Stool Impaction Research Articles

The Effect of the Flint Water Crisis Secondary to Increased Lead Levels in Drinking Water on Constipation in Children in the City of Flint, Michigan, USA.

Introduction Constipation is a common condition in children, affecting almost one-third of the population at some point in childhood across the world. Functional constipation is the most common cause, with no clear etiology. From April 25, 2014, through October 16, 2015, the water source for the city of Flint residents was untreated Flint River water, which resulted in lead-contaminated drinking water. Lead poisoning has been associated with constipation and has multisystem sequelae, including neurological, muscular, and hematological impacts. Children may be especially vulnerable to this with their higher water intake-to-body weight ratio. There has been no previous study examining the possible relationship between the Flint water crisis and constipation in children. In our study, we aimed to see if the increased lead level in the water had any effect on constipation in children in Flint. Methods We included all children seen and diagnosed with constipation at Hurley Medical Center's Pediatric Gastrointestinal (GI) Clinic. We included only children seen in 2013 (pre-water crisis) and 2017 (post-water crisis). Children with chronic neurologic disorders, celiac disease, hypothyroidism, diabetes, Hirschsprung's disease, short bowel syndrome, and gastrointestinal surgeries were excluded. We looked at the age of presentation, associated symptoms, medications used, need for hospital admission or emergency department (ED) visits, and improvements at follow-up. Results A total of 79 patients were included in the study. There were 29 patients from 2013 and 50 patients from 2017 (post-lead exposure period). The rate of constipation referrals to the GI clinic for the Flint population of children was significantly higher in 2017 (p=0.001). The most common associated symptom was abdominal pain in both groups. Straining was more prominent in the 2017 group (60%) compared to the 2013 group (34.5%, p=0.029). There was no clinical or statistically significant difference between the groups noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history ofurinary tract infection (UTI), abdominal distention, or stool impaction. Conclusions The number of patients referred to Hurley's Pediatric GI Clinic for constipation increased after the lead water crisis in Flint. Moreover, straining has significantly increased in post-lead exposure compared to pre-lead exposure. There was no clinical or statistically significant difference noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of UTI, abdominal distention, or stool impaction between both groups. A larger study would need to be done to confirm these findings, rule out other cofactors, and look into minerals in water and their effect on intestine innervations.

Endoscopic treatment for appendiceal intussusception due to barium stool impaction that mimics a submucosal tumor

Endoscopic treatment for appendiceal intussusception due to barium stool impaction that mimics a submucosal tumor

Self-expanding metal stent insertion by colorectal surgeons using a two-person approach colonoscopy without fluoroscopic monitoring in the management of acute colorectal obstruction: a 14-year experience

BackgroundPlacement of a self-expanding metal stent (SEMS) in patients presenting with an acute colorectal obstruction (ACO) may obviate emergency surgery (ES), potentially effectively palliating incurable tumors, acting as a bridge to surgery (BTS) in patients with operable or potentially operable tumors and achieving effective decompression of other ACO. We present our experience with SEMS insertion by colorectal surgeons without fluoroscopic monitoring for ACO especially for acute malignant colorectal obstruction (AMCO) for nearly a 14-year period (2007–2020).AimTo explore the safety and effectiveness of SEMS insertion in the management of ACO by colorectal surgeons using a two-person approach colonoscopy without fluoroscopic monitoring.MethodsWe reviewed the medical records of patients retrospectively to identify all patients presenting to our unit with ACO especially with AMCO who had stenting carried out to achieve colonic decompression. All 434 procedures were performed by colorectal surgeons using a two-person approach colonoscopy without fluoroscopic monitoring.ResultsThe overall technique success rate and clinic success rate by SEMS insertion were 428/434 (98.6%) and 412/434 (94.9%). The overall incidence of complications by SEMS insertion was 19/434 (4.4%). The complications included clinical perforation (6/434, 1.4%); stent migration (2/434, 0.5%), 1 of which re-stent; stent detachment (fell off) (3/434, 0.7%), none of them with re-stent; stool impaction (6/434, 1.4%), 1 of which re-stent; and abdominal or anal pain (2/434, 0.5%). There was no hemorrhage in any of the 434 patients.ConclusionsSEMS insertion is a relatively safe and effective technique for colonic decompression in dealing with ACO as either a BTS or as a palliative measure. It is also a solution to other causes of ACO such as recurrent tumor, benign diseases, or extra-luminal compression. Therefore, ES was largely avoided.

