Hernia hiatal tipo IV: presentación de caso / Hiatal hernia type IV: case presentation

RESUMEN Fundamento: la hernia hiatal es la anormalidad más frecuente del tracto digestivo superior, se clasifica en cuatro tipos, estas hernias pueden ser por deslizamiento y paraesofágicas, estas últimas de presentación mucho menos frecuente en la práctica clínica como es el caso que se presentó tipo IV; la mayoría son asintomáticas son descubiertas incidentalmente en radiografías de tórax o en tomografía computarizada multicorte y cuando son sintomáticas muchas veces están asociadas a complicación. Objetivo: presentar un paciente con hernia hiatal tipo IV diagnosticada por tomografía computarizada multicorte. Presentación del caso: paciente masculino, de 58 años de edad, con antecedentes de hipertensión arterial, que refiere presentar una hernia diafragmática diagnosticada hace 15 años, que presenta dolor abdominal a tipo cólico de moderada intensidad acompañado de distensión abdominal eructos, vómitos y disnea. Al examen físico, abdomen globuloso que sigue los movimientos respiratorios, doloroso a la palpación superficial y profunda. En el tórax se auscultan ruidos hidroaéreos en el lado derecho. La tomografía computarizada multicorte demuestra la herniación de estómago, colon transverso y epiplón en hemitórax derecho a través del hiato esofágico. Conclusiones: las hernias hiatales son las anomalías más frecuentes del tracto digestivo superior pero las gigantes tipo IV con herniación de otras estructuras abdominales, como colon, omento, intestino delgado, hígado y páncreas son una forma infrecuente de presentación de las mismas. La tomografía computarizada multicorte y el estudio baritado de esófago-estómago-duodeno, resultan fundamentales para el diagnóstico y caracterización de estas lesiones.

ABSTRACT Background: the hiatal hernia is the most frequent abnormality of the upper digestive tract, which are classified into four types, these hernias can be by sliding and paraesophageal, the latter being much less frequent presentation in clinical practice as is the case presented type IV; most of them are asymptomatic and are discovered incidentally on chest x-rays or multi-slice CT and when they are symptomatic they are often associated with complications. Objective: to describe a patient with hiatal hernia type IV diagnosed by multi-slice CT. Case report: a 58-year-old male patient with a history of arterial hypertension, who reported having a diaphragmatic hernia diagnosed 15 years ago, who presents with abdominal pain with a moderate intensity of colic accompanied by abdominal distension, belching, vomiting, and dyspnea. At physical examination, globular abdomen that follows the respiratory movements, painful to superficial and deep palpation. Hydro-aerial noises are heard in the right side of the thorax. Multi-slice CT shows herniation of the stomach, transverse colon and omentum in the right chest cavity through the esophageal hiatus. Conclusions: hiatal hernias are the most frequent anomalies of the upper digestive tract but type IV giants with herniation of other abdominal structures, such as colon, omentum, small intestine, liver and pancreas are an infrequent form of presentation of them. Multi-slice CT and barium study of the esophagus, stomach and duodenum are fundamental for the diagnosis and characterization of these lesions.

Is Barium Enema Reliable for the Diagnosis of Total Colonic Aganglionosis?

PURPOSE: Barium enema is one of the diagnostic modalities for Hirschsprung'sdisease. The present study aimed to investigate the diagnostic accuracy of barium enema for Hirschsprung's disease, especially total colonic aganglionosis (TCA). METHODS: We retrospectively reviewed the medical records of all the patients who were diagnosed as having TCA and underwent a barium enema in Asan Medical Center Children's Hospital between January 1998 and December 2016. All the tests were performed and reviewed by pediatric radiologists. RESULTS: Among the total 19 patients with TCA who underwent barium enema, 9 patients (47.4%) had accurate radiographic results. Eight of the 13 neonate patients (61.5%) showed typical TCA radiological findings. However, only one of the 6 patients aged >4 weeks (16.7%) had accurate radiological diagnosis. CONCLUSION: Barium enema showed low accuracy for TCA, and its diagnostic performance was better in neonatal period than in those aged >4 weeks.

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.

