Dilated Sigmoid Colon Research Articles

Early Diagnosis and Treatment of Stercoral Colitis With an Aggressive Bowel Regimen

Introduction: Stercoral colitis is a rare inflammatory colitis which results from fecal impaction causing increased colonic intraluminal pressure, which may progress to ischemic necrosis, ulcer formation, and colonic perforation. The majority of cases continue to be reported in the surgical literature with late complications of bowel perforation requiring surgical intervention, which is associated with a 35% mortality rate. We present a patient with acute symptoms of increased bowel urgency and frequency who was diagnosed with stercoral colitis and successfully treated with an aggressive bowel regimen, thus avoiding surgery. Case Report: A 92-year-old female with a history of chronic constipation presented with frequent diarrhea associated with pain, pressure, and small blood streaks for a period of 1 week. She had previously discontinued her anticonstipation bowel regimen and was taking Norco after sustaining a fall 3 weeks prior to admission. Abdominal radiograph revealed a large fecal ball in the rectosigmoid colon and CT abdomen showed stercoral colitis with impaction, dilation of the proximal sigmoid colon, and marked rectal wall thickening. Manual disimpaction was unsuccessful and an aggressive bowel regimen consisting of fleet’s enemas, magnesium citrate, mineral oil enema, and oral mineral oil was initiated. After 4 days of treatment there was clinical and radiographic evidence of resolution. Discussion: Stercoral colitis can be fatal and requires prompt treatment. The importance of early recognition is underscored by the high mortality rate associated with late complications reported in the surgical literature. Early diagnosis with CT imaging demonstrates a fecaloma, focal wall thickening of a dilated sigmoid colon and rectum representing edema from ischemia or ulceration, and peri-colonic or peri-rectal fat stranding. The most common site of impaction occurs in the sigmoid and rectosigmoid colon, which, in addition to having a relatively poor blood supply, have the narrowest colonic diameter allowing for higher intraluminal pressure. Ischemic pressure necrosis results when luminal distention increases pressure above bowel wall capillary perfusion pressure. Ulcerations are seen in up to 27% of cases, with 77% occurring in the sigmoid and rectosigmoid colon. The best way to prevent stercoral colitis is to prevent constipation, which is present in approximately 60% of patients with fecal impaction. Early diagnosis of fecal impaction should prompt aggressive bowel cleansing and manual disimpaction, which may reduce pressure and decrease the risk of ulceration.

Undefined

in all patients because of the poor condition of some patients or nonavailability, whenever possible, they may be useful in making an ISK diagnosis by demonstrating a whirl sign created by the twisted ileum and sigmoid colon mesenteries in addition to the dilated sigmoid colon with loss of haustral pattern and dilated ileum loops (1–8). In addition to the whirl sign on CT, Mandal et al. (2), Tamura et al. (4), and Lee et al. (5) reported a medial translocation of the cecum and left colon; Hirano et al. (6) and Hashimoto et al. (7) reported a radial distribution of the bowel and mesenteric vessels; Hirano et al. (6) reported the convergence of stretched and elongated superior and inferior mesenteric vascular structures toward the whirl; and Baheti et al. (8) reported the appearance of a beak in the afferent and effernet limbs of the sigmoid colon. In our opinion, the presence of the whirled ileum and sigmoid mesenteries in the knot in addition to the dilated sigmoid colon and intestinal air-fluid levels on abdominal CT or MRI is highly diagnostic in ISK, and the use these advanced techniques may be useful when this rare clinical entity is suspected, in addition to the preferable use of MRI in pregnant patients (9,10)

Sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer

We report the first case of sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer. The patient is a 75-year-old man who presented with the sudden onset of severe abdominal pain. He had undergone laparoscopic sigmoidectomy for cancer 2 years before presentation. CT scan showed a distended sigmoid colon with a mesenteric twist, or "whirl sign." Colonoscopy showed a mucosal spiral and luminal stenosis with dilated sigmoid colon distally and ischemic mucosa. The diagnosis of ischemic colonic necrosis due to sigmoid volvulus was established. Resection of the necrotic sigmoid colon was performed and a descending colon stoma was created. A long remnant sigmoid colon and chronic constipation may contribute to the development of sigmoid volvulus after laparoscopic sigmoidectomy. Prompt diagnosis is essential for adequate treatment, and colonoscopy aids in the diagnosis of ischemic changes in patients without definitive findings of a gangrenous colon.