S1762 An Atypical Presentation of Fulminant Clostridioides difficile Colitis Without Diarrhea

INTRODUCTION: Clostridioides difficile infection (CDI) occurs mostly after antibiotics use and presents almost invariably with watery diarrhea. Here, we described an unusual presentation of fulminant CDI in a middle aged woman who was admitted with altered mental status and ileus but no diarrhea. CASE DESCRIPTION/METHODS: A 62-year-old woman with a history of schizophrenia was admitted to inpatient psychiatry for treatment of schizophrenia. On hospital day 47, she was found to be severely somnolent with fecal incontinence. Vital signs were notable for tachycardia and fevers. Physical exam was remarkable for abdominal distension, tympany with hypoactive bowel sounds, and diffuse abdominal tenderness. Laboratory revealed marked leukocytosis of white blood cells (WBC) 51 × 109 cells/L, lactate 3.66 mg/dL, and acute kidney injury with creatinine 1.4 mg/dL. Abdomen and pelvis CT showed proctocolitis and distension of rectum and left colon along with significant stool burden. The patient was initially started on broad spectrum antibiotics for severe sepsis of unknown origin however without significant improvement. She was managed for constipation with oral bowel regimen, tap water enemas, suppositories, and manual disimpactions. Given persistent leukocytosis and overflow diarrhea, stool C. difficile toxin was checked and resulted positive. The patient was subsequently treated for fulminant CDI with oral vancomycin, vancomycin enemas and intravenous metronidazole. After the 14-day course of antibiotics, her abdominal pain and distension resolved and leukocyte count normalized. DISCUSSION: The most common symptom of CDI is watery diarrhea which is often associated with abdominal pain, fever, and leukocytosis. Unique features in our case include lack of diarrhea, a significantly high WBC count and no history of recent antibiotics use. The abdominal pain and distention were attributed to stool impaction. Persistent high WBC, minimal response to bowel regimen, and ileus led to further investigation with C. difficile stool test in our patient. Symptoms resolved after proper treatment of CDI. It was reported that CDI can present acutely as ileus with constipation and absence of diarrhea [1]. This is due to pooling of secretions in dilated and atonic colon. These patients are at high risk to progress rapidly to toxic megacolon and perforation if not treated promptly. CDI should be considered in the context of unexplained severe sepsis with high WBC even without diarrhea.