Clinical features and imaging diagnosis of colonic stenosis in infants / 天津医药

Objective To explore clinical features and imaging diagnosis of colonic stenosis in infants. Methods Seven patients with congenital and acquired colonic stenosis proved by surgery were included in this study. The clinical features, erect abdominal plain radiograph and barium enema were analyzed. Results Of the 7 patients, 4 were congenital colonic stenosis with progressive abdominal distention and vomiting. The erect abdominal plain radiograph showed that intestinal inflation in 3 patients, low-set mechanical intestinal obstruction in 1 patient. In the remaining 3 patients who underwent ileostomy after neonatal necrotizing enterocolitis (NEC). Barium enema showed colonic stenosis in 5 patients and 2 were missed diagnosed who underwent contrast examination in the small intestine, and which showed stenosis in ascending colon near the ileocecus. Seven patients were all proved by surgery. The stenosis sites were located in sigmoid colon in 2 cases, in descending colon in 2 cases, in ascending colon in 2 cases and in transverse colon in 1 case. In 4 cases of congenital colonic stenosis, 2 cases underwent surgical staging, 1 case was followed up for half a year, showing normal defecation and well development, the other 1 case was lost visit after hospital discharge. The other 2 cases received end-to-end ileum and colon anastomosis, the abdominal distension was relieved in outpatient review, showing well-developed. Three cases with NEC and secondary colonic stenosis underwent staged surgery. Two patients were followed up in outpatient 2 weeks after operation. They were followed up for half a year, showing normal defecation and well-developed. The other 1 case was lost visit after hospital discharge. Conclusion Clinical features of colonic stenosis are very different and depend on the stenosis degree. NEC is the main cause of acquired colonic stenosis and it can be diagnosed by barium enema.

Diagnostic accuracy of barium enema findings in hirschsprung's disease / Acurácia do diagnóstico de achados do enema opaco na doença de hirschsprung

ABSTRACT Background: Hirschsprung's disease is the most common cause of pediatric intestinal obstruction. Contrast enema is used for evaluation of the patients with its diagnosis. Aim: To evaluate sensitivity, specificity, positive predictive value, and negative predictive value of radiologic findings for diagnosis of Hirschsprung in patients underwent barium enema. Methods: This cross sectional study was carried out in Imam Khomeini Hospital for one year starting from 2012, April. Sixty patients were enrolled. Inclusion criteria were: neonates with failure to pass meconium, abdominal distention, and refractory constipation who failed to respond with medical treatment. Transitional zone, delay in barium evacuation after 24 h, rectosigmoid index (maximum with of the rectum divided by maximum with of the sigmoid; abnormal if <1), and irregularity of mucosa (jejunization) were evaluated in barium enema. Biopsy was obtained at three locations apart above dentate line. PPV, NPV, specificity , and sensitivity was calculated for each finding. Results: Mean age of the cases with Hirschsprung's disease and without was 17.90±18.29 months and 17.8±18.34 months respectively (p=0.983). It was confirmed in 30 (M=20, F=10) of cases. Failure to pass meconium was found in 21(70%) cases. Sensitivity, specificity, PPV, and NPV were 90%, 80%, 81.8% and 88.8% respectively for transitional zone in barium enema. Sensitivity, specificity, PPV, and NPV were 76.7%, 83.3%, 78.1% and 82.1% respectively for rectosigmoid index .Sensitivity, specificity, PPV, and NPV were 46.7%, 100%, 100% and 65.2% respectively for irregular contraction detected in barium enema. Sensitivity, specificity, PPV, and NPV were 23.3%, 100%, 100% and 56.6% respectively for mucosal irregularity in barium enema. Conclusion: The most sensitive finding was transitional zone. The most specific findings were irregular contraction, mucosal irregularity, and followed by cobblestone appearance.

