Normal Rectum Research Articles

Penis and Bladder Agenesis in a Living Male Neonate

A full-term newborn presented with ambiguous genitalia. Early prenatal sonography had demonstrated normal amniotic fluid volume. Physical examination revealed an absent phallus, a normal scrotum with bilaterally descended testes and a small skin tag just anterior to the rectum (fig. 1). Urine and meconium were intermittently passed separately from the otherwise normal rectum. Ultrasound demonstrated no bladder distension, a left cystic dysplastic kidney and severe right hydroureteronephrosis. Initial management included placement of a right nephrostomy tube. Despite a 46XY karyotype the neonate was assigned the female gender due to absence of the phallus. Surgical management at 4 days of life included endoscopy of the single perineal opening, bilateral orchiectomy and laparotomy. Exploration was remarkable for absence of the bladder with 2 ureters joining in the midline and inserting as a fibrous cord into the anterior wall of the rectum (fig. 2). Each vas deferens entered the ipsilateral ureter before this confluence. The right kidney was hydronephmtic and the left kidney was dysplastic. Additional findings included a duplicated aorta and bilateral retro-iliac ureters. The internal iliac arteries on both sides were intra-abdominal and joined as a common vessel ventral to the sigmoid colon. Left nephroureterectomy and right cutaneous ureterostomy were performed. Pathological evaluation confirmed a dysplastic left kidney and each vas entering the ipsilateral ureter. The perirectal skin tag consisted of poorly organized erectile tissue. A paucity of spermatogonia and Leydig cells was noted within each gonad.

The Anterior Sagittal Transanorectal Approach: A Modified Approach to 1-Stage Clitoral Vaginoplasty in Severely Masculinized Female Pseudohermaphrodites-Preliminary Results

We present a modified 1-stage clitoral vaginoplasty technique for severely masculinized female pseudohermaphroditism involving an anterior sagittal transanorectal approach with the patient prone after clitoroplasty according to the Passerini-Glazel procedure. An anterior sagittal transanorectal approach with protective colostomy was performed in 2 patients with severely masculinized female pseudohermaphroditism and a normal rectum. The anorectal sphincteric mechanism was divided only in the anterior midline, and the perineal body and rectum were opened in the anterior rectal wall, providing excellent exposure of the urogenital sinus. The vagina was easily and fully separated from the urogenital sinus, the site of vaginal attachment to the urethra was sutured, and anastomosis was created between the vaginal neo-introitus and vagina. The rectum, perineal body and anterior sphincteric mechanism were reconstructed. Cosmetic and anatomical results are satisfactory. The vaginal neo-introitus is located just below the urethral meatus, the clitoris appears almost normal and in the vulvar region a mucous lining is present in the front wall of the perineum between the clitoris and vagina. Convalescence was uneventful. The patients had normal bowel control after colostomy closure and no urinary incontinence. Our modified technique favors easy and safe posterior anastomosis between the vaginal neo-introitus and vagina under direct vision. Furthermore, suturing the vaginal stump is easier than in the original technique, since the approach to the vagina is posterior, not transvesical.

Colonic J-pouch rectal reconstruction--is it really a neorectum?

The aim of this study was to determine whether a colonic J-pouch has similar properties to that of a normal rectum, including recovery of rectoanal coordination. Ten patients with colonic J-pouch-anal anastomosis (anastomotic distance from anal verge, 3.5 (range, 2.0-4.5) cm for low rectal cancer (7 men; mean age, 64.7 (range, 44-76) years) were studied clinically and in the anorectal physiology laboratory at least one year after operation. Results were compared with a series of ten matched patients who underwent high anterior resection for upper rectal carcinoma (anastomotic height, 12.7 (range, 9.5-16) cm). Although results seemed to be slightly better in the group with the rectum preserved, no statistical differences could be found either in functional outcome or anorectal physiology. One-half of the patients with colonic J-pouch (neorectum) had a positive rectoanal inhibitory reflex. Addition of a colon pouch neorectum would appear to improve function to the level of those patients with a high anastomosis and "normal" rectum.

Does the posterior sagittal approach with perirectal dissection impair fecal continence in a normal rectum?

