Segment Of Terminal Ileum Research Articles

An exercise in radiologic-pathologic correlation.

Radiologic discovery of a cecal filling defect presents a diagnostic problem that often yields only to careful radiographic analysis, since the history, physical examination, and laboratory studies may be remarkably unhelpful. This reflects the clinical "silence" of the cecum where pain, overt bleeding, and obstruction are late phenomena. Even the findings at the time of surgery may be perplexing. The origin and nature of the filling defect may be inferred radiographically by systematically noting its size, location, and configuration, its effect on the adjacent bowel wall and mucosa, and the presence or absence of cecal spasm. Also important are the presence or absence of appendiceal filling and the appearance of the remainder of the colon and the terminal ileum. Any relevant clinical evidence may then be correlated with these findings. Radiography Radiographic Findings: A barium-enema examination of a middle-aged female (Fig. 1) reveals a sharply circumscribed, ovoid filling defect of the lower medial portion of the cecum. It is narrow at the base and deeply penetrates the cecal lumen. The cecal mucosal folds at the base of the filling defect appear crowded together with a resultant vortical (coiled-spring) appearance. No evidence of mucosal destruction or distortion is noted on multiple films. The appendix does not fill with barium, and there is no evidence of appendicolith. The remainder of the colon and the adjacent loops of ileum appear normal. The mass was inseparable from the cecum fluoroscopically and is unchanged in its relationship to it on the postevacuation film. The cecum shows normal mobility on the various views and is not displaced, but there is slight medial displacement of a 2-cm segment of terminal ileum just below the cecum (Fig. 2). The postevacuation film provided a relatively unobstructed view of the abdomen and pelvis. There was no visible calcification nor direct evidence of a mass in the region of the cecum. Previous abdominal plain films of December 1964 likewise showed no abnormality. Radiographic Analysis: Among the differential considerations on causes of a cecal filling defect are carcinoma, ulcerative colitis, regional enteritis, periappendiceal abscess, lymphoma, amebiasis, tuberculosis, carcinoid tumor, and appendix mucocele. To these may be added lipoma, leiomyoma, intussusception, endometrioma, and inverted appendiceal stump. Cecal carcinoma usually presents intra-luminally as an irregular, often lobulated outline with ill-defined borders. This filling defect has sharp, smooth margins and a definite form and shape. Such findings are usually indicative of an intramural or extrinsic lesion. In addition, the base of a carcinoma is much wider in proportion to its height, and mucosal destruction or distortion is expected. There are no such findings in this case.

Isolated ileal segment as urine conduit after exenteration for pelvic cancer: Further experiences with improved technic

When total cystectomy is necessary during pelvic exenteration to remove cancer in this region, an isolated short segment of terminal ileum functions well as a conduit for the urine. The ureters are anastomosed to the side of the ileal segment, the proximal end of which is closed and the distal end opening on the abdominal wall. The segment spontaneously empties at intervals by peristalsis into a receptacle attached to the abdominal skin around the ileostomy. Careful attention to the technical details of the operation, especially the ureteroileal anastomoses, heralds good results. The hazards of acidosis, hyperazotemia, hyperchloremia, and ascending urinary tract infection, the distressing continuous discharge of a liquid mixture of feces and urine which attends the “wet” colostomy, and the almost certain lethal outcome due to nephropathy are avoided. A personal experience with fifty-seven cases underscores the virtues of an isolated ileal segment with its fewer complications as the best available method of conducting the urine from the ureters to an external appliance when pelvic evisceration is performed.

Radiologic evaluation of the upper urinary tract following ileal loop urinary diversion.

Fifteen years have elapsed since Eugene Bricker first popularized the use of an isolated segment of terminal ileum as a urinary conduit in patients requiring urinary diversion (3). Since that time, nearly 400 urologic patients have undergone urinary diversion by means of the ileal conduit at Barnes Hospital in St. Louis, Mo. The postoperative course in this type of urinary diversion is generally more satisfactory than that following any other form of bladder substitution. Although much has been written in the surgical and urologic journals about the operation itself and the expected postoperative results, little has been published in the radiologic literature (7, 8). For this reason, we are presenting our experience with the procedure, together with illustrative cases to show the usual technics utilized in evaluating the surgical result postoperatively and the more common complications which may follow the operation. Indications Urinary diversion becomes necessary whenever the bladder must be removed in the attempted surgical cure of carcinoma or when the ureters become obstructed by intrinsic or extra-ureteral disease where local surgical repair of the obstructive process is not feasible. Other common indications are advanced bladder neck obstruction in children, congenital vesical exstrophy, and neurogenic bladder secondary to meningomyelocele. Table I shows the number of patients in each category. Description of Procedure A detailed description of the operation appears in Bricker's original communication. Briefly, the ureters are isolated and divided where they cross the brim of the bony pelvis. A suitable segment of terminal ileum is selected. The length of the segment depends on the thickness of the abdominal wall and should be only long enough to bridge the gap between the left ureter and the abdominal skin. Excessive length of the segment will result in poor drainage and stasis and may also contribute to the development of hyperchloremic acidosis. The proximal end of the isolated segment is closed, and the distal end is brought out through a stomal opening prepared in the right lower quadrant of the abdomen. It is extremely important that the surgeon bring the distal end of the segment to the skin, as an inadvertent transposition of the segment will result in retrograde peristalsis, poor drainage of urine, and the ultimate failure of the operation. The closed end of the ileum is then fixed to the posterior peritoneum, and the ureters are anastomosed to the ileum. The urine is subsequently collected in a bag cemented to the abdominal skin. Despite the fact that the operation calls for at least five separate anastomoses and closures, with careful surgical technic, early postoperative complications have been few (1, 2, 6).

