Abordagem cirúrgica de megaceco secundário a tumor de cólon descendente / Surgical approach of megacecum secondary to descending colon tumor

RESUMO: Obstrução intestinal é a manifestação clínica mais frequente de tumores de cólon sendo esses, em sua maioria, localizados no cólon descendente e reto-sigmoide. A cirurgia de emergência para obstrução intestinal é associada a altos riscos de mortalidade e de morbidade e a abordagem ideal permanece controversa. Procedimentos em vários estágios e o uso de stents como ponte para cirurgia são opções promissoras. É apresentado um caso de paciente de 61 anos, com abdome agudo obstrutivo secundário à neoplasia colorretal, com ênfase em seu diagnóstico e tratamento. (AU)

ABSTRACT: Intestinal obstruction is the most frequent clinical manifestation of colon tumors, most of which are located in the descending and recto-sigmoid colon. Emergency bowel obstruction surgery is associated with high mortality and morbidity risks and the ideal approach remains controversial. Multi-stage procedures and the use of stents as bridges for surgery are promising options. A case of a 61-year-old patient with an acute obstructive abdomen secondary to colorectal neoplasm is presented, with emphasis on its diagnosis and treatment. (AU)

Megaesôfago e megacólon na doença de Chagas: classificação de casos e possibilidades de atuação da atenção primária à saúde / Megaesophagus and megacolon in Chagas disease: classification of cases and possibilities of action in primary health care

Objetivos: classificar pacientes chagásicos com a forma digestiva da doença associando com variáveis demográficas, clínicas e de utilização de serviços de saúde, além de analisar as possibilidades de atuação da Atenção Primária à Saúde (APS) no manejo e acompanhamento dos casos. Casuística e métodos: estudo transversal com base em dados secundários provenientes de prontuários. Foram utilizadas as classificações do megaesôfago e do megacólon propostas por Rezende (1982) e Silva (2013), respectivamente. Resultados: Foram analisados 156 prontuários, sendo 94 (60,2%) relativos a megaesôfagos, 29 (18,6%) a megacólons e 29 (18,6%) a ambas as formas clínicas. O maior número de internações (p=0,02; OR=3,71) e de dias internados (p<0,01; OR=3,30) foi associado aos pacientes classificados nos grupos III e IV de megaesôfago. Em relação ao sexo masculino (p=0,02), o maior número de internações (p<0,0001) e de dias internados (p<0,0001) foi associado aos pacientes classificados no grau III de megacólon. Conclusões: Concluiu-se que a APS possui papel importante na diminuição da sobrecarga dos serviços de média e alta complexidade com o acompanhamento dos casos estáveis e menos graves e que a melhoria da qualidade de vida dos pacientes chagásicos é um efeito direto que pode ser esperado do protagonismo da APS neste cuidado.

Objectives: To classify chagasic patients with the digestive form of the disease, associating with demographic, clinical, and use of health services variables, in addition to analyzing the possibilities of Primary Health Care (PHC) acting in the management and follow-up of cases. Casuistry and Methods: A cross-sectional study based on secondary data from medical records was conducted. We used the classification of megaesophagus and megacolon proposed by Rezende (1982) and Silva (2013), respectively. Results: 156 medical records were analyzed: 94 (60.2%) related to megaesophagus, 29 (18.6%) to megacolon, and 29 (18.6%) with both clinical forms. The highest number of hospitalizations (p=0.02; OR=3.71) and days hospitalized (p<0.01; OR=3.30) were associated with patients classified in groups III and IV with megaesophagus. Male gender (p=0.02), more hospitalizations (p=0.0001), and more days in the hospital (p=0.0001) were all linked to patients classified as having gradeIII megacolon. Conclusions: We concluded that PHC has an important role in reducing the burden of medium and high-complexity services with the monitoring of stable and less severe cases. It also demonstrated the direct effect of PHC protagonism on the improvement of chagasic patients' quality of life.

