscopy for decompression was attempted, but unsuccessful. On hospital day 2, a segmental resection of the sigmoid colon with end colostomy was performed. Intraoperatively, the sigmoid colon was found to be significantly dilated; however, no redundant bowel, long mesentery, or adhesions were noted. The patient was discharged home 5 days after surgery. Discussion: SBE has been shown to be a safe and effective procedure for evaluation of the small bowel. Complication rates in SBE are reported to be similar to double balloon enteroscopy (DBE). Generally, complications are reported in 1% of SBE cases. Of those, the most serious are perforation (1.3-2.7%) and mucosal tears. In this case report, we describe sigmoid volvulus presenting after SBE. Sigmoid volvulus is responsible for 8% of all intestinal obstruction in Western countries, and is particularly common in the elderly. Other predisposing factors include male gender, chronic constipation, redundant bowel/mesentery, and adhesions. Sigmoid volvulus after SBE has not been reported. As this patient's only risk factors were his gender and age, it is unclear if his sigmoid volvulus was a direct complication of the SBE or simply a coincidental occurrence. As balloon assisted enteroscopy becomes a more common method of evaluating the small bowel, physicians should be aware that sigmoid volvulus may be an unexpected but potentially life threatening complication of this procedure.

Perforación estercórea de colon: caso clínico y revisión del tema

Colon perforation has several causes, including stercoral perforation of the colon, which was first described in 1894. Currently, reported cases are fewer than 100. Male patient of 67 years old, treated at Huichapan General Hospital, Hidalgo, Mexico, with abdominal pain, bloating and no bowel movements. He referred being constipated for the last ten years. Imaging revealed an extremely dilated sigmoid colon with fecal matter as well as free gas in the peritoneal cavity. The suspicion of stercoral colonic perforation is established. Exploratory laparotomy was performed immediately, finding a perforation and a hard scybalum protruding in the ascending colon. Colectomy, ileostomy and Hartmann's pouch are performed. After surgery, the condition of the patient worsened and progressed to septic shock and respiratory failure. The patient died four hours after surgery, with the diagnosis of organ failure due to sepsis. Stercoral perforation accounts for 3.2% of all colon perforations and is caused by a rupture of the intestinal wall through direct pressure of a fecaloma on the colon. It occurs especially in patients older than 70 years with severe chronic constipation, weakened and/or are hospitalized with multiple medications and immobilized. Stercoral perforation of the colon is a rare cause of bowel perforation, which should be suspected in patients with a history of chronic constipation, acute abdominal pain, bloating and sepsis, in order to intervene in a timely fashion.