Chilaiditi’s Syndrome with Interposed Sigmoid Colon Mimicking Traumatic Pneumoperitoneum

1Department of Internal Medicine; 2Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Correspondence: Dr Chang-Hsien Liu, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan. Telephone 886-2-87927244, fax 886-2-87927245, e-mail cute610627@yahoo.com.tw Received for publication May 3, 2013. Accepted May 6, 2013 Case presentation A 61-year-old man experienced a contusion on the right hypochondrium in a traffic accident. He was immediately taken to the emergency department and presented with severe pain over the contusion site. His surgical history was unremarkable. On arrival, physical examination revealed decreased breathing sounds in the right lower lung area on auscultation. Distention, hypertympanic percussion and local tenderness over the right upper quadrant of abdomen were also observed. A posteroanterior chest radiograph revealed elevation of the right hemidiaphragm with concerning features for subphrenic free air as well as fracture of right fifth to eighth ribs (Figure 1A). A computed tomography scan of the abdomen with coronal reconstruction revealed hepatodiaphragmatic interposition of the dilated sigmoid colon (Figure 1B). No evidence of pneumoperitoneum was identified. Conservative treatment with oxygenation, chest care and pain control was performed. After the medical therapy, the patient was discharged uneventfully.

S.P.61 Recurrent pseudo-obstruction and sigmoid volvulus in Duchenne Muscular Dystrophy: A case report

Abstract Dystrophin is expressed in the smooth muscle of the gastrointestinal tract (GIT). In Duchenne Muscular Dystrophy (DMD) a disruption of protein expression can lead to functional disturbances of the GIT including acute gastric dilatation, gastroparesis and intestinal pseudo-obstruction. We report a case of a 24 year old young man with DMD confirmed by a nonsense mutation of intron 44, who developed sigmoid volvulus requiring multiple surgical interventions. Our patient presented with a long-standing history of abdominal bloating and constipation. These episodes, which were initially attributed to the use of night-time BiPAP, progressed into acute abdominal distension with visible large loop of bowels and peristalsis. He had no preceding history of vomiting or abdominal pain. Abdominal radiography showed a dilated sigmoid colon with features suggestive of volvulus. He had recurrent episodes of pseudo-obstruction over the course of two months, requiring several emergency sigmoidoscopy procedures to decompress obstructed bowel. An abdominal CT scan with contrast confirmed significant pancolonic dilatation with volvulus. A definitive procedure was deemed necessary and he underwent subtotal colectomy with ileostomy and gastrostomy insertion. One week later he developed acute gastric necrosis, requiring total gastrectomy and oesophago-jejunostomy. His post-operative course was aggravated by a peritonitis necessitating a third emergency laparotomy with drainage of the peritoneum. Post-operatively he remained in ICU fully ventilated with a tracheostomy in situ and total parenteral nutrition. Echocardiography showed a moderately impaired systolic function. Our case illustrates that GIT functional disturbances may be serious sequelae in DMD. Non-invasive ventilation and use of steroids can be confounders for underlying GIT dysmotility. Young adults with DMD, who present with a history of abdominal bloating, should be routinely investigated with abdominal radiography.

Role of rectal myomectomy in refractory chronic constipation

To assess the role of diagnostic and therapeutic value of anorectal myectomy in cases of chronic refractory constipation. Twenty-eight patients 11 months to 9 years of age presenting with chronic constipation, with contrast enema showing dilated rectum and sigmoid colon were included in the study. Anorectal myectomy under general anaesthesia was carried out in these selected patients and were followed-up for up to 6 months to 5 years. Clinical improvement was measured by post-operative bowel habits and relief of symptoms. Twenty-two patients improved clinically; partial response in 4 patients, no response in 2 patients. Two patient required further pull through surgery and was found to have transition zone at the recto-sigmoid level. Ten patients had aganglionosis (of which 5 had ganglion cells present in the proximal part of speciment), 7 had normal histology, 7 had hypoganglionosis, 2 had intestinal neuronal dysplasia, one had nerve hypertrophy and one had immature ganglia. Anorectal myectomy is an effective and technically simple procedure in selected patients with chronic refractory constipation, for both diagnostic and therapeutic purpose. Because apart from confirming Hirschsprung's disease, it also therapeutically relieves symptoms in 93% of patients with chronic refractory constipation.