Etiological analysis and surgical method selection of adult megacolon / 中华胃肠外科杂志

Adult megacolon is a rare disease with heterogeneneous etiology. The treatment schemes of megacolon caused by different causes are also different, but surgery is the final and the most effective method. Due to the lack of early understanding of the disease, many patients have not been clearly diagnosed as adult megacolon and have not been properly treated. This article classifies adult megacolon according to the etiology and summarizes its surgical options. For adult Hirschsprung's disease, modified Duhamel, the Jinling procedure, low anterior resection, or pull-through low anterior resection can be used. For patients with idiopathic megacolon, one-stage subtotal colorectal resection can be selected with adequate preoperative preparations. Some patients admitted to the hospital with emergency intestinal obstruction can be treated with conservative treatment or decompression under colonoscopy followed by selective surgery. For patients with aganglionosis, the procedure is subtotal colorectal resection, the same as that of idiopathic megacolon. The procedure is to remove both the dilated proximal intestine and the stenotic distal intestine, then an ileorectal anastomosis or ascending colon rectal anastomosis is performed. For toxic megacolon, colostomy can be done for mild cases, and for severe infections, subtotal colorectal resection is required. Latrogenic megacolon is mostly caused by segmental stenosis or lack of peristalsis, resulting in chronic dilatation of the proximal end and the formation of megacolon. It is necessary to choose a reasonable surgical procedure according to the specific conditions of the patient. The first choice for the treatment of acute colonic pseudo-obstruction syndrome is decompression under colonoscopy. For those with the secondary changes in the intestine, ostomy is still the most effective surgical procedure, but should be performed with caution.

Chagasic megacolon in Venezuela - case report / Megacólon chagásico na Venezuela

ABSTRACT Chagasic megacolon is the second most frequent cause of manifestation of the digestive forms of Chagas disease (trypanosoma cruzi parasitosis), characterized by progressive pseudo-occlusive symptoms or chronic constipation, caused by an alteration in the functioning of the colonic wall musculature. In Venezuela, cases of chagasic disease reported in the past are referred to chagasic heart disease, this being the first documented case of chagasic megacolon. We broach herein a case of chagasic megacolon in which early diagnosis and prompt surgical treatment led to a successful outcome.

RESUMO O megacólon chagásico é a segunda causa mais frequente de manifestação das formas digestivas da doença de Chagas (parasitose do Trypanosoma cruzi), caracterizado por sintomas pseudo-oclusivos progressivos ou constipação crônica, causado por uma alteração no funcionamento da musculatura da parede do cólon. Na Venezuela, os casos da doença chagásica relatados no passado são referidos como doença cardíaca chagásica, sendo este o primeiro caso documentado de megacólon chagásico. Neste artigo, abordamos um caso de megacólon chagásico no qual o diagnóstico precoce e o tratamento cirúrgico imediato levaram a um resultado bem-sucedido.

Megadolicocolon de presentación poco usual en un paciente de edad avanzada: a propósito de un caso / Megadolicocolon with unusual presentation in an elderly patient: a case report

El megadolicocolon es una patología inusual, de etiología no bien esclarecida. Tal parece ser de origen congénito, se presenta con frecuencia en recién nacidos y lactantes con vólvulos de colon. Su incidencia es variable y se encuentra entre 1,9 y 28,5 %.Este reporte de caso es excepcional debido a que se presenta con una evolución y comportamiento agresivo de la enfermedad, pues se trata de un paciente de edad avanzada, con antecedente de sigmoidopexia y cuadro clínico de 7 meses de evolución consistente en estreñimiento crónico y exacerbación difusa de dolor abdominal incapacitante, quién requirió procedimiento quirúrgico de emergencia para su manejo

Megadolichocolon is an unusual pathology of not well clarified etiology. It seems to be of congenital origin and occurs frequently in newborns and infants with colon volvulus. Its incidence varies between 1.9% and 28.5%. This case report is exceptional because it presents with an aggressive evolution and behavior of the disease, since it is an elderly patient, with a history of sigmoidopexy and a clinical evolution of 7 months consisting of chronic constipation and diffuse exacerbation of disabling abdominal pain, who required an emergency surgical proce-dure for its management

Although with intact mucosa at colonoscopy, chagasic megacolons have an overexpression of Gal-3 / Embora com mucosa íntegra à colonoscopia, megacólons chagásicos apresentam superexpressão de Gal-3

ABSTRACT Objective To evaluate the density of anti-galectin-3-immunostained cells, collagen percentage, mast cell density and presence of pathological processes in intestinal muscle biopsies of patients. Methods Thirty-five patients who underwent intestinal biopsy were selected from 1997 to 2015. Patients were divided into three groups: chagasic patients with mucosal lesion (n=13), chagasic patients with intact mucosa (n=12) and non-chagasic patients with no mucosal lesion (n=10). Histological processing of the biopsied fragments and immunohistochemistry for galectin-3 were performed. Additional sections were stained with hematoxylin and eosin to evaluate the general pathological processes, picrosirius for evaluation of collagen and toluidine blue to evaluate the mast cell density. Results Patients of mucosal lesion group had a significantly higher frequency of ganglionitis and myositis when compared to the chagasic patients with intact mucosa and non-chagasic group. The density of anti-galectin-3-immunostained cells was significantly higher in the chagasic patients with intact mucosa group when compared to the non-chagasic group. The group of chagasic patients with intact mucosa presented a higher percentage of collagen in relation to the patients with mucosal lesion and to the non-chagasic group, with a significant difference. There was no significant difference in mast cell density among the three groups. Conclusion The higher density of anti-galectin-3-immunostained cells in patients in the chagasic patients with intact mucosa group suggested the need for greater attention in clinical evaluation of these patients, since this protein is associated with neoplastic transformation and progression.