S3391 Life-Threatening Complication of Chronic Constipation in a Young Patient

INTRODUCTION: Bowel Perforation secondary to stool impaction is a rare entity which has amortality rate of 32-57%. It has Predilection to age 22-85. Risk factors include chronic constipation, NSAIDs, narcotics, antacids, steroids, antidepressants and antipsychotics. Stercoral perforation results from compression of colonic mucosaby a hard fecaloma causing mucosal ischaemia on antimesenteric border withulceration and perforation. CASE DESCRIPTION/METHODS: A 41Year Old Female with PMH of Bipolar disorder, Hypothyroid, HTN, substanceabuse, End Stage Kidney Disease presented with diffuse severe abdominal pain for 2 days. She had bowel enema done one day prior to her presentation. Pain was 10/10 intensity associated with nausea and dizziness. Vitals Pulse rate 115/min, Respiratory rate 22/min, Blood pressure 90/54mmHg, Temperature 98.5F. Her Home medications included Methadone, Quetiapine, Trazodone, Clonazepam, Docusate, Levothyroxine.On examination, abdomen was diffusely tender with signs of peritonitis. Labs WBC: 3.80, AST/ALT 1277/989, Alkaline phosphatase 380, Total bilirubin 2.0. Hepatitis panel negative. Abdominal CT showed chronic obstruction with bowelperforation of redundant sigmoid colon and massively dilated colon with full of stool. Pt was immediately taken to surgery after initial resuscitation and antibiotics. Pt had left Hemicolectomy with primary anastomosis and drain placedin the paracolic gutter. Intraoperatively she was found to have ruptured proximaldescending colon secondary to rock hard stools with generalized fecal peritonitis and pathology report showed colonic transmural Necrosis. She was transferred toICU due to septic shock from Enterococcus faecalis bacteremia started on Zyvox.Patient went into cardiac arrest. Despite aggressive management, unfortunately Pt did not survive. DISCUSSION: Due to widespread use of opioids, antidepressants and antipsychotics earlyrecognition and proper management of constipation is crucial to prevent mortality. Only 10% of individuals are correctly diagnosed and managed properly. Our Pt was taking antipsychotics, antidepressants in addition to Methadone. This resulted in constipation due to disturbances with the migrating myoelectriccomplex causing delay in fecal transit time. Avoiding enema in a Pt like this would be a crucial step as the mucosa is very fragile to cause perforation easily. Frequent monitoring and proper management of constipation could save many young lives.Figure 1Figure 2

Usability and safety of the new 5 French air-charged catheter for performing urodynamic studies on pediatric patients.

To assess the performance and safety of the T-DOC® 5 French air-charged urodynamic catheters in pediatric patients and obtain feedback from providers related to usability performance. Patients ages 12 years and younger undergoing urodynamics were prospectively recruited from two institutions. The T-DOC® 5 French air-charged catheters were used. Issues with catheter placement, adverse events (AEs), and pain scores were assessed. A follow-up telephone call was made to assess for post-urodynamic AEs. Providers completed a clinical user questionnaire. Likert scale was used (1 = most negative and 5 = most positive response) and reported in mean (range). A total of 28 patients completed the study. The mean age was 55 months (5-130) (10 females, 18 males). One problem was noted with the insertion of an abdominal catheter, secondary to stool impaction. Catheters stayed in place on all subjects, except for one related to patient hyperactivity. There were no AEs during the studies. In total four reported post-urodynamics AEs (one hematochezia, three dysuria). Among nine patients, pain level on the bladder and abdominal insertion was 3.6/10 (0-10) and 3.1/10 (0-10). Five providers completed the questionnaire. The overall ease of use was rated 4.3/5 (3-5). The ease of insertion was 4.1/5 (2-5) and set-up/clean-up time was 4.4/5 (3-5). Tracing stability, subtraction accuracy, and artifact sensitivity were all perceived favorably (respectively 4.8/5 [4-5], 4.6/5 [4-5], and 4.4/5 [4-5]). The T-DOC® 5 French air-charged catheter was considered safe and effective in pediatric patients. No AEs occurred during the studies. Providers, using the catheters, reported favorably on catheter usage.

Getting Ready for Certification: Assessing Principles of Continence.

Getting Ready for Certification: Assessing Principles of Continence.

Primary care approach to urinary incontinence in the elderly

Urinary incontinence, which is the involuntary leakage of urine, is very common in the elderly. Temporally, incontinence can appear suddenly (transient), or be chronic in nature (established). Transient incontinence is usually due to the appearance of a new identifiable problem, the causes are embodied in the mnemonic DIAPPERS: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excessive urine, Restricted mobility, Stool impaction. Established Incontinence is one that persists even after correction of precipitating factors, or, lack of identifiable factors. The types are: stress, urge, and overflow, mixed, and functional. Stress incontinence: A weakened pelvic floor in females, leads to prolapsed pelvic organs, causing sphincter dysfunction. The role of pelvic floor exercises (Kegels exercises) and newer surgical interventions is discussed. Urge incontinence: The disturbance in cortical control of the pontine centers of micturition is highlighted. The use of anti-muscarinic agents, sympathetic receptor blockers, and agonists is explained. Overflow incontinence: The role of removing obstruction to urine flow, or catheterization in atonic bladders is discussed.