RESUMO Racional: A doença de Hirschsprung é a causa mais comum de obstrução intestinal pediátrica. Enema baritado é usado para a avaliação dos pacientes com o diagnóstico . Objetivo: Avaliar a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de achados radiológicos para diagnóstico de Hirschsprung em pacientes submetidos ao enema opaco. Métodos: Este estudo transversal foi realizado em Imam Khomeini Hospital por um ano a partir de abril de 2012. Sessenta pacientes foram incluídos. Os critérios de inclusão foram: recém-nascidos com insuficiência de passagem de mecônio, distensão abdominal, e constipação refratária sem resposta ao tratamento médico. Foram avaliadas no enema zona de transição, atraso na evacuação de bário após 24 h, índice retossigmoide (máximo do diâmetro do reto dividido pelo máximo do sigmóide; anormal se <1), e as irregularidades da mucosa (jejunização). Biópsia foi obtida em três localizações acima da linha dentada. VPP, VPN, especificidade e sensibilidade foram calculados para cada achado. Resultados: A idade média dos casos com a doença de Hirschsprung e sem foi 17,90±18,29 meses e 17,8±18,34 meses, respectivamente (p=0,983). Confirmou-se em 30 (M=20, F=10) dos casos. Falha no mecônio foi encontrada em 21 (70%) casos. Sensibilidade, especificidade, VPP e VPN foram de 90%, 80%, 81,8% e 88,8%, respectivamente, para a zona de transição no enema. Sensibilidade, especificidade, VPP e VPN foram 76,7%, 83,3%, 78,1% e 82,1%, respectivamente para o índice de retossigmoide. Sensitividade, especificidade, VPP e VPN foram 46,7%, 100%, 100% e 65,2%, respectivamente, para contração irregular detectada no enema baritado. Sensibilidade, especificidade, VPP e VPN foram de 23,3%, 100%, 100% e 56,6%, respectivamente, para a irregularidade da mucosa. Conclusão: O achado mais sensível foi zona de transição. Os achados mais específicos foram contração irregular, irregularidade da mucosa, e seguido por aparecimento de mucosa em forma de paralelepípedos.

Value of 24-hour Delayed Film of Barium Enema for Evaluation of Colon Transit Function in Young Children with Constipation

BACKGROUND/AIMS: A colon transit time test using radio-opaque markers (CTTRM) is considered the gold standard for evaluating colon transit function. A 24-hour delayed film of barium enema (BE) has been used as a supplementary method in structural evaluations. The aim of this study was to evaluate the utility of a 24-hour delayed BE film for assessing colon transit function in young children with constipation. METHODS: In total, 93 children with constipation who performed both single-contrast BE and CTTRM were enrolled in this study. Of these, the data from 70 children were analyzed (males 33, females 37; mean age [range], 5.63 ± 2.94 [2-14] years). The basic principle of the study is "velocity = distance/time". Time values were identified in both studies, and the colon length and distance of barium movement were measured on the 24-hour delayed BE film. Thus, colon transit velocity values could be calculated using both methods. The correlation between colon transit velocity using a 24-hour delayed BE film versus CTTRM was analyzed statistically. RESULTS: Median value (interquartile range) of colon transit velocity using CTTRM was 1.57 (1.07-2.89) cm/hr, and that using BE of that was 1.58 (0.94-2.07) cm/hr. The Spearman correlation coefficient was 0.438 (P < 0.001) for the overall group. The correlation was strongest in children younger than 4 years (r = 0.537, P = 0.032). CONCLUSIONS: Although the correlation between BE and CTTRM was not very strong, the 24-hour delayed BE film could provide broad information about colon transit function in young children, especially those under 4 years who usually cannot undergo CTTRM.

Invaginación intestinal en el niño, respuesta al tratamiento médico / Intestinal intussusception in children and response to medical treatment

INTRODUCCIÓN: la invaginación intestinal idiopática es la causa más frecuente de abdomen agudo en el lactante y en el transicional. El tratamiento de elección es el médico, siempre que cumpla los criterios de inclusión, por ser menos invasivo, presentar menos complicaciones, menor costo y más efectivo, al compararlo con el tratamiento quirúrgico. OBJETIVO: evaluar la efectividad del tratamiento médico en niños con invaginación intestinal. MÉTODOS: se realizó un estudio descriptivo, longitudinal y retrospectivo de 55 pacientes con el diagnóstico de invaginación intestinal idiopática con criterios de tratamiento médico, que ingresaron en el servicio de Cirugía Pediátrica del Hospital Pediátrico Universitario Centro Habana, en el período de enero de 2000 a diciembre de 2012. Los métodos de reducción empleados fueron mediante neumocolon y el colon por enema baritado. Se utilizó el test de chi cuadrado para el análisis. RESULTADOS: el tratamiento con enema de bario predominó ligeramente sobre el neumocolon (28/27) para 50,9 % y 49,1 % respectivamente. Su efectividad fue mayor para el neumocolon (77,8 %), en comparación con el enema de bario (57,1 %) (RR= 1,38, p> 0,05). La efectividad de estos procederes está en relación con el tiempo de evolución; a menor tiempo, mejores resultados. CONCLUSIONES: no se encontró una variación significativa en los resultados en los 2 procederes médicos propuestos, aunque fue más efectivo el neumocolon que el enema de bario.

