Water-soluble Contrast Enema Research Articles

Diagnostic effectiveness of preoperative water-soluble contrast enema in colorectal perforation

To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation. We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I-II versus those with Hinchey III-IV. WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I-II and Hinchey III-IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III-IV, with an odds ratio of greater than 24 (P=0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III-IV from those with Hinchey I-II were 76.5% and 97.1%, respectively. This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III-IV in patients with colorectal perforation.

Endoscopic Sinusotomy Using Needle Knife Technique for Treatment of H Pouch Sinus

J-shaped pouch is the most common pouch type used in restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) for medically refractory ulcerative colitis (UC). Due to anatomical difficulties, H-shaped pouch is occasionally performed during salvaging surgery for failed J-pouch. Here, we report the first case of an H-pouch complicated with a presacral sinus and successfully treated with needle knife sinusotomy (NKSi). A 62- year-old male with past medical history of UC, status post total colectomy with IPAA referred to our Pouch Center for progressive rectal pain, loose stool, and perianal swelling. Stool studies were negative including Clostridium difficile. A pouch stricture was found on barium enema. Flexible pouchoscopy revealed chronic fistula, abscess, and anastomotic stricture, for which he had exploratory laparotomy, lysis of adhesions, incision and drainage (I&D), extensive takedown of ileostomy, excision of the old J-pouch, excision of anastomotic stricture with creation of H-pouch with mucosectomy, handsewn anastomosis, and diverting loop ileostomy. Routine water-soluble contrast enema and abdominal computed tomography (CT) following surgery showed a pouch anastomotic leak. Pouchoscopy confirmed the deep sinus with thick walls. A wait and watch approach was tried for 2 months without antibiotics. However, repeat pouchoscopy showed a persistent pouch sinus. The decision was made to treat the sinus with endoscopic NKSi, followed by deployment of multiple endoclips along the edges of incised sinus wall. Patient's symptoms improved significantly following the procedure and he remained asymptomatic at 2 months post-procedure. A follow-up water-soluble contrast enema at 2 months showed normal appearing H pouch with no leak. Pouch sinus is a relatively infrequent complication after IPAA but has never been reported in patients with H-pouch IPAA. The ideal management is not well defined yet. In asymptomatic cases, patients are followed with repeat imaging to monitor for sinus healing. In cases where watchful waiting does not work, patients have habitually been treated with surgical interventions. We herein present the first case in the literature of an H-pouch complicated with anastomotic sinus successfully treated with NKSi. We suggest using NKSi as the preferred technique for H-pouch sinuses before performing any invasive surgical procedure.2053 Figure 1. No Caption available.

A Case of Obstructive Colitis due to Fecal Impaction Successfully Treated with a Water-soluble Contrast Enema

A Case of Obstructive Colitis due to Fecal Impaction Successfully Treated with a Water-soluble Contrast Enema

Colobronchial fistula: the pathogenesis, clinical presentations, diagnosis and treatment.

Colobronchial fistula (CBF) is rare and easy to be delayed in clinic. There is no systemic study about this disease. The pathogenesis, clinical presentations, diagnosis and treatment of CBF were analyzed in this study. The clinical data from 37 cases of CBF, which included one case in our institute and the other 36 cases in literature from January 1960 to August 2016, were reviewed and analyzed. The etiology, clinical presentations, diagnostic and therapeutic methods, and outcomes were summarized. The causes of CBF included Crohn's disease, postoperative intraperitoneal adhesion, diaphragmatic hernia, pulmonary infection or abscess, colonic malignancy, colonic interposition, radiation, hyperthermic intraperitoneal chemotherapy (HIPEC), diaphragmatic mesh repair, pulmonary tuberculosis and pyonephrosis. Based on the anatomical location and the causes of fistula, CBF were divided into four types: type I, CBF secondary to the adhesion among colon, diaphragm and lung; type II, CBF secondary to diaphragmatic hernia; type III, CBF secondary to sub diaphragmatic abscess or emphysema; type VI, CBF secondary to colon interposition. The characteristic clinical presentations of CBF was productive cough with foul smelling sputum (78.38%), most of the patients were finally confirmed the diagnosis by barium enema or water-soluble contrast enema study (67.57%) and computer tomography (CT) scan/with multiplanar reconstruction (16.22%); 35 cases (94.59%) accepted the surgical treatment. Among 31 patients with recorded follow-up data, 26 patients recovered unevenly, but 5 patients died in 1 month after treatment. CBF is a rare but can not be ignored disease. Anything which may induce the direct or indirect connection between colon and lung tissue may result in CBF. Productive cough with foul smelling sputum is the characteristic symptom. Radiological investigations such as barium enema and/or CT scan with multiplanar reconstruction are valuable for the confirmation of CBF. Surgery based on the etiology is the foundation of treatment.