Colonic duplication presenting as a huge abdominal mass in an adult female

IntroductionDuplications of the alimentary tract are a rare congenital malformation. Most of the cases are symptomatic and diagnosed before 2 years of age. Here, we report a young female presented with a huge abdominal mass, and colonic duplication was confirmed during laparotomy.Case presentationA 29-year-old female had chronic constipation treated with laxative agents. She presented to the emergency room with abdominal cramping for 3 days, accompanied with intermittent fever and vomiting. A huge movable abdominal mass was noted during physical examination. Computerized tomography showed a long segmental dilated bowel lumen with stool impaction and bowel wall thickening of the dilated lumen in the left abdomen, highly suggestive of a long tubular colon duplication. The patient underwent subtotal colectomy. Specimen subsequently confirmed the diagnosis for colonic duplication from cecum to sigmoid colon, and the duplicated colon was found on the antimesenteric side of the native colon. She had a stable postoperative course and was discharged 9 days later.DiscussionDuplications of the alimentary tract are a rare congenital anomaly. Colonic duplication is an even more unusual malformation of this type. It can be classified into cystic or tubular type according to the gross morphology and may or may not be associated with other congenital anomalies. Most common presentation includes abdominal distention, refractory constipation, and bowel obstruction like many other colorectal conditions. Thus, its indistinct symptoms make it difficult to be diagnosed preoperatively. The recommended treatment is surgical resection of the duplicated lumen along with the attached native colon.

3154 Severe Shock as the Initial Presentation of Inflammatory Bowel Disease Unclassified

INTRODUCTION: Age dependent immune modulation plays a major role in the late uncovering of inflammatory bowel disease (IBD). 1/3 of IBD occurs in elderly, yet the diagnosis is delayed by 6 years on average when compared to younger peers who have a 2-year delay. Subtle and unconventional symptoms plus comorbidities play a major role in this. CASE DESCRIPTION/METHODS: A 61-year-old veterinarian female with a long-standing history of constipation presented with acute sharp abdominal pain associated with bloating, nausea and non-bilious vomiting. Vital signs were within the normal range. Physical examination showed a slender female in mild distress, with a soft but distended abdomen that was tender to palpation mainly in the left lower quadrant. Pertinent laboratory tests showed bands 24%, WBC 7 × 103/µL, platelets 47103/µL, lactic acid 4.6 mmol/L, and alkaline phosphatase 216 IU/L. A computed tomography (CT) of the abdomen showed segmental narrowing of the body of the stomach and stool impaction. She was admitted for observation for possible early sepsis; over the course of the next 6 hours she developed severe diarrhea and shock and required admission to the ICU where she was treated empirically for a gastrointestinal infection. She was worked up extensively, but the only significant finding was a positive serum Salmonella IgM. She improved with medical management and eventually antibiotics were deescalated, she completed a 10-day course; however, diarrhea persisted and eventually became bloody. Given her history of chronic constipation the possibility of Celiac disease was entertained but work up was negative. Sigmoidoscopy with biopsy was suggestive of ischemic colitis. The hematochezia resolved by itself and apart from the ongoing diarrhea she was doing well; she was discharged home. At follow up 2 months later she was back to her baseline constipation, her calprotectin level was found to be high and upper and lower endoscopy with biopsies showed minimal active chronic colitis concerning for idiopathic IBD. DISCUSSION: The products of genetic mutations related to IBD are involved in antigenic recognition and the modulation of humoral and cell-mediated immunity, at times this leads to loss of self-tolerance, normal flora tolerance or tolerance to antigens that are present at low concentrations or in immune privileged locations and this event is now considered the trigger that unleashes IBD.