228 Single Balloon Assisted Colonoscopy for Placement of Colonic Manometry Catheters - Initial Single Center Experience in Children Using a Novel Technique

Colonic manometry is being increasingly used in patients with severe constipation to assess colonic motility and to aid in surgical decisions. This procedure involves placement of a manometry catheter in the colon from the anus to the ascending colon. It is imperative, for proper manometric interpretation, to place the catheter without loops in the colon. However, most patients with long standing constipation have a very dilated and redundant sigmoid colon which makes proper placement of the catheter as well as the colonoscopy technically challenging.

Colon Resection For Volvulus Recurrence In Chilaiditi’s Syndrome: Report Of A Case

PURPOSE: The management of sigmoid volvulus remains controversial. The aim of this study was to evaluate the feasibility of treating sigmoid volvulus by using sigmoid resection. We present a case of severe sigmoid volvulus recurrence at seven month after colon detorsion for volvulus in a patient with Chilaiditi’s syndrome who did not respond to medical therapy and required an additional operation by using a single-stage sigmoid resection and anastomosis.METHODS: Routine blood and urine tests were done. Upright abdominal radiograph and CT of abdomen before operation showed a markedly dilated transverse and sigmoid colon. Conservative decompression failed and surgical treatment was applied. Preoperative bowel preparation and prophylactic antibiotics were used. The patient underwent single-stage sigmoid resection with descendo-rectal end-to-side anastomosis.RESULTS: After the operation the patient had abdominal bloating with vomiting and in a period of treatment he passed stool on the 4th day. Postoperative hospital stay was 10 days.CONCLUSION: We suppose that single-stage resection and anastomosis appear to be the treatment of choice in Chilaiditi’s syndrome in patients with sigmoid volvulus.

Sigmoid volvulus.

In sigmoid volvulus (SV), the sigmoid colon wraps around itself and its mesentery. SV 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 SV 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 SV 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-definitive or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful non-operative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.

Tension Gastrothorax-Colothorax Secondary to Traumatic Diaphragmatic Hernia

Traumatic diaphragmatic hernia secondary to diaphragmatic injury is a recognized complication following trauma. It is frequently unrecognized in acute trauma, and delayed presentations with complications are not uncommon.We report the case of a 12-year-old boy presenting in respiratory distress 1 year after blunt abdominal trauma. A chest radiograph demonstrated dilated bowel loops in the left hemithorax mimicking tension pneumothorax. At emergency laparotomy, dilated sigmoid colon was found in the left hemithorax. The hernia was reduced, and a noncongenital diaphragmatic defect was repaired.Although well described in patients with congenital diaphragmatic hernia, tension gastrothorax-colothorax has not been well characterized in traumatic diaphragmatic hernia. We present the second reported pediatric case and discuss the diagnostic workup, operative approach, and postoperative course of this unusual condition.

PTH-007 Percutaneous endoscopic colostomy prevents repeated hospital admission in colonic pseudo-obstruction with or without sigmoid volvulus