The aim of this study was to determine, using human material and animal experiments, whether the posterior sagittal approach with perirectal dissection (PSAPD) in patients with an intact anorectum is a suitable means of exposure for the correction of complicated anomalies of the genitourinary tract without impairment of fecal continence. Over the last 6 years, the authors have performed PSAPD in seven children with an intact anorectum. At the time of operation, their ages ranged from 8 months to 14 years. All patients showed normal fecal continence at the end of follow-up (averaging 32 months). Only after completion of the study did the authors read that Peña et al had found that PSAPD provoked severe changes in bowel control in dogs. This contradiction prompted the authors to repeat the animal experiments, and they could not reproduce the favorable results obtained in children. This might be explained by the following factors: the surgical dissection used in the dogs was more extensive, anatomic differences between man and dog, the relatively much younger age of the animals (versus the patients), and the shorter follow-up and lack of educability of the dogs. The authors conclude that PSAPD is a suitable approach for selected lesions of the genitourinary tract in children who have a normal rectum and it does not impair fecal continence.

Rectal mucosal electrosensitivity - what is being tested?

The results of rectal mucosal electrosensitivity (RME) testing have been used to support theories regarding the aetiology of both idiopathic constipation and bowel dysfunction following rectopexy. The aim of this study was to assess the validity of tests of RME. Sixty-eight patients, comprising three groups (group 1: 50 patients undergoing assessment in the Anorectal Physiology Unit, group 2: 10 patients with coloanal or ileoanal anastomosis, group 3: 8 patients with a stoma) underwent mucosal electrosensitivity testing, with the threshold stimulus required to elicit sensation being recorded. In addition the RME was measured in groups 1 and 2 when placing the electrode, mounted on a catheter with a central wire, against the anterior, posterior, right and left rectal or neorectal walls. To asses the influence on this test of loss of mucosal contact due to faeces, a further 8 cases with a normal rectum had RME performed with and without a layer of water soaked gauze around the electrode to stimulate faeces and prevent the electrode from making contact with the rectal mucosa. There was marked variance in the sensitivity of the different regions of rectal wall tested (P < 0.001). In group 1 patients the mean sensitivities were: central 36.6 mA, anterior 27.4 mA, posterior 37.9 mA, right 22.3 mA and left 25.6 mA. This circumferential variation suggests that the pelvic floor rather than rectal mucosa was being stimulated. All patients in group 2 had recordable sensitivities, and the mean sensitivity threshold was significantly higher than group 1 patients in the central (P = 0.03), right (P = 0.03) and left (P = 0.007) positions. In group 3 the sensitivity was greater within the stoma at the level of the abdominal wall muscle than intra-abdominally or subcutaneously, again suggesting an extra-colonic origin of the sensation. The sensitivity threshold was significantly greater with the electrode wrapped in gauze (P < 0.01), and loss of mucosal contact was not detected by the EMG machine. Therefore RME testing would seem not to measure mucosal sensitivity, and is probably influenced by the presence of faeces.

Escherichia coli heat-stable enterotoxin receptors. A novel marker for colorectal tumors.

Receptors for Escherichia coli heat-stable toxin (ST) are selectively expressed in membranes of intestinal mucosa cells and colon carcinoma cells in vitro, suggesting their use as a marker for colorectal tumors in vivo. The present studies examined the expression and function of ST receptors in normal human tissues and primary and metastatic colorectal tumors obtained from patients at surgery. Surgical specimens were obtained as follows: from normal colon; from primary adenocarcinomas from all anatomic divisions of the colon and rectum; from gallbladder, kidney, liver, lung, lymph node, ovary, peritoneum, stomach; and from colon carcinomas metastatic to liver, lung, lymph node, ovary, and peritoneum. Membranes prepared from these specimens were assessed for the presence and functional characteristics of ST receptors. ST bound specifically to membranes from each division of normal colon and rectum and all primary and metastatic colorectal tumors examined. The affinity and density of ST receptors were similar in tumors of different grades and from various metastatic sites. ST-receptor interaction was coupled to activation of guanylyl cyclase in all normal samples of colon and rectum and all primary and metastatic colorectal tumors examined. In contrast, neither ST binding nor ST activation of guanylyl cyclase was detected in any extraintestinal tissues examined. Functional ST receptors are expressed in normal colonic tissue and primary and metastatic colorectal tumors but not by extraintestinal tissues in humans. Expression of ST receptors does not vary as a function of the metastatic site or grade of these tumors. Receptors expressed by colorectal tumors retain their characteristic function, with binding of ST coupled to activation of guanylyl cyclase. These studies support the suggestion that ST receptors represent a specific marker for human colorectal tumors that may have use as a target for directing diagnostics and therapeutics to these tumors in vivo.