Developing Sigmoid Volvulus after Medical Disimpaction of a Patient with Stool Impaction: A Case Report

Developing Sigmoid Volvulus after Medical Disimpaction of a Patient with Stool Impaction: A Case Report

Revision Surgery in the Management of Anorectal Malformations: Experience from a Tertiary Center of India.

Aim and Objectives:Despite the significant advancements in the management of anorectal malformations (ARMs), there are various surgical and functional complications reported. Complications are closely related with the surgical techniques adopted and the types of malformations. In this article, we present our experiences with ARM patients who required reoperation after unsuccessful previous surgeries or who had developed complications related to the previous surgical techniques.Materials and Methods:We retrospectively reviewed clinical and electronic records of all the patients with ARM who were operated for ARMs in our institute from June 2010 to May 2016. All ARM patients who needed reoperation were included in the study. These patients were previously operated outside our institute and referred to us with ongoing problems of constipation, stool impaction with overflow incontinence, perineal soiling, and difficult urination.Results:There were 31 patients (M:F = 2.1:1) of ARM, reoperated for 38 indications during the above-mentioned period. Five patients had more than one problem. Presentation included neoanal stenosis (11), complete obliteration of neoanus (2), malpositioned neoanus (2), persistent/recurrent rectourethral fistula (3), iatrogenic rectovaginal fistula (4), rectal prolapse (5), large widened neoanus with soiling (2), and urethral stricture (2), which required revision interventions. Six patients had megarectum. All patients showed improvement in their symptoms after revision surgery, but 10 (41.7%) patients required further regular bowel management program (BMP) to avoid the soiling and constipation. Fourteen (58.3%) patients stayed clean without regular BMP.Conclusion:All these complications had clear explanations and are well described in the literature. Revision surgery in such patients had fair outcome, but some sort of BMP was required. Both posterior sagittal anorectoplasty and anterior sagittal anorectoplasty are excellent techniques for revision surgery with few simple modifications.

The Problem of Polypharmacy in Female Patients with Overactive Bladders - Cross-Sectional Study in a Specialist Outpatient Department.

Background: The consumption of certain drugs can cause urinary incontinence. The aim of this study is to determine the frequency of consumption of drugs that can favour incontinence, the incidence of polypharmacy and the incidence of potentially dangerous drug-drug interactions in female patients suffering from overactive bladder (OAB) who presented to a urogynaecological outpatient department. Methods: We undertook a retrospective case series study. The data from 100 female patients who attended the urogynaecological outpatient department of the Vienna General Hospital [VGH; Allgemeinen Krankenhauses Wien (AKH)] in the period from 20. 07. 2010 to 30. 08. 2011 were evaluated. The patients suffered either from an OAB or mixed incontinence with predominantly urge components. Among other factors, we were interested in the drugs taken for longer periods of time as well as the general and the urogynaecological case histories. 15 parameters were recorded: age, BMI, menopausal status, parity, pelvic organ prolapse, DIAPPERS criteria (delirium, infection (urinary), atrophic urethritis and vaginitis, pharmaceuticals, psychological disorders (especially depression), excessive urine output, restricted mobility, stool impaction), drug side effects and drug-drug interactions. A descriptive statistical analysis was performed. The drugs were checked with the help of a drug information system (Intranet-KH [V 6.0]). Of particular interest was the consumption of drugs that could favour urinary incontinence as an adverse side effect. In addition the frequency of polypharmacy and the frequency of potentially health-threatening drug combinations were registered. Results: 57 % of the patients consumed at least one drug that could reinforce urinary incontinence. The frequency of polypharmacy was 38 %. In 45 % of the patients the possibility for health-damaging interactions existed as a result of the consumed drugs. Conclusion: The frequencies of consumption of drugs that can favour urinary incontinence and of polypharmacy are high among the patients who attend a specialist outpatient department for urinary incontinence. This emphasises the importance of a complete drug history in the diagnostic work-up for urinary incontinence.