RESUMO Objetivo Avaliar a densidade de células imunomarcadas por anti-galectina-3, a percentagem de colágeno, a densidade de mastócitos e a presença de processos patológicos na musculatura intestinal de pacientes biopsiados. Métodos Foram selecionados 35 pacientes submetidos à biópsia de intestino entre 1997 a 2015. Os pacientes foram divididos em três grupos: chagásicos com lesão de mucosa (n=13), chagásicos com mucosa íntegra (n=12) e não chagásicos sem lesão de mucosa (n=10). Foram realizados processamento histológico dos fragmentos biopsiados e imunohistoquímica para galectina-3. Cortes adicionais foram corados por hematoxilina e eosina, para avaliar os processos patológicos gerais, pelo picrosírius, para avaliação do colágeno, e pelo azul de toluidina, para avaliar a densidade de mastócitos. Resultados Os pacientes do grupo chagásicos com lesão de mucosa apresentaram frequência significativamente maior de ganglionite e miosite quando comparados aos dos grupos chagásico com mucosa íntegra e não chagásicos. A densidade das células imunomarcadas por anti-galectina-3 foi significativamente maior no grupo chagásicos com mucosa íntegra quando comparada ao grupo não chagásico. O grupo de chagásicos com mucosa íntegra apresentou maior percentagem de colágeno em relação aos grupos chagásicos com mucosa lesada e ao grupo de não chagásicos, com diferença significativa. Não houve diferença significativa com relação à densidade de mastócitos entre os três grupos. Conclusão A maior densidade de células imunomarcadas por anti-galectina-3 nos pacientes do grupo chagásico com mucosa íntegra sugere a necessidade de maior atenção na avaliação clínica desses pacientes, uma vez que essa proteína está associada com transformação e progressão neoplásica.

Clinical and manometric investigation in constipated Chagasic patients with and without megacolon / Investigação clínica e manométrica de pacientes chagásicos constipados com e sem megacolon

ABSTRACT Background: Chagasic colopathy is the second most common digestive manifestation, and constipation is the main symptom. The absence of the Rectoanal Inhibitory Reflex plays an important role in constipation and anal manometry is crucial for appropriate evaluation. Purpose: Evaluate anal manometry findings (mainly Rectoanal Inhibitory Reflex) in Chagasic patients with chronic constipation, with and without megacolon and correlate these findings with clinical and demographic data. Methods: Cross-sectional study of patients with chronic constipation who underwent Chagasic serologic test, barium enema, and anal manometry. The absence of Rectoanal Inhibitory Reflex was evaluated using the mid-P Exact Test. Results: 64 Patients were included: 23 Chagasic patients with megacolon/megarectum (G1), 21 Chagasic patients without megacolon/megarectum (G2) and 20 non-Chagasic patients without megacolon/megarectum (G3). Chagasic patients with megacolon had a higher incidence of fecaloma (39%) compared to the other two groups (9.5% and 10% for G2 and G3, respectively, p = 0.03). Rectal capacity on manometry was statically higher for G1 patients. Rectoanal Inhibitory Reflex was absent in 91.3% of patients in G1, 47.29% in G2 and present in all patients in G3. There was a significant difference in the absence of the Rectoanal Inhibitory Reflex when comparing the groups (G1 vs. G2: p = 0.002, G1 vs. G3: p < 0.001, G2 vs. G3: p < 0.001). Conclusion: The absence of RAIR confirms the diagnosis of Chagasic colopathy and endorses surgical treatment whenever clinical treatment fails. The presence of the RAIR in patients with positive serology for Chagas disease without megacolon/megarectum might not be due chagasic colopathy and other causes should be considered.