Introduction Percutaneous endoscopic colostomy (PEC) for venting and fixation is a treatment option in patients with severe physical and/or mental disability and chronic intestinal pseudo-obstruction/megacolon, who need repeated hospital admissions with acute episodes of pseudo-obstruction with or without sigmoid volvulus. These patients are normally treated by repeated endoscopic decompression but are unfit for major surgery. We present our series of 38 such patients who underwent PEC with a mean follow-up of 10.6 (range 1–79) months. Methods Thirty-eight patients underwent PEC. Mean age was 72.4 (range 40–93) years. One or two PEC tubes were placed in the dilated sigmoid colon for venting and fixation. The tubes were subsequently changed to low-profile ballooned devices which were left in place indefinitely. Patients or carers vented the tubes as necessary to keep the colon decompressed. Data were collected prospectively. Results There were no deaths within 30 days. Two patients underwent Hartmann9s operation after early PEC dislodgement. There were no further hospital admissions for pseudo-obstruction or volvulus in the remaining 36 patients after 10.6 (range 1–79) months including four patients whose PEC device fell out at 8–10 months. Two patients died at 10 and 12 months, respectively, due to peritonitis and 13 patients died of unrelated causes. Conclusion PEC is a relatively safe treatment option in high-risk patients with colonic pseudo-obstruction/megacolon with or without volvulus and prevents further hospital admissions in all patients.

Treatment of Recurrent Sigmoid Volvulus with Percutaneous Endoscopic Sigmoidopexy

Purpose: In the United States, sigmoid volvulus is second only to cancer and diverticulitis as a cause of colonic obstruction. Prompt endoscopic decompression followed by surgical correction has become the accepted treatment method in most patients. There is, however, a small subset of patients in which comorbidities preclude the possibility of surgical intervention. Recurrence rates in these patients after nonoperative reduction are as high as 70%, with a resultant mortality rate of 21%. Percutaneous endoscopic sigmoidopexy has been proposed as a safe and effective treatment option in this population. We present a case of one such patient. Methods: A 93 year old female nursing home patient with a history of advanced Alzheimer's dementia, Parkinson's disease, CHF, PEG tube, and eight previous episodes of sigmoid volvulus within the prior year presented with a two day history of abdominal pain and distention. Abdominal X-ray confirmed the presence of sigmoid volvulus. The patient underwent directly visualized endoscopic reduction of volvulus with no evidence of gangrenous bowel wall or other pathology. As the patient was deemed a poor surgical candidate (ASA score 4), percutaneous endoscopic sigmoidopexy was considered as an alternative therapy. The patient received intensive bowel prep, conscious sedation and premedication with IV antibiotics prior to the procedure. On colonoscopy, a massively dilated rectum and sigmoid colon were noted. An area of the sigmoid with good 1:1 and transillumination was identified as the likely apex of the volvulus. Two 16 French PEG tubes were placed via pull technique per rectum and confirmed endoscopically at 40 cm and 55 cm from the anal verge. There were no immediate complications noted. Results: Diet was advanced after two days. The patient remained afebrile, and was subsequently transferred back to her nursing home with instructions on tube maintenance. No further episodes of confirmed revolvulus have occurred 12 months post procedure. Conclusion: A small number of reports of percutaneous endoscopic sigmoidopexy have appeared in the literature, most notably from the U.K., where the National Health Service has issued guidelines for its use in the treatment of sigmoid volvulus. To our knowledge, PES use has only been reported once prior in the United States. As surgical correction is the accepted modality in the majority of patients, PES is suggested as an alternative to expectant management in patients too ill to undergo general anesthesia or surgical intervention. As so few cases have thus been reported, many questions pertaining to methodology and outcomes must be answered prior to this procedure becoming a well accepted tool in the treatment of sigmoid volvulus.

Seromuscular Tear of the Sigmoid Colon in the Absence of Trauma: A Case Report

A 16-year-old adolescent boy was admitted to our hospital with severe lower abdominal pain and was found to have peritonitis, probably caused by acute appendicitis. At laparotomy, we found a paper-thin, dilated sigmoid colon; the seromuscular layer on the antimesenteric side was torn, and the untorn mucosa showed a pinpoint perforation. The seromuscular defect had spread circumferentially to involve the entire circumference of the colon wall. We performed sigmoidectomy, and the patient recovered uneventfully. This case showed many similarities, both in terms of the macroscopic and pathological findings, to seromuscular tear, an entity specifically associated with seatbelt use. This case is noteworthy because seromuscular tear-like lesions of the colon without a history of trauma has not previously been reported.