A Painful Groin Pseudotumor Mimicked an Incarcerated Hernia

Incarcerated inguinal hernia is one of the emergency operations for delay diagnosis may cause serious dreadful effects such as bowel obstruction, bacterial translocation with sepsis, intestinal wall necrosis, bowel perforation, or even death. On the other hand, inflammatory pseudotumors (IPTs) were first described by Brunn, but their cause remains unknown. These benign lesions are common in children and young adults, but they can also occur in elderly adults. An 88-year-old Chinese man was referred to our hospital with a painful mass in his right inguinal region for 3 days. The patient complained about abdominal fullness, poor appetite, and right groin painful and an enlarged lesion in his groin site since five days ago. Physical examination revealed a tender, painful, untouchable, and nonpulsatile mass lesion in the right groin area. Non-specific bowel gas and stool impaction in the KUB. Ultrasound and color Doppler images showed a laminated and well-defined mass on the right inguinal region with a hypoechoic center without blood flow signals and increased peripheral vascularity, which was similar to a bowel loop through the inner ring into the inguinal canal. Computed tomography revealed a soft tissue mass-like lesion in right inguinal area. We performed an emergent exploratory laparotomy under a tentative diagnosis of an incarcerated hernia, but just found a mass in the hernia sac during the operation. Histopathologic examination showed typical findings of the IPT. The patient was followed for 6 months without evidence of local recurrence or distant metastasis. As it is nearly impossible to make a correct judgment prior to operation, surgical resection is usually required for diagnosing IPTs.

Management of ureteral obstruction with daVinci laparoscopic surgery

Management of ureteral obstruction with daVinci laparoscopic surgery

Recommandations concernant l’incontinence urinaire de la personne âgée : construction et validation de l’algorithme décisionnel GRAPPPA

Provide guidelines presented as an algorithm for practical evaluation and first line therapy of urinary incontinence in elderly. Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 40 experts quoting proposals, subsequently reviewed by an independent group of multidisciplinary experts (urologist, general practitioner, neurologist, gynecologist, geriatrist, specialist in physical medicine and rehabilitation). By means of 3 rounds of interrogation of the expert panel, GRAPPPA algorithm was constructed. This algorithm take in account both evaluation and first line therapeutic options in the different type of incontinences observed in this population (urge, stress and mixed incontinence). Initial evaluation consists to track down urinary retention (and subsequently fecal stool impaction, use of anticholinergic or morphinic drugs), urinary tract infection and cognitive impairment. Haematuria, bladder-pelvic pain, history of radiotherapy or recent pelvic surgery, lead to refer the patient to a specialized unit. First line therapy is in all the cases pelvic floor training, use of local oestrogenotherapy and dietetic measures. In urge incontinence, anticholinergic drugs may be used. Implementation of this algorithm may promote best practice in management of urinary incontinence in elderly.

Enteral stents: from esophagus to colon

Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure.The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes.

Poststroke constipation in the rehabilitation ward: incidence, clinical course and associated factors

Constipation is a common poststroke complication. This study was designed to document the incidence and clinical course of poststroke constipation in a rehabilitation ward, as well as identify the factors independently associated with the condition. This retrospective study involved patients who were admitted to the rehabilitation ward of our institute due to an acute stroke between 1 August 2010 and 31 July 2011. The main outcome measured was the incidence of poststroke constipation, defined as the use of laxative after stroke, fulfilment of the Rome II diagnostic criteria for functional constipation and/or stool impaction. The variables examined were basic demographic data, presence of impairment, degree of disability (evaluated using the Barthel index), walking ability, medications taken and medical complications. Out of the 155 patients who met the inclusion criteria, 123 (79.4%) had poststroke constipation. All 123 patients used oral laxatives; 56 received additional rectal medications and 13 discontinued their use of laxatives at discharge. Patients with poststroke constipation were more likely to have major medical complications (p = 0.04). Those who used rectal medications had a higher risk of major medical complications than those who used only oral laxatives (p < 0.01). Infratentorial lesions were an independent predictor of poststroke constipation (p = 0.003). More severe disability increased the severity of constipation, as indicated by the use of rectal medication. Poststroke constipation is a common complication during inpatient rehabilitation. Healthcare providers should be aware of the incidence of poststroke constipation. Further studies are required to establish standard guidelines for screening and managing bowel function in patients with stroke.

