Unusual presentation of colon cancer as rectal prolapse in middle-aged male.

Rectal prolapse is typically a benign idiopathic condition. Rarely, rectal prolapse can be due to or associated with colorectal carcinoma. Here we present a middle-aged gentleman with no previous medical or surgical history, who presented with rectal prolapse secondary to sigmoid adenocarcinoma.

Alcohol decreases intestinal ratio of Lactobacillus to Enterobacteriaceae and induces hepatic immune tolerance in a murine model of DSS-colitis.

Alcohol can potentiate disease in a mouse model of dextran sodium sulfate (DSS) colitis; however, the underlying mechanism remains to be established. In this study, we assessed whether the potentiated disease could be related to Enterobacteriaceae and Lactobacillus, as changes in their relative abundance can impact intestinal health. We also assessed whether the intestinal barrier is compromised after alcohol and DSS as it may increase bacterial translocation and liver inflammation. Mice were administered DSS followed by binge ethanol or water vehicle, generating four experimental groups: (Control+Vehicle, Control+Ethanol, DSS+Vehicle, DSS+Ethanol). DNA was isolated from colon and cecal contents followed by qPCR for levels of Enterobacteriaceae and Lactobacillus. Colon and liver sections were taken for histology. Intestinal epithelial cells were isolated from the colon for RNA expression. DSS+Ethanol cecal contents exhibited a 1 log increase in Enterobacteriaceae (p < .05), a 0.5 log decrease in Lactobacillus, and a 1.5 log decrease (p < .05) in the Lactobacillus:Enterobacteriaceae ratio compared to DSS+Vehicle, with similar trends in colon contents. These changes correlated with shorter colons and more weight loss. Irrespective of ethanol administration, DSS compromised the mucosal barrier integrity, however only DSS+Ethanol exhibited significant increases in circulating endotoxin. Furthermore, the livers of DSS+Ethanol mice had significantly increased levels of triglycerides, mononuclear cells, yet exhibited significantly depressed expression of liver inflammatory pathways, suggestive of tolerance induction, compared to mice receiving DSS+Vehicle. Our results suggest that ethanol after DSS colitis increases the intestinal burden of Enterobacteriaceae which may contribute to intestinal and liver damage, and the induction of immune tolerance.

Chilaiditi Syndrome: A Case Report Highlighting the Intermittent Nature of the Disease.

BACKGROUND: Chilaiditi syndrome is a phenomenon where there is an interposition of the colon between the liver and the abdominal wall leading to clinical symptoms. This is distinct from Chilaiditi sign for which there is radiographic evidence of the interposition, but is asymptomatic. CASE PRESENTATION: Here, we present the case of a patient who, despite having clinical symptoms for a decade, had a delayed diagnosis presumably due to the interposition being intermittent and episodic. CONCLUSIONS: This case highlights the fact that Chilaiditi syndrome may be intermittent and episodic in nature. This raises an interesting question of whether previous case reports, which describe complete resolution of the syndrome after nonsurgical intervention, are perhaps just capturing periods of resolution that may have occurred spontaneously. Because the syndrome may be intermittent with spontaneous resolution and then recurrence, patients should have episodic follow-up after nonsurgical intervention.

Alcohol enhances symptoms and propensity for infection in inflammatory bowel disease patients and a murine model of DSS-induced colitis.