Gastrointestinal: Fecaloma in a dilated sigmoid colon

Gastrointestinal: Fecaloma in a dilated sigmoid colon

Sigmoid volvulus and unexpected death in the elderly

An 84-year-old female who was found unexpectedly dead at her home was shown at autopsy to have a massively dilated sigmoid colon with twisting of the lower colon on an unusually long mesentery. The volvulus had caused mechanical obstruction of the bowel with critical reduction of the blood supply resulting in intestinal infarction. Death was due to ischaemic necrosis of the lower large intestine with significant fluid and electrolyte sequestration within the bowel lumen, associated with disseminated sepsis. Gastrointestinal disorders that may result in unexpected death are uncommon in adults and may present atypically in the elderly. The diagnosis of unexpected death due to an infarcted sigmoid volvulus may not be established until an autopsy has been undertaken.

Intestinal neuronal dysplasia: Results of treatment in 33 patients

Purpose: Intestinal neuronal dysplasia (IND) is a disease of the enteric nervous system, which clinically resembles Hirschsprung's disease. The authors reviewed their experience of IND over an 8-year period. Methods: Between 1992 and 1999, 418 patients underwent rectal suction biopsy for persistent constipation. Thirty-three (7.8%) patients had histologic evidence of IND. There were 26 boys and 7 girls (age range, 1 week to 10 years). The diagnosis of IND was based on the presence of hyperganglionosis of the submucous plexus and giant ganglia and at least one of the following features in rectal biopsies: (1) ectopic ganglia, (2) increased acetylcholinesterase (AChE) activity in the lamina propria, and (3) increased AChE nerve fibers around the submucosal blood vessels. All patients were started on laxatives with or without enemas after the diagnosis was made. Patients have been followed up from 1 to 8 years (mean, 2.4 years). Results: Twenty-one (64%) patients had a good response to conservative management and currently have normal bowel habits. Twelve patients (36%) underwent internal sphincter myectomy after failed conservative management. Seven of these patients now have normal bowel habits. Two patients are able to stay clean with regular enemas. Three patients who continued to have persistent constipation after myectomy and underwent resection of redundant and dilated sigmoid colon now have normal bowel habits. Conclusion: The majority of patients with IND can be treated successfully with conservative treatment. J Pediatr Surg 36:777-779. Copyright © 2001 by W.B. Saunders Company.

Internal anal sphincter achalasia: Outcome after internal sphincter myectomy

Background: Internal anal sphincter achalasia (IASA), also referred to as ultrashort segment Hirschsprung's disease (HD), is a clinical condition with presentation similar to HD, but with the presence of ganglion cells on rectal biopsy. The diagnosis of IASA is made on anorectal manometry, which shows the absence of rectosphincteric reflex on rectal balloon inflation. Altered intramuscular innervation has been reported in IASA. The purpose of this study was to review the outcome after internal sphincter myectomy in patients with IASA. Methods: Fifteen consecutive patients (age range, 2 years to 12 years) with IASA underwent posterior internal sphincter myectomy. All patients presented with severe constipation with or without soiling. The diagnosis of IASA was made by anorectal manometry. HD was excluded in these cases by the presence of ganglion cells and normal acetylcholinesterase activity on suction rectal biopsies. Internal sphincter (IS) specimens were examined using immunohistochemistry for the general neuronal marker PGP 9.5 and synapsin 1 (a presynaptic marker) and using general histochemistry for NADPH-diaphorase. All patients underwent follow-up for periods from 2 years to 6 years. Results: PGP 9.5, synapsin 1 and NADPH-diaphorase positive nerve fibers were either absent or markedly reduced in IASA specimens compared with controls, confirming previous reports of defective intramuscular innervation in IASA. At the time of follow-up, 7 patients have regular bowel motions and are not on any laxatives. Six patients have normal bowel habits but are on small doses of laxatives. One patient is able to stay clean with regular enema regimen. One patient required resection of dilated and redundant sigmoid colon and now has normal bowel habits with laxatives. Conclusion: The majority of patients with internal anal sphincter achalasia can be treated successfully by internal sphincter myectomy. J Pediatr Surg 36:736-738. Copyright © 2001 by W.B. Saunders Company.