Sigmoid Volvulus in a Young Woman Nearly Misdiagnosed as Fecal Impaction

BackgroundVolvulus of the sigmoid colon is a potentially life-threatening condition rarely seen in younger age groups and is male predominant. ObjectiveWe report a previously healthy young woman with the triad of constipation, progressive abdominal distension, and severe abdominal pain, with plain-film x-ray studies mimicking stool impaction and computed tomography disclosing the typical findings of sigmoid volvulus. The case reminds Emergency Physicians to consider sigmoid volvulus if mechanical obstruction is suspected, even in a young patient. Case ReportA 33-year-old woman had the triad of symptoms for 3 days. Physical examination did not show peritoneal signs. Digital rectal examination disclosed neither palpable mass nor stool in rectum. Computed tomography revealed “coffee bean” sign and “whirl” sign. Laparoscopy demonstrated redundant sigmoid colon and she was treated with detorsion with colopexy uneventfully. ConclusionsSigmoid volvulus is rarely seen in developed countries. Clinical manifestations vary with disease progression, but it typically presents with a triad of constipation, progressive abdominal distension, and severe abdominal pain. Plain-film x-ray studies can demonstrate a coffee bean or “omega loop” (inverted-U sigmoid) sign in <60% cases, but it was reported as high as 86% in computed tomography. The whirl sign on computed tomography might also be observed. The cause is multifactorial and colonic length is the most important predisposing factor. Flexible colon fiberscopic decompression followed by elective definitive surgery is the treatment choice, but exploratory laparotomy is mandatory if any complicated entity occurs. The mortality rate is still >50% when bowel gangrene develops.

A Twisted Case of Severe Megacolon Complicated by Recurrent Volvulus

Purpose: A 69-year-old male with morbid obesity and 10 years of progressive abdominal distension presented with decreased stool output and mild abdominal pain over one week. His last bowel movement was two days prior and mostly mucous. His weight was 345 lbs and he appeared comfortable with massive abdominal distension that was diffusely tympanic and non-tender. A rectal exam was without stool impaction. His labs showed new iron deficiency anemia. CT scan revealed marked dilatation (>20 cm) of the colon without a transition point. A water-soluble contrast enema was unable to reach the splenic flexure. Colonoscopy was limited by inadvertent retroflexions in the dilated sigmoid but did reveal severe erythema, edema, and ulcerations with significant narrowing of the distal sigmoid. The patient was subsequently admitted to the hospital for small volume hematochezia and hypotension. He underwent emergent surgery, with removal of a massively dilated colon with a sigmoid volvulus. Pathology did not reveal Hirschsprung's disease or neoplasm. His clinical status improved daily and he was discharged 80 lbs lighter at 265 lbs. Megacolon has been defined as a luminal diameter of >6.5 cm when applied to the rectosigmoid or descending colon. Its etiologies include aganglionosis (Hirschsprung's), medications, chronic constipation, infection, acquired colonic dysmotility, or true mechanical obstruction. Megacolon is a predisposing factor to sigmoid volvulus. There have been a few cases of megacolon presenting as sigmoid volvulus in the literature. This is a case of chronic megacolon from chronic constipation leading to a sigmoid volvulus. Notably, sigmoid volvulus is a rare cause of obstruction in the United States and this diagnosis can be made even more difficult with imaging limitations in the obese population. In this case, the iron deficiency anemia raised the possibility that he was bleeding from ischemic ulcers. If such as suspicions exist, a patient should not be given a colonoscopy prep as this can worsen the obstruction. Additionally, endoscopy should be performed with caution given the difficulties of safely advancing in dilated colons. Ultimately, in cases where chronic constipation and megacolon co-exist, an abrupt clinical change warrants consideration for colonic volvulus.Figure: [1230]