Distribution of extrinsic enkephalin-containing nerve fibers in the rat rectum and their origin in the major pelvic ganglion

The distribution of nerve fibers containing enkephalin (ENK)-like immunoreactivity was examined in the rectum of aganglionosis rats (AGRs) which completely lack the intramural ganglion cells in the large intestine, and was compared with that of their normal littermates. Furthermore, Met 5-enkephalin-Arg 6-Gly 7-Leu 8 (MEAGL)-like immunoreactive neurons projecting to the rectum were examined using retrograde tracing combined with immunohistochemistry in the major pelvic ganglion of normal male rats. In the intermuscular space of the aganglionic rectum of AGRs, unlike the pattern of the normal intermuscular plexus, moderate numbers of ENK-like-immunoreactive fibers were arranged in an irregular, coarse network; greatly diminished numbers of immunoreactive fibers were found in the submucosa. No ENK-like-immunoreactive fibers were seen in the circular muscle layer and mucosa. In the normal rat rectum, ENK-like-immunoreactive fibers were seen throughout all layers, and immunoreactive nerve cells were found predominantly in the myenteric plexus of colchicine-treated animals. Fluoro-Gold injected into the upper rectum labelled numerous principal ganglion neurons in the major pelvic and inferior mesenteric ganglia. Less than 10% of tracer-labelled neurons were positive for fluorescein immunolabelling of MEAGL in the major pelvic ganglion; no immunoreactive neurons were found in the inferior mesenteric ganglion. In the major pelvic ganglion of the colchicine-treated normal rats, about 5% of principal ganglion neurons were immunoreactive for MEAGL. Comparison of serial paraffin sections of the major pelvic ganglion stained for tyrosine hydroxylase (TH), MEAGL and vasoactive intestinal polypeptide (VIP), respectively, revealed that more than half of MEAGL-like immunoreactive neurons were also positive for TH; there was no case showing co-existence of MEAGL with VIP in the principal neurons. These results indicate that a small number of enkephalin-containing neurons in the major pelvic ganglion project to the rectum, and that more than half of these neurons are postganglionic sympathetic. They may terminate mainly in the myenteric ganglia in the rectum.

Abnormal expression of blood group-associated antigen (BGA) in colon of Hirschsprung's disease

The entire segment of resected colon obtained from 15 patients with Hirschsprung's disease (HD) was examined with conventional mucin histochemistry (PASAB, HID-AB) to investigate the mucin composition and blood group-associated antigens (BGA) (sialosyl-Lea, Lea, Ley, Leb) for detecting mucosal cell differentiation. The BGA Leb were absent in normal distal colon and rectum but present in fetal colon. Immunoreactivity of Leb, which is a marker of undifferentiated crypt cells, was observed through out the crypts in aganglionic colon. Depletion of sulphated and neutral mucin was also a characteristic finding in the aganglionic mucosa. These findings suggest that the colonic mucosa of aganglionic bowel represents persistence of a fetal stage of development. These cellular abnormalities may be a factor in the pathogenesis of enterocolitis complicating HD.

Diversion colitis and involution of the defunctioned anorectum.