The novel appearance of low rectal anastomosis on contrast enema following laparoscopic anterior resection: discriminating anastomotic leaks from "dog-ears" on water-soluble contrast enema and flexible sigmoidoscopy.

Interpretation of water-soluble contrast enema following laparoscopic low anterior resection can be very challenging for both radiologists and colorectal surgeons. Discriminating the radiological appearances secondary to anastomotic configuration from those caused by actual anastomotic dehiscence is a common problem and may be made worse with the advent of laparoscopic surgery. The aim of this study is to identify potential novel appearances of the water-soluble contrast enema (WSCE) images of rectal anastomosis following laparoscopic low anterior resection to radiologists and surgeons. We enrolled 45 patients who underwent laparoscopic low anterior resection with proximal de-functioning loop ileostomy within a specialized colorectal unit. The water-soluble contrast enema reports were reviewed. Two blinded colorectal radiologists independently reviewed the images of patients suspected of anastomotic leak. All of these patients also underwent a flexible sigmoidoscopy to confirm or exclude anastomotic leak before reversal of loop ileostomy. Inter-observer concordance was calculated. Seven out of eighteen patients (38.9%) were found to have true anastomotic leaks on flexible sigmoidoscopy (15% overall leak rate). In the remaining eleven patients the image appearances were attributed to the appearance of the anastomotic 'dog-ear effect', created by the anastomotic configuration due to multiple firing of the intra-corporeal laparoscopic stapling device. Radiologist inter-observer concordance was 83%. Sensitivity was 100%, specificity 71%, positive-predictive value (38.9%) and negative-predictive value (100%). The novel appearances of laparoscopic-stapled rectal anastomoses in WSCE can be mistaken for anastomotic leak. To avoid delay in reversal of ileostomy, a flexible sigmoidoscopy can be used to confirm or exclude a leak.

Indocyanine green fluorescence angiography during laparoscopic low anterior resection: results of a case-matched study.

Colorectal anastomoses after anterior resection for cancer carry a high risk of leakage. Different factors might influence the correct healing of anastomosis, but adequate perfusion of the bowel is highlighted as one of the most important elements. Fluorescence angiography (FA) is a new technique that allows the surgeon to perform real-time intraoperative angiography to evaluate the perfusion of the anastomosis and hence, potentially, reduce leak rate. The aim of this study was to evaluate the impact of FA of the bowel on postoperative complications and anastomotic leakage after laparoscopic anterior resection with total mesorectal excision (TME). FA was performed in all patients undergoing laparoscopic anterior resection with TME for cancer followed by colorectal or coloanal anastomosis. Results were compared to a historical controls group of 38 patients previously operated by the same surgeon for the same indication but without the use of FA. From October 2014 to November 2015, 42 patients underwent laparoscopic anterior resection with TME and FA of the bowel. The surgeon subjectively decided to change the planned anastomotic level of the descending colon due to hypoperfused distal segment in two out of 42 patients in the FA group (4.7%). Anastomotic leakage, confirmed by postoperative CT scan and water-soluble contrast enema, was found in two cases of a historical controls group and none in the FA group. No adverse events (side effects or allergic reaction) related to FA were recorded. All the other postoperative complications were comparable between the two groups. In our experience, ICG FA was safe and effective in low rectal cancer resection, possibly leading to a reduction in the anastomotic leakage rate after TME.