INTRODUCTION: idiopathic intestinal intussusceptions are the most frequent cause of acute abdomen in the breastfed baby and in the transitional infant. The medical treatment is the choice provided that the inclusion criteria are met since it is less invasive, costly and complicated but more effective than the surgical treatment. OBJECTIVE: to evaluate the effectiveness of the medical treatment in children with intestinal intussusception. diagnosed with idiopathic intestinal intussusceptions and met the medical treatment criteria met; they had been admitted to the pediatric surgical service of Centro Habana university pediatric hospital in the period of January 2000 through December 2012. The used methods were pneumocolon and barium enema colon. Chi-square test was used for the analysis. RESULTS: the barium enema treatment slightly prevailed over pneumocolon (28 vs. 27) for 50.9 % and 49.1 %, respectively. The pneumocolon effectiveness (77.8 %) was higher than the barium enema (57.1 %) (RR= 1.38, p> 0.05). The effectiveness of both procedures depends on the time of progression of disease, which means that best results go to less time of progression. CONCLUSIONS: no significant variations were found in the results of the two suggested medical procedures, although pneumocolon was more effective than barium enema.

Avaliação topográfica do cólon transverso pelo enema opaco: definição, prevalência e proposta de classificação da ptose do cólon transverso / Topographic evaluation of the transverse colon by barium enema: definition, prevalence and proposed of a classification of the enteroptosis

Objetivo: a ptose do cólon foi definida em 1922 por Cannon como rebaixamento do segmento transverso, em forma de V, podendo estender-se até o nível pélvico, sendo que quanto mais agudos forem os ângulos das flexuras esplênica e hepática, maior será a gravidade da sintomatologia, que inclui flatulência, distensão abdominal e constipação. Embora seja consenso na prática clínica que a enteroptose seja detectada frequentemente nos enemas opacos, ainda não há unanimidade na sua definição conceitual, além da inexistência de dados sobre sua prevalência. A possível relação entre esta alteração patológica e a constipação intestinal torna ainda mais relevante e instigante o seu estudo. Objetivo: definir e estabelecer a prevalência em nosso meio, e propor uma classificação radiológica para a enteroptose. Método: este estudo foi realizado em duas etapas. Na primeira foram analisados 193 enemas opacos digitais, visando estabelecer a prevalência da ptose. E a segunda propôs uma classificação topográfica em graus (0, 1 e 2), sendo a de Grau 2 considerada como a enteroptose verdadeira. Resultados: a prevalência de enteroptose verdadeira foi de 35 (18%) dos 193 enemas opacos examinados, sendo estatisticamente mais prevalente em mulheres (p=0,039). Considerando a prevalência mundial da constipação de até 20%, é plausível supor que possa haver correlação entre constipação e ptose Grau 2. Conclusão: não há na literatura mundial estudos sobre prevalência ou classificação da ptose do transverso, e acreditamos que a presente classificação em graus, associada à avaliação sintomatológica baseada nos critérios de Roma III, será um grande norteador para indicar a conduta diagnóstica na constipação.

Introduction: the enteroptosis was defined in 1922 by Cannon as flattening of the transverse segment, in V form, extending to the pelvic level, and if more acute are the angles of splenic and liver flexures, greater will be the symptom including flatulence, bloating and constipation. Although consensus in clinical practice often detected enteroptosis in barium enemas, there is no unanimity in the conceptual definition, besides there is no data about the prevalence. The possible relationship between this pathological change and constipation becomes this study even more relevant and compelling. Objective: define, establish the prevalence in our environment and propose a radiological classification for enteroptosis. Method: this study was conducted in two phases. In the first 193 digital barium enemas were analyzed to establish the prevalence of eneroptosis. The second proposed a topographic classification in degrees (0. 1 and 2), being considered Degree 2 as the true enteroptosis. Results: the prevalence of true enteroptosis was 35 (18 %) of the 193 examined barium enemas, being statistically more prevalent in women (p=0.039). Given the global prevalence of constipation up to 20% it is plausible that there may be a correlation between constipation and enteroptosis Degree 2. Conclusion: there are no studies in the literature about the prevalence or classification of enteroptosis, and we believe that the present classification in degrees, associated with the symptomatology assessment based in Rome III criteria will be a great guiding to indicate the diagnostic of constipation.