To measure the effects of defunction in the anorectum, 12 patients (seven men and five women aged 59 (44-81) years) were studied after the Hartmann operation. The operation was for septic complications of diverticular disease in nine and sigmoid carcinoma in three patients. Physiology studies were undertaken 1 and 3 months after surgery, and diversion colitis was assessed endoscopically and by mucosal biopsy at 3 months. There was no change in anal sphincter function by three months. Proctometrogram studies, however, showed an appreciable decrease in rectal volume in all cases, by a mean of 35% of the 1 month volume. The maximum tolerable volume at 1 month was 157 (111-210) ml and at 3 months 87 (71-145) ml; p < 0.01. There was no change in rectal sensation or compliance. Erythema and granularity without gross erosions or ulceration were found at endoscopy. Histology showed abnormalities in all cases by 3 months. The characteristic features were of a chronic inflammatory cell infiltrate with surface exudate, microscopic erosions, and lymphoid follicular hyperplasia. Crypt abscesses were not a feature at this stage and there was no distortion of crypt architecture. After defunction the previously normal rectum is affected by diversion colitis which, at 3 months, is mild but has characteristics that distinguish the changes from those of inflammatory bowel disease. It is associated with progressive rectal stump involution.

Immunohistochemical study of globotriaosyl ceramide (Gb3) in testicular tumors

Testicular tumor tissues and various normal tissues were examined by immunohistochemical techniques for expression of globotriaosylceramide (Gb3) using anti-Gb3 monoclonal antibody (1A4). In formalin fixed paraffin-embedded specimens (31 cases), Gb3 was positive for every kind of elements of testicular germ cell tumors, especially it's incidence of positive staining were 100% in seminomas (16/16) and embryonal carcinomas (6/6). On the other hand, four cases of testicular malignant lymphoma were all negative for Gb3, and some normal testicle, liver, kidney, pancreas, spleen, ileum and rectum showed very weak reactivity with 1A4. In frozen materials (10 cases), similar incidence of positive staining with that of paraffin-embedded specimens were observed in drying only manner, 4% parafolm-aldehyde fixation following drying and 10 min. of acetone fixation following drying. Incidence of very strong staining in testicular germ cell tumors were as follows, 7/10 in 4% parafolmaldehyde fixation, 6/10 in drying only, 4/10 in 10 min. of acetone fixation and 7/22 in paraffinembedded specimens. Fixation with 30 min. of acetone fixation and 10 min. of 90% ethanol and treatment with 10 min. of chloroform:methanol (2:1, v/v) extremely decreased the reactivity with 1A4, suggesting that Gb3 exists mainly as glycolipid. Gb3 may thus be a useful histological marker for testicular germ cell tumor, and the tissue should be treated with the process of freezing followed by 4% parafolm-aldehyde fixation, drying only or 10 min. of acetone fixation, and formalin fixed paraffin-embedded specimens were also available enough.

Transanorectal approach for the treatment of urogenital sinus: Preliminary report

The treatment of the urogenital sinus with normal rectum still represents a challenge. A perineal approach with or without a skin flap seems to be effective for those patients with a low implantation of the vagina. However, in patients with a high vaginal implantation, this treatment frequently fails to provide a good, functional vagina due to a narrow, strictured vaginal opening. Based on previous experience in the treatment of more than 80 patients with a persistent cloaca, a posterior sagittal transanorectal approach with a protective colostomy was performed in three patients with urogenital sinus and normal rectum. The pelvis was approached through a midsagittal posterior incision; the coccyx was split and the entire anorectal sphincteric mechanism was divided in the midline. The rectum was bivalved in the midline including both posterior and anterior rectal walls. This provided excellent exposure to the urogenital sinus. The vagina was then fully separated from the urogenital sinus (as described in cases of persistent cloacas), and then mobilized and sutured to the perineum. The rectum and sphincteric mechanism were meticulously reconstructed. A midline incision assures the preservation of anorectal innervation, and provides excellent exposure to the pelvis. Anal dilatations are not necessary to maintain a patent and supple anorectal opening because the rectum has two suture lines, one in front of the other. After the colostomy was closed, all patients had appropriate bowel control for their age; two of them are fully continent for urine and the third one still has a suprapubic cystostomy tube waiting for a repair of an additional urethral malformation.

Human gut mucosal mast cells: ultrastructural observations and anatomic variation in mast cell-nerve associations in vivo.