Sigmoid volvulus in children

Fig 1. Abdominal radiograph showing massive dilatation of the whole colon, without signs of intestinal perforation. A 10-YEAR-OLD GIRL was evaluated at the Emergency Department because of a 2-day history of abdominal distension with pain and nonbilious vomiting. She had a 5-year history of chronic constipation, previously diagnosed as functional constipation. On physical examination, her abdomen was massively distended with voluntary guarding. Laboratory evaluation showed an elevated C-reactive protein (24 mg/dL, normal range 0–5 mg/dL). Abdominal radiograph showed a massively dilated colon (Fig 1). A nasogastric tube was placed, and a water-soluble contrast enema was obtained (Fig 2). The enema showed the “twisted taper” or “bird’s beak” configuration of the twisted colon, in which the dilated proximal segment represents the bird’s head, and the tapered distal end its beak. These findings were consistent with the diagnosis of sigmoid volvulus. After an unsuccessful attempt at endoscopic decompression and derotation, the patient underwent an emergency exploratory operation. At laparotomy, 1808 counterclockwise torsion of the sigmoid colon was confirmed. The dilated sigma had a maximal diameter of 17 cm, without sign of ischemia or necrosis. Colonic irrigation with saline solution was performed, and the patient underwent derotation and resection of 25 cm of dilated sigma and primary end-to-end colocolonic anastomosis with sigmoidopexy. Sigmoid volvulus is extremely rare in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. In these patients, redundant sigmoid colon could

Is the routine use of a water-soluble contrast enema prior to closure of a loop ileostomy necessary? A review of a single institution experience.

BackgroundThe aims of the study were to determine the radiological leak rate in those patients who had undergone a resection for left-sided colorectal cancer and to see if the presence of a leak can be related with the postoperative clinical period. We also aimed to identify any common factors between patients with leak.MethodsA retrospective analysis of prospectively collected data of all patients who underwent a left-sided colorectal cancer resection with formation of a defunctioning ileostomy was undertaken. Between 2005 and 2010, 418 such patients were identified.ResultsA water-soluble contrast enema was performed in 339 patients (81.1 %). Of these, 24 (7.1 %) were reported to show an anastomotic leak. Data for these 24 patients is presented in this study.Twenty-three (95.8 %) of the leaks occurred in patients who had undergone an anterior resection; 95.8 % of the patients with a leak were male. Fifteen (62.5 %) patients underwent neo-adjuvant radiation. The mean length of stay in those patients shown to have a subsequent radiological leak was 18.8 days (median), compared with the overall unit figures of 12 days. Only 29.2 % of the patients who had a leak identified had an uncomplicated postoperative period. Overall 87.5 % of the patients had a reversal of the ileostomy.ConclusionsRadiological leakage is not uncommon. The majority of patients, who were shown to have a radiological leak in this study, were male, had undergone an anterior resection, had received neo-adjuvant radiation, had a longer initial length of stay and had postoperative complications. Water-soluble contrast enemas could be selectively used in patients with these characteristics.

A case of advanced rectal cancer with rectovesical and ileal fistulae that developed hyperammonemic encephalopathy.

Hyperammonemic encephalopathy is rarely caused by a urinary diversion. We herein experienced a case of rectal carcinoma with rectovesical and ileal fistulae that developed hyperammonemic encephalopathy. A 72-year-old man suffered from a fever, diarrhea, pneumaturia, and fecaluria beginning in April 2013 and was referred to our hospital in May 2013. He developed a loss of consciousness and whole body cramping on the first hospital day. The laboratory data indicated an inflammatory reaction and hyperammonemia with a highly elevated serum ammonia (NH3) level of 703 μg/dl.The patient was diagnosed to have rectal carcinoma with rectovesical and ileal fistulae according to computed tomography (CT) and a water-soluble contrast enema.We administered a solution of branched chain amino acids (BCAA) and antibiotics. Furthermore, we repeatedly irrigated bladder through the urethral catheter. The patient’s symptoms recovered, and the serum ammonia levels on the second and third hospital day were decreased to 210 and 135 μg/dl, respectively. However, the symptoms of infection and confusion were suspected to repeat; we elected to perform surgical treatment. An ileal disconnection with ileocecal bypass and sigmoidostomy were effective for preventing hyperammonemic encephalopathy.