RESUMO Fundamento: A colopatia chagásica é a segunda manifestação digestiva mais comum e a constipação é o principal sintoma. A ausência do Reflexo Inibitório Retoanal desempenha um papel importante na constipação e a manometria anal é crucial para avaliação adequada. Objetivo: Avaliar os achados da manometria anal (principalmente o Reflexo Inibitório Retoanal) em pacientes chagásicos com constipação crônica, com e sem megacólon, e correlacionar esses achados com dados clínicos e demográficos.Métodos: Estudo transversal de pacientes com constipação crônica submetidos ao teste sorológico para doença de chagas, enema de bário e manometria anal. A ausência de Reflexo Inibitório Retoanal foi avaliada por meio do Teste Exato de Ponto Médio. Resultados: Foram incluídos 64 pacientes: 23 chagásicos com megacólon/megarreto (G1), 21 chagásicos sem megacólon/megarreto (G2) e 20 não chagásicos sem megacólon/megarreto (G3). Os pacientes chagásicos com megacólon apresentaram maior incidência de fecaloma (39%) em comparação aos outros dois grupos (9,5% e 10% para G2 e G3, respectivamente, p = 0,03). A capacidade retal na manometria foi estatisticamente maior nos pacientes do G1. O Reflexo Inibitório Retoanal estava ausente em 91,3% dos pacientes do G1, em 47,29% no G2 e presente em todos os pacientes do G3. Houve diferença significativa na ausência do Reflexo Inibitório Retoanal quando comparados os grupos (G1 vs. G2: p = 0,002, G1 vs. G3: p < 0,001, G2 vs. G3: p < 0,001). Conclusão: A ausência de RIRA confirma o diagnóstico de colopatia chagásica e endossa o tratamento cirúrgico sempre que o tratamento clínico falhar. A presença de RIRA em pacientes com sorologia positiva para doença de Chagas, sem megacólon/megarreto, pode não ser devida à colopatia chagásica e outras causas devem ser consideradas.

Radiological study of megacolon in trypanosoma cruzi infected rats / Estudo radiológico de megacólon em ratos infectados por trypanosoma cruzi

ABSTRACT Background: Researches on Chagas disease still use several animals and rats, due to size and susceptibility were preferred by many authors. Aim: To develop an experimental model of megacolon in rats inoculated with the strain Y of Trypanosoma cruzi. Methods: Thirty male Wistar rats were distributed in three groups inoculated with different inoculants: Group A: 600000, Group B: 1000000 and Group C: 1500000 blood trypomastigotes of T. cruzi. Animals were sedated intramuscularly at zero inoculation time (T0) and 60 days after inoculation (T60), to perform the barium enema in order to evaluate the dilatation of the different segments of colon in a comparative study of the measurements obtained, using a digital caliper. Evidence of infection was performed by blood smear collected from the animal's tail 18 days after inoculation with observation of blood forms. Results: Comparing the intestinal diameter of the inoculated animals with 60,0000 trypomastigotes in the T0 of infection with T60 days after the inoculation, significant dilatation was observed between the proximal, medial and distal segments (p<0.01), indicating the establishment of the megacolon model. In addition, comparing intestinal diameter between the different segments, with in the T0 of infection and the T60 after inoculation, significant alterations were observed (p<0.05). Conclusion: The proposed model was possible for in vivo studies of alterations due to infection by T. cruzi and functional alterations of the colon. In addition, the changes manifested in the colon are not directly proportional to the size of the inoculum, but to the time of infection that the animals were submitted, since the animals inoculated with 60,0000 blood forms were the ones which presented the most significant alterations.

RESUMO Racional: Pesquisas para doença de Chagas ainda utilizam diversos animais e o rato por seu tamanho e sua suscetibilidade foi o preferido por muitos pesquisadores. Objetivo: Desenvolver um modelo experimental de megacólon em ratos inoculados com a cepa Y de Trypanosoma cruzi. Métodos: Utilizou-se 30 ratos, machos, distribuídos em três grupos inoculados com diferentes inóculos: Grupo A: 600000, Grupo B: 1000000 e Grupo C: 1500000 tripomastigotas sanguíneos da cepa Y de T. cruzi. Os animais foram sedados via intramuscular no tempo zero de inoculação (T0) e aos 60 dias após a inoculação (T60) para realização de enema opaco para avaliação da dilatação dos diferentes segmentos do cólon em estudo comparativo das medidas obtidas, com o auxílio de um paquímetro digital. A comprovação da infecção foi realizada com esfregaço de sangue coletado a partir da cauda do animal 18 dias após a inoculação com observação das formas sanguíneas. Resultados: Ao comparar o diâmetro intestinal dos animais inoculados com 60.0000 formas tripomastigotas no T0 de infecção com T60 dias após a inoculação, observou-se dilatação significativa entre os segmentos proximal, medial e distal (p<0,01), indicando o estabelecimento do modelo de megacólon. Além disso, ao comparar o diâmetro intestinal entre os diferentes segmentos, dentro do T0 de infecção e do T60 após a inoculação, observou-se alterações significantes (p<0,05). Conclusões: O modelo proposto mostrou-se factível para estudos in vivo das alterações decorrentes da infecção pelo T. cruzi e alterações funcionais do cólon. Além disso, as alterações manifestadas no cólon não são diretamente proporcionais ao tamanho do inóculo, mas sim ao tempo de infecção que os animais foram submetidos, visto que os inoculados com 600000 formas sanguíneas foram as que mais apresentaram alterações significantes.

Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

Experimental study of neural plasticity in chagasic megacolon in rats

This is a cross-sectional and experimental study. The purpose of the study was to measure enteric neurons in rats with chagasic megacolon. Twenty-three male rats inoculated with 1,500,000 trypomastigotes of the Y strain of Trypanosoma cruzi were used. The animals were sedated intramuscularly at zero inoculation time (T0 ) and at sixty days after inoculation (T60), to perform a barium enema test to evaluate the dilatation of the different segments of the colon. Evidence of infection was performed with a blood smear collected from the animals' tails 18 days after inoculation with observation of blood forms. Membrane preparations underwent dual-label immunofluorescence of global and nitrergic neurons with HuC / HuD antibody and nNOS antibody, respectively. Subsequently, quantitative and morphometric analysis of cecal and proximal colon segments were performed. In the quantitative analysis of the proximal colon segment there was a significant decrease in the numbers of total neurons (Hucolo p=0.001), as well as in the number of nitrergic neurons (NOScolo p=0.032) in the population of rats with chagasic megacolon in relation to the control group. In the cecal segment, this difference was not observed in the result of the total neuron counts (Huceco p=0.289) and nitrergic neurons (NOSececo p=0.466). In the morphometric analysis, considering only the cell body area, a significant difference in the size of the neurons with p=0.000 was observed in the cecal segment. The extensive loss of total neurons that cause predominance of nitrergic neurons contributes to the development of megacolon and neuronal volume increase in the cholinergic neurons, this plasticity does not reestablish the lost equilibrium, causing megacolon.

Megacolon tóxico en una paciente con colitis seudomembranosa / Toxic megacolon in a patient with colitis pseudomembranous

La colitis seudomembranosa es una patología relacionada con el uso de antibióticos. En raras ocasiones, evoluciona a megacolon tóxico que podría requerir resolución quirúrgica. Comunicamos el caso de una mujer de 22 años, que recibió amoxicilina/ácido clavulánico unos días antes de la consulta. Presentó diarrea, fiebre y vómitos. Radiografía y tomografía computarizada de abdomen: distensión de colon derecho >6 cm. Toxina para Clostridium: positiva. Comienza con el tratamiento médico y requiere cirugía por megacolon tóxico. El megacolon tóxico es una complicación infrecuente de la colitis seudomembranosa. Es rara en pacientes jóvenes y sin comorbilidades. Se llega al diagnóstico mediante los criterios de Jalan. La tasa de mortalidad se aproxima al 70%. Se debe mantener alto nivel de alerta ante signos de toxicidad sistémica y la dilatación colónica es diagnóstica de la entidad. El uso indiscriminado de antibióticos constituye un serio factor de riesgo.(AU)

Pseudomembranous colitis is a condition associated with the use of antibiotics. On rare occasions, it evolves to toxic megacolon which may require surgical resolution. We report the case of a 22-year-old woman who received amoxicillin/clavulanic acid a few days before the consultation. She referred diarrhea, fever and vomiting. Radiography and computed tomography of abdomen: distension of the right colon >6 cm. Clostridium toxin: positive. Medical treatment is administered and surgery is needed for toxic megacolon. Toxic megacolon is an infrequent complication of pseudomembranous colitis. It is rare in young patients without comorbidities. The diagnosis is reached using the Jalan criteria. The mortality rate approaches 70%. A high level of alertness should be maintained for signs of systemic toxicity and colonic dilation is diagnostic of the entity. Indiscriminate use of antibiotics is a serious risk factor.(AU)

Cardiac Arrest in a Patient with a Severely Distended Colon

Toxic megacolon is a devastating complication of colitis, which is commonly caused by inflammatory bowel disease. Frequently reported complications of toxic megacolon are bleeding, sepsis, colon perforation, and shock. Herein, we report a rare case of cardiac arrest that was likely caused by toxic megacolon in a 49-year-old male, who experienced 3 months of intermittent dyspnea and abdominal distension that abruptly worsened before presentation. Our case suggests that severe colon dilation complicated by toxic megacolon, especially accompanied by cardiopulmonary symptoms and signs, has the potential to progress to an abdominal compartment syndrome, which is a rare but life-threatening complication.