One hundred and seventeen coded intestinal biopsy specimens were examined by electron microscopy. All surgical biopsies were obtained from uninvolved sites of patients with two inflammatory bowel diseases (ulcerative colitis or Crohn's disease) and from patients with preneoplastic and neoplastic diseases (adenocarcinoma, rectal polyp, familial polyposis). Biopsy sites included normal ileum, colon, and rectum as well as conventional ileostomies and continent pouches constructed from the ileum. The data reported here describe the ultrastructural anatomy of human gastrointestinal tract mucosal mast cells in vivo and their anatomic associations with enteric nerves.

Density of lymphoid follicles in the rectum and at the anorectal junction.

To determine the density of mucosal lymphoid follicles in 10 histologically normal rectums, including the anorectal junction, we counted the follicles macroscopically after the specimens were fixed in 10% acetic acid. The mean density in the rectum was 25.6/cm2. The mean density at the anorectal junction was slightly but not significantly higher, at 29.2/cm2. We found no significant change in follicle density with increasing age in specimens from people between the ages of 17 and 90 years.

Fate of the rectum after colectomy and ileostomy for Crohn's colitis

Eighty-four patients had colectomy with ileostomy and oversewing of the rectum for Crohn's colitis. Seventy-two patients were operated on because of intractable disease, colitis in combination with rectal fistulas, and toxic megacolon. The operative mortality was 6 percent, and neither emergency surgery nor treatment with steroids correlated with operative morbidity. After a median 7.7 years of follow-up, 25 ileorectal anastomoses had been undertaken, 16 of which were successful. Twenty-nine protectomies were performed; the resulting 10-year cumulative risk of proctectomy was 50 percent. While the risk of proctectomy was significantly less among patients with a normal rectum at colectomy compared with patients with proctitis, the initial macroscopic degree of proctitis did not correlate with the risk of subsequent proctectomy. The 5-year cumulative ileal resection rate in 29 patients with a rectum in situ but out of circuit was 29 percent. The possibility of a future ileorectal anastomosis should still be considered in patients with proctocolitis.

Lymphoid follicular hyperplasia–a distinctive feature of diversion colitis

Diversion colitis refers to the inflammatory changes that occur in the defunctioned segment of the large intestine following diversion of the faecal stream. We report the histological features in the defunctioned rectums from seven patients: one each with severe constipation and Behçet's disease, two with Crohn's disease with rectal sparing and three with ulcerative colitis. The appearances of diversion colitis in a previously normal rectum are compared with diversion colitis with superimposed inflammatory bowel disease. Lymphoid follicular hyperplasia was found in all cases. This was marked in patients with inflammatory bowel disease, with or without initial rectal involvement. Other changes comprised surface epithelial degeneration and ulceration, mucosal inflammation including crypt abscesses, and crypt branching. Inflammatory and crypt changes were mild, except in ulcerative colitis where changes were marked and resembled those of the proximal colon. Lymphoid hyperplasia is a distinctive feature in diversion colitis. The term follicular proctitis, previously used to indicate chronic ulcerative colitis exclusively, should be re-examined.

Phantom-related phenomena after rectal amputation: prevalence and clinical characteristics

Phantom sensations are well known and almost inevitable sequels to limb amputation, whereas similar phenomena are only rarely described after rectum amputation (phantom rectum). Our study attempted to assess the frequency and character of phantom rectum. All surviving patients (n = 22), who had undergone abdominoperineal surgical resection of the rectum in the period 1980–1986 at our clinic, were interviewed by a standard questionnaire and underwent a physical examination. Sixty-eight per cent of the patients experienced a sensation of a missing rectum (phantom rectum), and in 27% of these or 18% of all patients this sensation was painful (phantom pain). The most common symptoms were sensations of flatus and/or faeces in a normal rectum, phantom flatus or phantom faeces. The phantom pains were described as either pricking and shooting or like haemorrhoids or hard stools that would rupture the rectum. Neither age, sex, preoperative pain, the Duke classification of the tumour nor the healing of the perineal wound seemed related to the likelihood of phantom rectum. The pathophysiological mechanisms underlying phantom-related phenomena following amputation have not yet been elucidated. This study describes a relatively unknown phantom-related clinical entity after amputation and may thus contribute to the understanding of this phenomenon.