Acute colonic pseudo-obstruction: Ogilvie syndrome

Acute colonic pseudo-obstruction (ACPO) is characterized by marked colonic dilatation which develops over several days. ACPO is due to a motility disorder and is not caused by colonic obstruction and occurs in patients with severe, often acute underlying diseases or postoperatively. It is associated with a 25-30% mortality overall that increases to up to 50% in patients who develop complications (e.g. colonic ischemia and perforation). The pathogenesis of the disorder has not yet been clarified and clinical symptoms and signs are relatively unspecific. In particular, ACPO has to be differentiated from colonic obstruction and toxic megacolon. For this blood tests and radiological tests are required, e.g. plain abdominal radiograph, abdominal computed tomography (CT) and water soluble contrast enema, which are also required for detection of complications. Patients with ACPO should generally receive supportive therapy for decompression of the gastrointestinal tract (e.g. gastric and rectal tubes) and to minimize predisposing factors. In most uncomplicated cases this leads to resolution of colonic dilatation. Clinical and radiological controls at close intervals are required until the condition is resolved. If patients do not respond within 1-2 days or if ACPO has already reached a critical duration (>3-4 days) or extent (i.e. cecal diameter ≥12 cm), neostigmine should be administered and leads to durable success in approximately 3 out of 4 patients. Patients who are still refractory to treatment should receive endoscopic decompression. More invasive therapeutic options, such as cecostomy or (segmental) colonic resection should only be considered for patients who still do not respond to treatment or present with the abovementioned complications.

Ultrasound-guided contrast enema for meconium obstruction in very low birth weight infants: Factors that affect treatment success

IntroductionThis study aimed to assess the therapeutic results of ultrasound (US)-guided water-soluble contrast enema in very low birth weight (VLBW) preterm infants (<1,500g) with meconium obstruction and to study factors that affect therapeutic results. MethodsThis study included a total of 33 consecutive VLBW infants with clinically diagnosed meconium obstruction underwent US-guided water-soluble contrast enema, from April 2007 to March 2014. Patients were classified into two groups based on to procedure outcome: the success group (evacuation of the meconium plug resolution followed by improved bowel distention within 2 days of the procedure, without additional interventions), and the failure group (the contrast enema failed to relieve the obstruction, or other procedure-related complications occurred). Patient- and mother-related clinical factors and procedure-related factors were compared between both groups. ResultsOverall success rate was 54.5%, with 18 successful (M:F=10:8), and 15 failure (M:F=7:8) cases. When compared with the failure group, the success group patients showed statistically significant older gestational age (29+1 vs. 27 weeks; p=0.028), larger birth weight (1023.1g vs. 790.3g; p=0.048), and higher body weight on the day of the procedure (1036.2g vs. 801.6g, p=0.049). However, no statistically significant differences were seen between other patient and maternal factors. Among the procedure-related factors, retrial of contrast injection during the procedure was associated with significantly higher success than the single trial (p=0.027). The presence of refluxed contrast into the distal ileum was the statistically significant predictor for success of the procedure (p=0.038). There were three cases of bowel perforation (9.1% per person). ConclusionUS-guided water-soluble contrast enema in VLBW infants with meconium obstruction showed a 54.5% success rate and a 9.1% perforation rate per person. Among the procedure-related factors, retrial of contrast injection during the procedure and the presence of refluxed contrast into the distal ileum were related to the success of the procedure.