How Reliable Are Diagnostic Methods of Hirschsprung Disease? / 소아외과

PURPOSE: The purpose of this study was to compare the diagnostic accuracy of the non-invasive diagnostic methods and rectal suction biopsy for the detection of Hirschsprung disease (HD). METHODS: We reviewed diagnostic methods and results retrospectively in patients who underwent anorectal manometry, barium enema and rectal suction biopsy for the diagnosis of HD at Asan Medical Center from January 2000 to December 2012. RESULTS: There were 97 patients (59 neonates and 38 infants) in the study period. The overall accuracy of anorectal manometry for the diagnosis of HD was 71.1% and its sensitivity was 51.4% (48.1% in neonate and 62.5% in infant, respectively) and its overall specificity was 82.3% (81.3% in neonate and 83.3% in infant, respectively). The Overall accuracy of barium enema was 66.0% (72.8% in neonate and 55.3% in infant, respectively) and specificity of barium enema was 53.2% (56.3% in neonate and 50.0% in infant, respectively). These results were lower than those of anorectal manometry. The overall sensitivity of barium enema was 88.6% (92.6% in neonate and 75.0% in infant, respectively) and it was higher than the sensitivity of anorectal manometry. Histological studies confirmed HD in 35 patients, in one of whom the suction biopsy showed negative finding. CONCLUSION: Accuracy of non-invasive methods for diagnosis of HD in our study is lower than those in previous study, so we need to improve the quality of diagnostic tools in our hospital. We conclude that the rectal suction biopsy is the most accurate test for diagnosing HD, so the biopsy to confirm the diagnosis of the HD is very important.

Colonic Strictures after Necrotizing Enterocolitis in Infants: Case Series.

The fate of neonates with necrotizing enterocolitis is variable, with colonic strictures being one rare phenomenon after the insult. We describe here two infants with colonic strictures, which developed secondary to neonatal necrotizing enterocolitis. Infants recovered or in the process of recovery after it should be investigated for possibility of development of colonic strictures.

Clinical Analysis, Management and Outcome of Intussusception in Children.

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and management is essential to reduce morbidity and mortality. The objective was to To review the diagnostic criteria of intussusception in infants and children to increase awareness of attending personnel for effective management decrease the rate of operative treatment and complications. Materials and Methods: The data collected of all 38 patients admitted in Kanti Childrens Hospital between 2008 September to 2009 September were studied prospectively. Each patient was evaluated in regard to age at presentation, sex, signs and symptoms, diagnostic method, treatment (operative, non-operative). Results: During study period of one year there were a total of 20 (52%) males and 18 (48%) females of age 3 months to 6 years. Pain abdomen was seen in 25(66%), vomiting 16(42%), diarrhea 15(40%), blood mixed with stool 10(26%). These symptoms were seen in different combination. X-ray erect abdomen was done in 15 and ultrasound in all 38 cases. Ten out of 15 (66.6%) patients with early presentation and diagnosis had successful barium enema reduction.10 (66.6%) had successful reduction and admitted to our hospital. 28(74%) patients were undergone laparatomy. Among 28 (74%) patents that had lapartotomy, manual reduction was successful in 18 and 10 required bowel resection and anastomosis. Conclusion: The awareness of early features of intussusception is important for early referral to tertiary centers for successful non-operative barium reduction and reduce the need of laparotomies in children.

Routine barium enema prior to closure of defunctioning ileostomy is not necessary / 대한외과학회지

PURPOSE: The use of barium enemas to confirm the anastomotic integrity prior to ileostomy closure is still controversial. The purpose of the study was to determine the utility of routine contrast enema prior to ileostomy closure and its impact on patient management in patients with a low pelvic anastomosis. METHODS: One hundred forty-five patients had a temporary loop ileostomy constructed to protect a low colorectal or coloanal anastomosis following low anterior resection for rectal cancer. All patients were evaluated by physical examination, proctoscopy, and barium enema prior to ileostomy closure. RESULTS: The median time from ileostomy creation to closure was 8 months. Five (3.5%) of the 144 patients were found to have clinically relevant strictures at the colorectal anastomosis on routine barium enema. One patient (0.7%) showed anastomotic leak on their barium enema. Overall, 141 patients (97.9%) had an uncomplicated postoperative course. Postoperative complication occurred in three patients (2.1%). None of them showed abnormal barium enema finding, which suggested that routine contrast enema examination did not predict postoperative complication. CONCLUSION: Routine barium enema evaluation of low pelvic anastomoses before loop ileostomy closure did not provide any additional information for postoperative colorectal anastomotic complication.