Autoregulation of intestinal blood flow

Previous experiments have shown that the arterial vessels of the intestine are responsive to changes in portal venous pressure, with pressure elevation causing arterial constriction. The purpose of the present study was to determine whether these vessels respond in a similar fashion to changes in arterial pressure. In 39 pressure flow studies on segments of terminal ileum, resistance decreased with pressure reduction in 72% of the experiments and increased in 28%. The passive increase in resistance with pressure reduction was seen primarily shortly after the surgical procedure was completed. Thus, it appears that the resistance vessels of the intestine are not ordinarily passively distensible with changes in arterial pressure. As a result of this vascular reaction, the influence of arterial pressure on blood flow is at least partially counteracted. The mechanism of this autoregulation of flow is not a local reflex, a change in interstitial fluid volume, or a change in tone of the intestinal muscle. Changes in concentration of aerobic or anaerobic metabolites, and oxygen tension of the tissues were likewise eliminated. It is concluded that autoregulation of intestinal blood flow is a result of the sensitivity of vascular smooth muscle to change in tension (a myogenic response).

Segmental colitis.

The purpose of this paper is to demonstrate the roentgen features of chronic colitis involving limited portions of the colon. Numerous terms have been used to describe this condition, namely, right-sided ulcerative colitis, regional colitis, Crohn's disease of the colon, segmental colitis. When there is simultaneous involvement of the small bowel, enterocolitis and ileocolitis have been included. Of these various terms, “segmental colitis” has become the most popular. We define segmental colitis as a chronic, non-specific inflammatory process involving a limited portion of the colon. The pathologists at this hospital (Mount Sinai, New York) have reported these cases as ulcerative, resembling universal ulcerative colitis, or granulomatous, akin to regional enteritis. At the present time, we do not consider segmental colitis as a separate disease entity. One hundred and forty-six cases of limited colitis have been studied, exclusive of isolated involvement of the rectum and sigmoid. This report represents a preliminary attempt to distinguish, on a roentgen basis, segmental ulcerative colitis from segmental granulomatous colitis. It should be noted that in many instances this differentiation is impossible. The effort to distinguish the two would appear, however, to be of practical usefulness because of the variations in clinical behavior, prognosis, and treatment. History Diffuse ulcerative colitis was described in 1880 in a textbook of pathology by Wilks and Moxon (1) and there have been a tremendous number of articles on this topic since that time. On the subject of limited colitis, the literature is relatively scanty. From 1890 to 1930, only scattered case reports of localized inflammatory disease of the colon appeared. The hyperplastic or granulomatous nature of the lesion was emphasized, as well as its resemblance to carcinoma and to tuberculosis. In 1930 Bargen and Weber (2) described a group of these cases, emphasizing the lack of involvement of the rectum and sigmoid. To this entity they applied the term “regional migratory chronic ulcerative colitis.” As in diffuse ulcerative colitis, it was noted that a short segment of terminal ileum in continuity with the diseased colon could be involved by “backwash ileitis.” In 1938 Crohn and Berg (3) reported a similar group of cases under the name of “right-sided regional colitis.” These investigators preferred to stress the localization in the right side of the colon. They considered the process, however, to be a form of diffuse ulcerative colitis. Neuman and Dockerty (4) in 1954 described the pathologic alterations, employing the term “regional colitis,” and noted involvement of the distal ileum in 25 per cent of their cases.

Effect of acute elevation of portal venous pressure on mesenteric blood volume, interstitial fluid volume and hemodynamics.

Measurement of blood flow through the portal vein of the dog revealed a reduction of flow and an increase in vascular resistance of the mesenteric bed in proportion to the elevation of portal venous pressure. To obtain further information on this mechanism, studies were performed on segments of terminal ileum with continuous measurement of both weight and flow. These studies demonstrated that the increase of vascular resistance was not dependent upon extrinsic or adrenergic innervation, and did not appear to be secondary to interstitial fluid formation. It is suggested that the response in this bed is due to a local reflex to a myogenic reaction of the resistance vessels to increased transmural pressure.

Preliminary report on the use of ileum as oviduct in the dog

Recent surveys23, 27 show that 30 per cent of infertile women have occluded Fallopian tubes. To restore these oviducts gynecologists have carried out many different procedures.4, 8, 12, 16, 18, 19, 21 These include linear salpingostomy, reconstruction and reimplantation of the oviducts over catheters and tubing of various materials, some native to the patient, such as arteries and veins, others foreign, such as allantoic membrane and polyethylene tube. These operative procedures give a fair rate of anatomic patency but a low incidence of pregnancy.6, 13, 14, 21, 24 One might infer that the operative procedure did not restore the physiologic function. This altered physiologic integrity may be concerned with the reception, fertilization, or transportation of the ovum. The following is a preliminary report of an attempt to replace an oviduct system with an isolated intact segment of terminal ileum.