Water soluble contrast enema examination of the integrity of the rectal anastomosis prior to loop ileostomy reversal may be superfluous.

Defunctioning loop ileostomy in low anterior resection (LAR) is routinely used to reduce consequences of anastomotic leakage. The purpose of this study was to analyze which examination technique is optimal for evaluating the integrity of the anastomosis prior to loop ileostomy reversal. Retrospective analysis of 95 patients who had been subjected to LAR at Helsingborg Hospital and Skåne University Hospital, Sweden, was undertaken between January 2007 and June 2009. The examination techniques of the rectal anastomosis prior to reversal and the clinical outcome after reversal were studied. Radiologic anastomosis control using water soluble contrast enema, digital rectal examination (DRE), and rectoscopy were performed in 53 % (50/95), 98 % (93/95), and 69 % (66/95), respectively. In two patients, no control of the anastomosis was performed before reversal. Fifty-two percent (49/95) of the patients were examined using all techniques. Six patients demonstrated leakage detected before reversal of which two were only radiological leakages. These two patients underwent loop ileostomy reversal after delay without complications. They were the only ones where the three examination techniques did not prove coherence. Four patients had symptomatic leakage; these were detected with rectoscopy and DRE and verified with enema. Three patients developed anastomotic leakage after loop ileostomy reversal despite normal preoperative examinations. Two of these patients had rectovaginal fistulas (AVFs). This retrospective study indicates that contrast enema does not provide additional information if rectoscopy and DRE are normal. Despite negative examinations, three of nine leakages were diagnosed after loop ileostomy reversal. Especially, AVFs seem difficult to diagnose.

Assessment by Using a Water-Soluble Contrast Enema Study of Radiologic Leakage in Lower Rectal Cancer Patients With Sphincter-Saving Surgery.

PurposeThis study evaluated the efficacy of a water-soluble contrast enema (WCE) in predicting anastomotic healing after a low anterior resection (LAR).MethodsBetween January 2000 and March 2012, 682 consecutive patients underwent a LAR or an ultra-low anterior resection (uLAR) and were followed up for leakage. Clinical leakage was established by using physical and laboratory findings. Radiologic leakage was identified by using retrograde WCE imaging. Abnormal radiologic features on WCE were categorized into four types based on morphology: namely, dendritic, horny, saccular, and serpentine.ResultsOf the 126 patients who received a concurrent diverting stoma, only two (1.6%) suffered clinical leakage due to pelvic abscess. However, 37 patients (6.7%) in the other group suffered clinical leakage following fecal diversion (P = 0.027). Among the 163 patients who received a fecal diversion, 20 showed radiologic leakage on the first WCE (eight with and 12 without a concurrent diversion); 16 had abnormal features continuously until the final WCE while four patients healed spontaneously. Eleven of the 16 patients (69%), by their surgeon's decision, underwent a stoma restoration based on clinical findings (2/3 dendritic, 3/4 horny, 5/7 saccular, 1/2 serpentine). After stoma reversal, only 2 of the 11 (19%) complained of complications related to the rectal anastomosis.ConclusionWCE is helpful for detecting radiologic leakage before stoma restoration, especially in patients suffering clinical leakage after an uLAR. However, surgeons appear to opt for stoma restoration despite the persistent existence of radiologic leakage in cases with particular features on the WCE.

Should a Contrast Enema Be Performed Before Reversal of a Diverting Stoma in Lower Rectal Surgery?