Intestinal γ/δ Receptor-Bearing T Lymphocytes in Celiac Disease and Inflammatory Bowel Diseases in Children. Constant Increase in Celiac Disease

We studied the numbers of T-cell receptor alpha/beta- and gamma/delta-bearing lymphocytes in 27 jejunal specimens from 19 celiac patients, 27 rectal and colonic specimens from 14 ulcerative colitis patients and four patients with Crohn's disease, and 24 control specimens. MAb and a three-layer peroxidase staining method were used. Only low numbers of gamma/delta + cells were seen in normal jejunum and rectum of controls, as well as in the specimens of patients with inflammatory bowel diseases. In the lamina propria of celiac patients, the mean number of gamma/delta + cells was significantly higher than in the controls before treatment, during gluten-free diet, and after the gluten challenge. Within the jejunal epithelium, the number of gamma/delta + cells was elevated before and during gluten elimination and after the challenge test. The absolute number of intraepithelial gamma/delta + cells remained constant during gluten elimination and provocation. We infer that the constantly elevated population of gamma/delta + T cells in the epithelium of celiac patients may play an important role in the pathogenesis of celiac disease.

Videoproctographic assessment after restorative proctocolectomy

Videoproctography was performed in 40 patients after restorative proctocolectomy to evaluate pouch emptying, anopouch angle, and pelvic floor movement in relationship to functional outcome. Results were compared between the two different pouch designs tested and a control group of 26 patients who had an intact rectum. There was no difference in emptying between the two pouch designs or compared with the control subjects. Emptying did not influence either the frequency of defecation or patient soiling rate. The presence of an anal stricture was associated with poor emptying in each case in the pouch group. Anorectal angle was no different between the different pouch designs or compared with the control group at rest, during pelvic floor contraction, or attempted defecation. A similar finding was obtained with anorectal angle position and movement during pelvic floor contraction and attempted defecation in both pouch design groups and when compared with normal rectum. This study shows that the only factor that is consistently associated with poor pouch emptying is the presence of an anal stricture.

Histoarchitecture of the ileal pouch after total colectomy

AbstractTotal colectomy and the construction of an ileal pouch reservoir that preserves the patient's continence has become a surgical option for the treatment of patients who undergo total colectomy. By using histologic, electron microscopic, and morphometric methods, the histoarchitecture of the terminal ileal pouch, now functioning as a neorectum, was compared with preoperative biopsies from the normal terminal ileum, transverse colon, and rectum from patients undergoing the construction of a pouch as well as controls. Twelve patients, each of which had undergone a total colectomy with an ileal J‐pouch anal anastomosis in our hospital between 1984 and 1987, were included in the study. Over a three year period a progressive transformation to a colonic type mucosa was observed in the ileal pouch. While total mucosal thickness remained unchanged, the number and size of the crypts increased dramatically, making some specimens indistinguishable from normal colonic mucosa on histologic examination. The number of mucus producing goblet cells and Paneth cells increased, whereas the endocrine cell population demonstrated no change. The possible metabolic and physiologic consequences of this mucosal transformation are discussed.

Intestinal Motility after Ileal Pouch-Anal Anastomosis

Colectomy, mucosal proctectomy and ileal pouch-anal anastomosis, has become the procedure of choice for carefully selected patients with ulcerative colitis requiring surgery. Pathophysiological studies after the operation have led to a better understanding of the mechanisms of continence and to the development of new technology to study anorectal function. Manometric studies of the anal sphincter, ileal pouch and distal ileum have shown that the operation alters the mechanisms of continence. The maximal tolerable volume of distension of an ileal pouch often approximates that of a normal rectum and yet the functional outcome may differ from a well functioning ileorectal anastomosis. Many other factors influence the result of the operation. The influence of the pattern of motility of the proximal and distal small bowel has been evaluated. The ileal pouch accommodation to distension has been correlated to clinical outcome. Scintigraphic techniques were designed to study the relationship between motility, filling and emptying of the ileal reservoirs. Measures designed to slow intestinal transit, increase absorption and reduce stool output are under investigation.