Idiopathic megacolon in a teenager treated by laparoscopic rectosigmoidectomy / Megacolon idiopático em adolescente tratado por retossigmoidectomia videolaparoscópica

Abstract Chronic constipation in children and adolescents is relatively common and a reason for consultation with pediatricians and proctologists. Most cases respond to medical treatment. Advanced cases of megacolon and megarectum can be treated surgically by Duhamel technique. This case report describes a 15-year-old patient with chronic intestinal constipation refractory to clinical treatment associated with megacolon and megarectum, which was surgically treated.

Resumo A constipação intestinal crônica em crianças e adolescentes é relativamente comum e motivo de consultas a pediatras e coloproctologistas. A maioria dos casos responde ao tratamento clínico. Casos avançados de megacolon e megarreto podem ser tratados cirurgicamente através da cirurgia de Duhamel. Este relato de caso descreve um paciente de 15 anos de idade com quadro de constipação intestinal crônica refratária ao tratamento clínico associada a megacolon e megarreto, o qual foi tratado cirurgicamente.

Fístula cólon-jejunal em paciente com fecaloma e volvos jejunal e sigmoideano devido à dolicomegassigmoide: relato de caso / Colon fistula-jejunal in patient with fecaloma and volvos jejunal sigmoideano and due to dolicomegassigmoide: case report

O dolicomegacólon consiste no aumento do comprimento e diâmetro dos segmentos do cólon, causando alteração da motilidade e interferindo no funcionamento do trânsito intestinal. Pode ser classificado em: Aganglionose Congênita ou Doença de Hirschsprung; o Megacólon Chagásico ou Adquirido e o Idiopático. Suas principais complicações são fecalomas, volvos, úlceras por estase fecal com isquemia da parede intestinal e perfurações. Relatamos o caso de uma paciente com quadros recorrentes de suboclusões intestinais que melhoravam com tratamentos clínicos conservadores. Os preparos mecânicos para realização de uma colonoscopia sempre foram inadequados devidos aos fecalomas, volvo sigmoideano e a dor forte apresentada pela paciente durante tais tentativas. Indicado laparotomia exploradora, evidenciou-se volvo de sigmoide com fecaloma impactado, aderido e fistulizado para um volvo de jejuno distal.

The dolicomegacólon is to increase the length and diameter of the parts of the colon, causing changes in motility and interfering with the operation of the intestinal transit. Can be classified into: Aganglionosis Congenital or Hirschsprung disease; the Chagas Disease or Acquired megacolon and idiopathic. Its main complications are fecalomas, volvulus, fecal stasis ulcers with ischemia of the bowel wall and perfurações. We report the case of a patient with recurrent episodes of intestinal sub-occlusion that improved with conservative medical treatment. Mechanical preparation for performing a colonoscopy were always inadequate due to fecalomas, sigmoideano volvo and severe pain presented by the patient during such attempts. Suitable exploratory laparotomy, revealed a sigmoid volvulus with impacted fecal impaction, and joined fistulized for volvo distal jejunum.

Megacolon chagásico en un adulto mayor / Chagasic colon enlargement in an elderly

Se presenta el caso clínico de un paciente de 63 años de edad, con antecedente de constipación crónica, quien asistió al puesto de salud de Santa Johana del municipio de Itamarandiba, estado brasileño de Minas Gerais, por presentar cansancio, decaimiento, constipación y distensión abdominal. Estos síntomas se correspondían con un megacolon chagásico; por tanto, fue remitido al Hospital Municipal de Itamarandiba donde se le indicó tratamiento quirúrgico. Luego de la colostomía la evolución fue favorable.

The case report of a 63 year patient, with history of chronic constipation who attended Santa Johana health institution in the municipality of Itamarandiba, Brazilian state of Minas Gerais, is presented due to tiredness, fatigue, constipation and enlarged abdomen.These symptoms were related to a chagasic colon enlargement; therefore, he was referred to Itamarandiba Municipal Hospital where surgical treatment was indicated. After colostomy the clinical course was favorable.