See Article on Page 131-137 A defunctioning loop ileostomy is often used to reduce the consequences of anastomotic leakage, especially in a low rectal anastomosis. Hanna et al. [1] showed that fecal diversion could be recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. Tan et al. [2] also argued that the creation of diverting stomas could potentially minimize the fatal outcomes of anastomotic leakage, although it might not substantially decrease the incidence of anastomotic leakage in rectal cancer surgery. However, some authors reported that a diverting stoma did not have a significant relationship with symptomatic anastomotic leakage before and after their propensity score matching [3]. Another study also argued that a diverting stoma did not affect postoperative morbidity in a large cohort of patients undergoing low rectal anastomosis and that the routine use of a diverting stoma could rather delay postoperative recovery [4]. In the stage of stoma reversal, there are many different concepts and ideas about the effectiveness of a water-soluble contrast enema for the assessment of anastomotic integrity after low rectal surgery. Some investigators report that the contrast enema does not provide additional information when the results of rectoscopy and digital rectal examination (DRE) are normal [5]. However, in other studies, a contrast enema was effective in excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks [6]. Most surgeons perform the closure of the ileostomy after using a water-soluble contrast enema to check the anastomosis to confirm there is no sign of leakage. However, Palmisano et al. [7] performed the reversal of a protective stoma, despite a finding of persistent radiological and subclinical leakage, in selected patients. Seo et al. [8] evaluated the efficacy of a water-soluble contrast enema in predicting anastomotic healing after low rectal anastomosis and categorized the abnormal radiologic features into four types of their design based on the morphologic patterns: namely, dendritic, horny, saccular, and serpentine. They found that certain types of leakage forming cavitary lesions had better clinical outcomes after leakage had been arrested and the stoma had been restored. This issue should be discussed and evaluated through a larger-scale study for more definitive clinical implications. A water-soluble contrast enema study is helpful in detecting radiologic leakage before reversal of a diverting stoma, but these examinations are sometimes difficult to interpret, especially in the presence of a pouch or a dog-ear from a colo-anal anastomosis constructed by using the double-stapling technique. Therefore, for patients with a diverting stoma, surgeons should always be mindful to select the best way and the appropriate time to perform the stoma restoration, or they should decide to delay the stoma restoration, based on the radiologic finding, as well as clinical information, such as the results of a digital rectal examination.

How Useful is Contrast Enema in the Diagnosis of Hirschsprung’s Disease? Five-year Experience from a Local Referral Centre

Objective: To review the diagnostic performance of contrast enema examinations for the investigation of Hirschsprung’s disease, determine the usefulness of delayed 24-hour X-rays, and validate water-soluble contrast enemas for the investigation for patients with suspected Hirschsprung’s disease. Methods: This was a retrospective study of all neonates and infants referred for radiological evaluation of symptoms and signs suspicious of Hirschsprung’s disease in Queen Mary Hospital, Hong Kong from January 2007 to December 2011. Patients were included in this study when all radiographs were available and Hirschsprung’s disease had been confirmed or excluded by rectal biopsy or by a combination of enema results, manometry, and close clinical follow-up. Radiographs and reports were reviewed with a checklist of radiological criteria described in the literature, including transitional zone, rectosigmoid index (maximum width of rectum divided by maximum width of sigmoid; abnormal if <1), irregular contractions, mucosal irregularity, spasm, serrations and retention of contrast agent on delayed radiographs. The sensitivity, specificity, positive and negative predictive values of each of these criteria were calculated and considered in the context of recommendations described in the literature. Results: A total of 136 such patients were evaluated during the study period, of whom 86 had barium enemas and 57 had water-soluble contrast enemas. Among all the patients reviewed, the sensitivity, specificity, positive and negative predictive values for all enema examinations (excluding delayed films) in the diagnosis of Hirschsprung’s disease were 69%, 89%, 44% and 96%, respectively. While the corresponding values of all enema examinations (including delayed films) were 100%, 78%, 36% and 100%, respectively. Similar results were noted in patients having barium enemas and water-soluble contrast enema examinations. For patients having barium enemas or water-soluble contrast enemas, with the inclusion of delayed films there was a significant increase in sensitivity compared to sensitivity derived without recourse to delayed films, whilst there was only a slight reduction in specificity. Conclusion: Recourse to water-soluble contrast enemas with the addition of a 24-hour delayed film was useful in the diagnosis of Hirschsprung’s disease.