Comparison between CT Colonography and Double-Contrast Barium Enema for Colonic Evaluation in Patients with Renal Insufficiency

OBJECTIVE: To compare the CT colonography (CTC) and double-contrast barium enema (DCBE) for colonic evaluation in patients with renal insufficiency. MATERIALS AND METHODS: Two sequential groups of consecutive patients with renal insufficiency who had a similar risk for colorectal cancer, were examined by DCBE (n = 182; mean +/- SD in age, 51 +/- 6.4 years) and CTC (n = 176; 50 +/- 6.7 years), respectively. CTC was performed after colon cleansing with 250-mL magnesium citrate (n = 87) or 4-L polyethylene glycol (n = 89) and fecal tagging. DCBE was performed after preparation with 250-mL magnesium citrate. Patients with colonic polyps/masses of > or = 6 mm were subsequently recommended to undergo a colonoscopy. Diagnostic yield and positive predictive value (PPV) for colonic polyps/masses, examination quality, and examination-related serum electrolyte change were retrospectively compared between the two groups. RESULTS: Both the CTC and DCBE were positive for colonic polyps/masses in 28 (16%) of 176 and 11 (6%) of 182 patients, respectively (p = 0.004). Among patients with positive findings, 17 CTC and six DCBE patients subsequently underwent a colonoscopy and yielded a PPV of 88% (15 of 17 patients) and 50% (3 of 6 patients), respectively (p = 0.089). Thirteen patients with adenomatous lesions were detected in the CTC group (adenocarcinoma [n = 1], advanced adenoma [n = 6], and non-advanced adenoma [n = 6]), as compared with two patients (each with adenocarcinoma and advanced adenoma) in the DCBE group (p = 0.003). Six (3%) of 176 CTC and 16 (9%) of 182 DCBE examinations deemed to be inadequate (p = 0.046). Electrolyte changes were similar in the two groups. CONCLUSION: In patients with renal insufficiency, CTC has a higher diagnostic yield and a marginally higher PPV for detecting colorectal neoplasia, despite a similar diagnostic yield for adenocarcinoma, and a lower rate of inadequate examinations as compared with DCBE.

Barium enema reduction of intussusception in a developing country / Reducción de la intususcepción mediante enema de bario en un país en vías de desarrollo

OBJECTIVE: To determine the current success rate of barium enema reduction of intussusception and to investigate the factors affecting successful reduction. DESIGN AND METHODS: All patients admitted to the Eric Williams Medical Sciences Complex during the 8-year period from January 1, 2000 to December 31, 2007 with a diagnosis of intussusception were included. Patients' demographics, date and time of admission, clinical features, success of barium reduction, surgical findings and length of stay were recorded. The SPSS 12.0 programme was used for data analysis. RESULTS: There were 65 cases of intussusception. Vomiting and rectal bleeding were the most common presenting symptoms (55, 85% / 49, 75%). Fifty-eight patients underwent barium enema reduction with 41.4% (24/58) having successful reduction. Factors which significantly increased the success rate included males older than 12 months, non-opioid analgesia or no analgesia and an admission to enema reduction time of less than 6 hours. CONCLUSION: The successful reduction rate is relatively low (41%). A higher index of suspicion is needed in order to make a timely diagnosis and institute appropriate treatment quickly.

OBJETIVO: Determinar la tasa de éxito actual de reducción de la intususcepción por edema de bario e investigar los factores que afectan la reducción exitosa. PLAN Y MÉTODOS: Todos los pacientes ingresados en el Complejo de Ciencias Médicas Eric Williams por el período de 8 años que va del 1ero de enero de 2000 al 31 de diciembre de 2007 con diagnóstico de intususcepción, fueron incluidos. Se registró toda la información relacionada con los datos demográficos de los pacientes, fecha y tiempo de ingreso, características clínicas, éxito de la reducción por bario, resultados quirúrgicos, y duración de la hospitalización. Se usó el programa SPSS 12.0 para el análisis de los datos. RESULTADOS: Se produjeron 65 casos de intususcepción. Los vómitos y el sangramiento rectal fueron los síntomas presentes más comunes (55, 85%/49, 75%). A cincuenta y ocho pacientes se les practicó la reducción por enema de bario, logrando 41.4% (24/58) una reducción exitosa. Los factores que aumentaron la tasa de éxito de manera significativa fueron los varones con más de 12 meses, la analgesia no-opioide o ninguna analgesia, y un tiempo de ingreso para la reducción por enema, de menos de 6 horas. CONCLUSIÓN: La tasa de reducción exitosa es relativamente baja (41%). Se requiere un índice más alto de sospecha para hacer un diagnóstico oportuno e iniciar un tratamiento apropiado rápidamente.