Preliminary exploration on accurately preoperative evaluation of colonic lesions in slow transit constipation complicated with adult megacolon / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the application value of colonic transit test (CTT) combined with anorectal manometry (ARM), barium enema (BE) and defecography (DFG) in accurately evaluating colonic lesions of slow transit constipation complicated with adult megacolon.</p><p><b>METHODS</b>Clinical data of 47 above patients admitted between October 2007 and February 2015 in the People's Hospital of Hunan Province were analyzed retrospectively. All the patients were examined with≥2 times of CTT combined with ARM and BE, and 42 cases received additional DFG at the same time, to evaluate colonic lesions before operation. Operative biopsy pathology was used as the standard. The sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) of positioning in the ascending colon and caecum, transverse colon and descending colon were calculated, and the consistency was represented by Kappa test(Kappa value≥0.75 indicates good consistency, meanwhile higher Kappa value indicates better consistency). The Heikkinen score was used to evaluate defecation function at postoperative 6 months.</p><p><b>RESULTS</b>The age of 47 patients was from 18 to 56 years old. Compared with intraoperative findings and biopsy pathology, the diagnostic coincidence rate was 89.4% by CTT combined with BE and DFG positioning, which suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=12), transverse colon (n=26) and descending colon (n=9), while intraoperative findings and biopsy pathology suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=11), transverse colon (n=23) and descending colon (n=13). The sensitivity was 88.3%, specificity 93.5%, PPV 92.1%, NPV 94.9% and Kappa value was 0.827(P<0.001). Procedures performed included segmental colectomy (n=8), subtotal colectomy (n=29), total colectomy (n=10). There was no serious complication during and after operation. Defecatory function was excellent in 24 cases (60.0%), good in 10 (25.0%), and moderate in 6 (15.0%) evaluated by Heikkinen score at postoperative 6 months. A total of 40 patients were followed up from 1 to 7 years (median 3 years) and there was no long-term diarrhea and recurrence of constipation or giant colon after operation.</p><p><b>CONCLUSION</b>Preoperative detection of CTT combined with ARM, BE and DFG in patients with slow transit constipation complicated with adult megacolon can make a more precise assessment of the extent of colonic lesions in advance, which has a good clinical predictive value.</p>

Megacólon psicogênico em gêmeos: relato de caso / Psychogenic megacolon in twins: case report

Megacólon psicogênico (MP) é uma doença difícil de ser diagnosticada. O artigo propõe a descrever um caso de MP em crianças gêmeas com idade de 6 anos. Sua relevância científica está na escassez de relatos na literatura sobre gêmeos que possuem esta patologia ao mesmo tempo.

Psychogenic Megacolon (MP) is a disease hard to diagnose. The article aims to describe a MP case in twin children at the age of six years. The scientific relevance of this submission lies in the scarcity of reports on twins with this same pathology at the same time.

Laparoscopic treatment of acquired megacolon / Tratamento laparoscópico do megacolo adquirido

In spite of the large experience acquired in the last 50 years with the surgical treatment of the Chagasic megacolon, the use of colorectal video laparoscopic surgery brought some controversy in several aspects of the treatment that already had been considered as resolved. One of the basic aspects to the establishment of the colorectal video laparoscopic surgery is to maintain the same procedure of the conventional surgery, since the results obtained in this operation were considered as curative. Constipation is only a symptom of a multisymptomatic disease, and the surgical treatment of acquired megacolon must be considered as definitive in the cure of this symptom; recurrence of the constipation or dilatation after a short period of time must be considered deleterious to the patient. Based in 41 years of experience with the Duhamel procedure in the treatment of 912 patients with acquired megacolon, the authors propose to apply the same technique in the surgical laparoscopic approach of acquired megacolon, including the same colon-recto-anal anastomosis. The results obtained in 56 patients operated on by laparoscopic approach showed the same curative results, but with lower morbidity. (AU)