Renal Excretion of Water-soluble Contrast Media After Enema in the Neonatal Period

When abdominal distention occurs or bowel obstruction is suspected in the neonatal period, a water-soluble contrast enema is helpful for diagnostic and therapeutic purposes. The water-soluble contrast medium is evacuated through the anus as well as excreted via the kidneys in some babies. This study was designed to evaluate the incidence of renal excretion after enemas using water-soluble contrast media and presume the causes. Contrast enemas using diluted water-soluble contrast media were performed in 23 patients under 2 months of age. After the enema, patients were followed with simple abdominal radiographs to assess the improvement in bowel distention, and we could also detect the presence of renal excretion of contrast media on the radiographs. Reviewing the medical records and imaging studies, including enemas and consecutive abdominal radiographs, we evaluated the incidence of renal excretion of water-soluble contrast media and counted the stay duration of contrast media in urinary tract, bladder, and colon. Among 23 patients, 12 patients (52%) experienced the renal excretion of water-soluble contrast media. In these patients, stay-in-bladder durations of contrast media were 1-3 days and stay-in-colon durations of contrast media were 1-10 days, while stay-in-colon durations of contrast media were 1-3 days in the patients not showing renal excretion of contrast media. The Mann-Whitney test for stay-in-colon durations demonstrated the later evacuation of contrast media in the patients with renal excretion of contrast media (p=0.07). The review of the medical records showed that 19 patients were finally diagnosed as intestinal diseases, including Hirschsprung's disease, meconium ileum, meconium plug syndrome, and small bowel atresia or stenosis. Fisher's exact test between the presence of urinary excretion and intestinal diseases indicated a statistically significant difference (p=0.04). The intestinal diseases causing bowel obstruction may increase the water-soluble contrast media's dwell time in the bowel and also increase urinary excretion.

Visual Diagnosis: An 11-Month-Old With Nausea, Vomiting, and an Abdominal Mass

Children with intussusception can present with a wide variety of symptoms, including vomiting, fever,lethargy, and abdominal pain. The classic triad of abdominal pain, hematochezia, and palpable abdominal mass is seen in a few patients.• Early diagnosis of intussusception depends on a high level of clinical suspicion in any child with non specific abdominal findings followed by appropriate radiographic or ultrasonographic evaluation and confirmation with a contrast enema.• Abdominal radiography, although an appropriate component of the initial workup for gastrointestinal symptoms, lacks the sensitivity to reliably exclude the presence of intussusception.• Because ultrasonography is a safe, sensitive, and specific test for the diagnosis of intussusceptions, it should be performed early whenever there is clinical suspicion of intussusception.• Contrast enema is the gold standard for diagnosis and first-line treatment of intussusception. There is an increasing trend for pneumatic reduction of intussusception compared with hydrostatic reduction.Intravenous placement, fluid resuscitation, and notification of the pediatric surgeon should be completed before contrast enema.

Images in medicine: Diagnosis and pre-surgical triage of transanal rectal injury using multidetector CT with water-soluble contrast enema

Transanal rectal injuries caused by foreign body insertion, sexual abuse, or iatrogenic procedures represent a very uncommon surgical emergency. Morbidity may be further increased by patient's embarrassment and delayed presentation. Since management decisions largely depend on anatomic and severity assessment, multidetector Computed tomography with rectally administered water-soluble iodinated contrast medium is highly valuable to accurately depict traumatic rectal injuries, and to distinguish between intraperitoneal vs extraperitoneal injuries that require different surgical approaches.

Rectoseminal vesicle fistula as a rare complication after low anterior resection: a report of three cases

A rectoseminal vesicle fistula is a rare complication after a low anterior resection for rectal cancer, usually developing in the outpatient postoperative period with pneumaturia, fever, scrotal swelling or testicular pain. A diagnostic water-soluble contrast enema, cystography and computed tomography reveal a tract from the rectum to the seminal vesicle. Anastomotic leakage is thought to be partially responsible for the formation of such tracts. This report presents three cases of rectoseminal vesicle fistula, and the presumed course of the disease and optimal treatment options are discussed.

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]