A Case of Malignant Duodenocolic Fistula / 대한소화기내시경학회지

Malignant duodenocolic fistula is a rare complication of colon cancer, and this usually develops as the right-side colon cancer or colonic hepatic flexure cancer infiltrates into the second portion of the duodenum. Six Korean cases of this malignancy have been previously reported on. The patients usually complain of watery diarrhea, feculant vomiting and weight loss that can be attributed to the altered normal flora. Barium enema has been the diagnostic procedure of choice to demonstrate the fistulous tract, but with the technical development of gastroendoscopy, the primary procedure is also changing. Curative resection is not possible in many cases. Palliative ileotransverse colostomy with gastrodjejunostomy is performed to relieve symptoms, but it cannot completely prevent the vomiting or diarrhea. We herein present a case of malignant duodenocolic fistula in a patient who had been suffering from indigestion, loose stool and feculant vomiting for one year. This case was diagnosed by endoscopy and the patient underwent a palliative operation.

Divertículo gigante de colon: presentación de un caso / Giant colonic diverticulum: case report

El divertículo gigante de colon (DGC) es una rara complicación de la enfermedad diverticular. Se considera divertículo gigante cuando su diámetro supera los 4 cm. Descrito por primera vez en la literatura francesa en el año 1946, se han publicado hasta la fecha 155 casos. Nuestro paciente, de 59 años, refirió clínica de dolor abdominal leve de 4 meses de evolución. Se le solicitó un estudio de colon por enema, el que reveló una formación sacular de 15 cm en colon sigmoideo, de contenido aéreo y cuello corto, a través del cual se opacificó la cavidad con la sustancia baritada, confirmando el diagnóstico de DGC. Al paciente se le realizó, además, tomografía computada y resonancia magnética. El diagnóstico se confirmó con cirugía y estudio histopatológico. Se practicó una resección sigmoidea con DGC y anastomosis colorrectal lateroterminal. El estudio anatomopatológico informó DGC tipo II.

Giant colonic diverticulum is a rare diverticular disease complication. It is considered giant when its diameter is longer than 4 cms. It was reported the first time by french authors in 1946 and there is 155 cases reported in world literature. Our patient aged 59 years old, referred four month of abdominal pain. A barium enema was made showing a sigmoid cavity with air and fill of barium contrast with short neck continuing with the colon lumen. It was also studied with CT and MRI. The diagnosis was confirmed by surgery and histopathologic exam. The pathologic report informed giant colonic diverticulum type II.

Fechamento de colostomias: com ou sem estudo do cólon? / Colostomy closure: with or without pre-operative colon study

O estudo pré-operatório do cólon para fechamento de colostomias em alça devido a trauma vem perdendo importância nos últimos anos. A necessidade de se avaliar as alterações anatômicas pós-traumáticas do cólon vai de encontro aos custos, desconforto e morbidade dos exames. OBJETIVO: analisar a real necessidade do estudo prévio do cólon no fechamento de colostomia pós-trauma. MÉTODO: foram analisados, retrospectivamente, 98 prontuários de pacientes, no período de janeiro de 2004 a janeiro de 2006, portadores de colostomia em alça confeccionada após traumatismo e que foram alocados em dois grupos: grupo A, composto de 32 casos com estudo do cólon e o grupo B, 66 casos sem estudo colônico prévio. RESULTADOS: 94,9 por cento dos pacientes eram do sexo masculino e a média de idade foi de 27 anos. O tempo de permanência da colostomia foi, em média, 32,8 meses, sendo o flanco esquerdo a localização mais comum em ambos os grupos. A morbidade geral foi de 7,1 por cento, sendo 3,1 por cento de complicações no grupo A e 9,1 por cento no grupo B (p=0,16) e sem mortalidade. A complicação mais freqüente foi hematoma da parede abdominal em cinco casos (5,1 por cento), e apenas um caso de infecção de ferida operatória (1 por cento), e mais um de deiscência de anastomose (1 por cento). CONCLUSÃO: o estudo pré-operatório do cólon para fechamento de colostomia feita após trauma colorretal é dispensável.