Apesar da vasta experiência adquirida nos últimos 50 anos com o tratamento cirúrgico do megacolo adquirido, a introdução da cirurgia laparoscópica voltou a trazer controvérsia para alguns pontos anteriormente considerados como esclarecidos. Uma das regras básicas para a introdução da videolaparoscopia no tratamento das enfermidades colorretais tem sido a de se manter a técnica original utilizada em cirurgias pela via convencional, desde que os resultados observados na mesma conduzam à cura dos sintomas ou da enfermidade causal. Em especial, no referente ao tratamento cirúrgico do megacolo adquirido a proposta de um tratamento cirúrgico deve ter em mente que diferentemente do que ocorre com a cirurgia para tratamento de outras enfermidades, benignas ou malignas, neste caso não se almeja o tratamento causal da enfermidade, mas essencialmente a cura da manifestação de um de seus sintomas. É, pois, realmente importante que se considere um tratamento que não venha a resultar em bons resultados por apenas um curto espaço de tempo, mas que possibilite ao paciente livrar-se definitivamente de um sintoma, visto que é possível que em curto espaço de tempo ele venha a necessitar tratar outra manifestação sintomatológica (cardíaca ou esofágica) da enfermidade causal. Baseados na experiência adquirida nos últimos 50 anos (912 pacientes) com a técnica de Duhamel, em que o ponto importante é a realização de uma ampla anastomose da parede anterior do cólon abaixado à parede posterior (mucosa) do reto, ao mesmo tempo em que se anastomosa a parede posterior do cólon abaixado ao canal anal, são analisados os resultados obtidos com esta mesma técnica realizada por laparoscopia. Esta mesma incisão no canal anal serve para a retirada do segmento cólico ressecado, sem necessidade de laparotomia auxiliar. Os resultados observados em 56 pacientes quanto à cura da obstipação são similares aos registrados na cirurgia convencional, porém com um menor índice de morbidade, seja intra ou pós-operatória. (AU)

Myenteric plexus is differentially affected by infection with distinct Trypanosoma cruzi strains in Beagle dogs

Chagasic megaoesophagus and megacolon are characterised by motor abnormalities related to enteric nervous system lesions and their development seems to be related to geographic distribution of distinct Trypanosoma cruzi subpopulations. Beagle dogs were infected with Y or Berenice-78 (Be-78) T. cruzi strains and necropsied during the acute or chronic phase of experimental disease for post mortem histopathological evaluation of the oesophagus and colon. Both strains infected the oesophagus and colon and caused an inflammatory response during the acute phase. In the chronic phase, inflammatory process was observed exclusively in the Be-78 infected animals, possibly due to a parasitism persistent only in this group. Myenteric denervation occurred during the acute phase of infection for both strains, but persisted chronically only in Be-78 infected animals. Glial cell involvement occurred earlier in animals infected with the Y strain, while animals infected with the Be-78 strain showed reduced glial fibrillary acidic protein immunoreactive area of enteric glial cells in the chronic phase. These results suggest that although both strains cause lesions in the digestive tract, the Y strain is associated with early control of the lesion, while the Be-78 strain results in progressive gut lesions in this model.

Manejo del vólvulo del sigmoides en el Hospital PNP. Luis N. Saénz: 2004-2012 / Management of the volvulus of sigmoid in the Hospital PNP. Luis N. Saenz: 2004-2012

El presente trabajo de investigación titulado "Manejo del Vólvulo de Sigmoides". La investigación estuvo orientada a determinar los resultados del manejo de los pacientes con vólvulo de sigmoides en el Hospital PNP Luis N Sáenz en el periodo comprendido del 1 de Enero del 2004 al 31 de Diciembre del 2012, para ello se realizó un estudio, descriptivo, retrospectivo, de casos. La muestra seleccionada estuvo comprendida por 397 pacientes, que ingresaron al servicio de cirugía general del Hospital PNP Luis N Sáenz en el periodo que comprende el estudio. Los instrumentos empleados estuvieron conformados por una ficha de recolección de datos convenientemente elaborada para los fines de estudio. La frecuencia del Vólvulo de Sigmoides en el servicio de cirugía del Hospital PNP Luis N Sáenz en el periodo que. corresponde al estudio, es del 10.04 por ciento, el grupo etario más frecuente está entre los 60 y 69 años de edad (27.7 por ciento); el 78.3 por ciento (311) fueron del sexo masculino y 21.7 por ciento (86) del sexo femenino; el antecedente fisiológico más frecuente fue la constipación crónica (46.3 por ciento); en el 100 por ciento de los pacientes hubo dolor abdominal y no eliminación de heces y flatos; el diagnóstico definitivo se fundamentó, además de la evaluación clínica, en la Radiografía Simple de Abdomen en posición de pie en el 100 por ciento de los casos; Se operaron 333 pacientes (83.9 por ciento); de estos el procedimiento más frecuente fue la sigmoidectomía y anastomosis primaria termino terminal en el 77.6 por ciento de los casos. Hubo complicaciones en 53 pacientes operados siendo la más frecuente las bridas y adherencias postoperatorias. La mortalidad fue del 11.3 por ciento; siendo la causa más frecuente la sepsis abdominal y shock séptico. Hubo asociación estadísticamente significativa de mortalidad con el tratamiento quirúrgico, con el antecedente fisiológico de constipación, con la corta estancia hospitalaria, con el sexo femenino y con...