The northern exposure sign: a newly described finding in sigmoid volvulus.

Previous studies of sigmoid volvulus have focused on the migration and dilatation of the sigmoid with respect to both fixed and mobile landmarks in the abdomen. None has specifically referred to the relationship of this colonic segment to the more proximal large intestine. We analyzed findings on abdominal radiographs, all of which had been obtained with the patient supine, of sigmoid volvulus, with particular attention to the juxtaposition of the sigmoid colon with the transverse colon. The abdominal radiographs of 30 patients with clinically confirmed sigmoid volvulus were obtained from the teaching files of four hospitals and were retrospectively reviewed. These radiographs were compared with abdominal radiographs of 28 individuals, each of whom had a dilated colon but not sigmoid volvulus. All radiographs had been obtained with the patient in the supine position. The transverse colon was identified in 26 of the 30 patients with sigmoid volvulus. In each of these 26 patients, the sigmoid colon was cephalad to the transverse colon. Of the patients in the control group, the transverse colon was identified in 24 of the 28 patients. In none of these control group patients did the sigmoid colon extend rostral to the transverse colon. Thus, this sign had a sensitivity of 86% and a specificity of 100%. A dilated sigmoid colon that ascends cephalad to the transverse colon is a newly described and accurate finding of sigmoid volvulus on abdominal radiographs obtained with the patient supine.

ADULT CHRONIC IDIOPATHIC PSEUDO-ILEUS OF THE LARGE INTESTINE -A REPORT OF AN OPERATED CASE-

A recently operated case of chronic idiopathic pneudo-ileus in an adult is reported with some bibliographical comments. A 27-year-old man who had had no abnormal bowel movements in his childhood had been taking cathartics for constipation and abdominal distention for these 15 years. And the patients was seen at the hospital because constipation was aggravated and his bowel movements became once a month. On admission the abdomen remarkably distended and abdominal x-ray film and CT revealed the dilated sigmoid colon with the diameter to 22cm and a large quantity of coprostasis. Barium enema study revealed no narrow segment in the rectum and a colonoscopic fiber visualized an infant's head sized coprolith. Rectal biopsy demonstrated the presence of ganglion cells. From these findings, the diagnosis of chronic idiopathic pseudo-ileus of the large intestine was made and an operation was performed. Upon laparotomy, a significant dilatation of the colon with maximum diameter of 35cm extending about 50cm in length from the turning point of peritoneum to descending colon was confirmed. An excision of the intestine by 50cm starting at 5cm oral side from the peritoneal turning point was performed, with an end-to-end anastomosis. Histo-pathologically, a mild degeneration in ganglion cells was noted. Postoperative course was uneventful. As of 1.5 years after the operation, he has bowel movements on an once-a day basis and the abdominal distention disappeared.

A CASE OF ILEOSIGMOID KNOT FOLLOWING A GASTRECTOMY

We experienced a case of ileosigmoid knot following a gastrectomy. A 69-year-old man was seen at the hospital because of severe abdominal pain when he was already associated with severe peritoneal signs. There was a previous history of undergoing a gast rectomy for a gastric cancer. Abdominal Xp on left side decubitus revealed air fluid level formation in the duodenum and sigmoid colon. Abdominal CT scan showed a dilated sigmoid colon. Since the abdominal pain was so severe, an emergency operation was performed with a diagnosis of ileus combined intestinal necrosis. The small intestine involving about 1m became red in color and edematous. The small intestine was strangulated by the sigmod colon like it was wrapped due to counterclockwise volvulus of the sigmoid colon. When the colon was turned clockwise, the strangulation was relieved and then the circulation to the sigmoid colon and small in testine was restored. Both the colon and intestine were not resected. The clinical course was uneventful and the patient was discharged from the hospital on 21 st hospital day. Mechanisms of onset of ileosigmoid knot in clude an ingestion of large volume of foods in an empty stomach. In gast rectomized patients, the food retension ability of the stomach decreased and a large volume of food is liable to flow in the intestine at once that might cause the disease in this case.