The pre-operative study of the colon before loop colostomy closure in trauma patients has been loosing its importance since last few years. The need of evaluating the pos-traumatic anatomic alterations of the colon goes against the costs and morbidity of the examinations. OBJECTIVE: to analyze the real necessity of the colon study before colostomy closure in trauma patients. METHODS: a retrospective study of 98 patients submitted to colostomy closure after trauma, from January of 2004 to January of 2006 was carried out. They were divided in two groups: group A, composed of 32 patients with previews colon study and group B, composed of 66 patients without it. RESULTS: 94.9 percent of all patients were male and the average age was 27 years old. The time interval between colostomy and its closure was in average 32.8 months. The left side location was the most common sight. Overall morbidity was 7.1 percent, being 3.1 percent in group A and 9.1 percent in group B (p=0,16). The operative mortality was zero in both groups. The most common complication was wound haemathomas (5,1 percent) and only one case of wound infection. Anastomosis dehiscence occurred also in only one case, from group B. CONCLUSION: the pre-operative study of the colon for loop colostomy closure in trauma patients is not necessary.

A Case of Idiopathic Colitis Developed after Barium Enema / 대한소화기학회지

It has been reported that colitis may be associated with intrarectally administered drugs or chemicals. Colonotoxicity may results from conventional medical therapy, herbal or other illicit drugs, contrast materials, and detergents. Clues that a colitis may be due to an intrarectally administered agent include perianal excoriation, segmental distal colitis due to a concentration gradient from enema administration, and recent diagnostic or therapeutic administration of high risk solutions such as hypertonic contrast agents or detergent enemas. Barium is a highly viscous contrast agent that is insoluble in water. Barium enemas are usually very safe. Also, no case report of barium-induced chemical colitis has been reported yet. We report a case of chemical colitis with colonic stricture occurring after the barium enema for diagnostic purpose.

Divertículo cólico gigante: manifestación infrecuente de una enfermedad muy frecuente / Giant colic diverticulum: rare manifestation of a very common disease

: A rare complication of diverticulosis of the colon is a giant colonic diverticulum. The condition was first described in French literature in 1946 and English literature in 1953. We communicate four personal cases including diagnosis by different modalities, evolution and surgical treatment, photography of pathological specimens and X ray study of the resected giant diverticula and colonic segment. A short review of the related literature is included.

Una complicación infrecuente de la diverticulosis del colon es el divertículo cólico gigante. Esta patología fue descrita inicialmente en la literatura francesa en 1946 y en la inglesa en 1953. Comunicamos cuatro casos, incluyendo los diagnósticos mediante diferentes exámenes de imágenes, evolución y tratamiento quirúrgico con fotografías intraoperatorias y de las piezas resecadas, como también radiografías de los especímenes. Se incluye una revisión concisa de la literatura.

Is Barium Enema Prior to Ileostomy Closure Necessary?

PURPOSE: A barium enema is frequently performed to check for healing prior to ileostomy closure, but there have been reports that ileostomy closure without a contrast study is safe in selected patients. The aim of this study was to assess the necessity of a routine barium enema prior to ileostomy closure. METHODS: Between January 1994 and June 2005, 51 patients with a temporary loop ileostomy who had a barium enema prior to ileostomy closure at Chonbuk National University Hospital were retrospectively reviewed. These patients were divided into 2 groups, the protective ileostomy group and the ileostomy-after-leakage group. To examine the necessity of a routine barium enema prior to ileostomy closure, we assessed whether the barium enema results changed management and whether there were pelvic sepsis and obstructive symptoms following ileostomy closure. RESULTS: In the protective ileostomy group (n=39), the barium enema was performed after a mean of 59 days (range: 27~151 days). There were no abnormal findings at the barium enema, no schedule changes, no pelvic sepsis, and no obstructive symptoms following ileostomy closure. In the ileostomy-after-leakage group (n=12), the barium enema was performed after a mean of 54 days (range: 30~82 days). In 2 patients, with barium enemas at 33 days and 36 days, an anastomotic leakage was found, and ileostomy closure was delayed. CONCLUSIONS: In patients with a protective ileostomy, a barium enema prior to ileostomy closure is unnecessary, but in patients with an ileostomy after leakage, barium enema should be considered.