Over 1.4 million Americans have been diagnosed with inflammatory bowel disease (IBD), and ulcerative colitis (UC) makes up approximately half of those diagnoses. As a disease, UC cycles between periods of remission and flare, which is characterized by intense abdominal pain, increased weight loss, intestinal inflammation, rectal bleeding, and dehydration. Interestingly, a widespread recommendation to IBD patients for avoidance of a flare period is "Don't Drink Alcohol" as recent work correlated alcohol consumption with increased GI symptoms in patients with IBD. Alcohol alone not only induces a systemic pro-inflammatory response, but can also be directly harmful to gut barrier integrity. However, how alcohol could result in the exacerbation of UC in both patients and murine models of colitis has yet to be elucidated. Therefore, we conducted a retrospective analysis of patients admitted for IBD with a documented history of alcohol use in conjunction with a newly developed mouse model of binge alcohol consumption following dextran sulfate sodium (DSS)-induced colitis. We found that alcohol negatively impacts clinical outcomes of patients with IBD, specifically increased intestinal infections, antibiotic injections, abdomen CT scans, and large intestine biopsies. Furthermore, in our mouse model of binge alcohol consumption following an induced colitis flare, we found alcohol exacerbates weight loss, clinical scores, colonic shortening and inflammation, and propensity to infection. These findings highlight alcohol's ability to potentiate symptoms and susceptibility to infection in UC and suggest alcohol as an underlying factor in perpetuating symptoms of IBD.

Burn Injury Alters the Intestinal Microbiome and Increases Gut Permeability and Bacterial Translocation.

Sepsis remains one of the leading causes of death in burn patients who survive the initial insult of injury. Disruption of the intestinal epithelial barrier has been shown after burn injury; this can lead to the translocation of bacteria or their products (e.g., endotoxin) from the intestinal lumen to the circulation, thereby increasing the risk for sepsis in immunocompromised individuals. Since the maintenance of the epithelial barrier is largely dependent on the intestinal microbiota, we examined the diversity of the intestinal microbiome of severely burned patients and a controlled mouse model of burn injury. We show that burn injury induces a dramatic dysbiosis of the intestinal microbiome of both humans and mice and allows for similar overgrowths of Gram-negative aerobic bacteria. Furthermore, we show that the bacteria increasing in abundance have the potential to translocate to extra-intestinal sites. This study provides an insight into how the diversity of the intestinal microbiome changes after burn injury and some of the consequences these gut bacteria can have in the host.

Combined laparoscopic cholecystectomy with ileostomy reversal: A method of delayed definitive management of postoperative gallstone pancreatitis.

Traditional management of gallstone pancreatitis (GP) has been to perform cholecystectomy during the same hospital admission after resolution. However, when GP develops in the immediate postoperative period from a major colorectal operation, cholecystectomy may be fraught with difficulty due to the inflammatory response that occurs. Thus, delaying cholecystectomy until the inflammatory response subsides may be worthwhile, and it maximizes the chances of completing the cholecystectomy laparoscopically. We have described our management of 2 patients with GP occurring after colorectal operations, which required proximal diverting ileostomy. In both cases, we deferred management of GP with either endoscopic retrograde cholangiopancreatography (ERCP) or medical conservative measures during the acute attack and performed laparoscopic cholecystectomy during ostomy reversal surgery utilizing the existing ostomy takedown site for port placement. Both patients tolerated this management well.

Obstructive sleep apnea in general surgery patients: is it more common than we think?

BACKGROUND: To determine the risk of obstructive sleep apnea (OSA) in preoperative surgical patients. METHODS: Three hundred seventy-one new patients presenting to an outpatient general surgery clinic were prospectively screened for risk of OSA using the STOP-Bang questionnaire. Patients were classified as high risk with a score of >3 on the STOP-Bang questionnaire. Polysomnography results were reviewed when available. RESULTS: Complete questionnaires were available on 367 (98.9%) patients. Two hundred thirty-seven patients (64.6%) were classified as high risk of OSA on the questionnaire. Polysomnography results available on 49 patients revealed severe OSA in 17 (34.5%), moderate in 8 (16.5%), mild in 14 (28.5%), and no OSA in 10 (20.5%) patients. The positive predictive value and sensitivity of the questionnaire were 76%, and 92% for the STOP-Bang questionnaire, respectively. The sensitivity increased to 100% for severe OSA. CONCLUSION: Preoperative screening for OSA should be considered to diagnose patients at risk.

Common anorectal disorders for the intensive care physician.

Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.

Development of cerebral metastasis after medical and surgical treatment of anal squamous cell carcinoma.

Squamous cell carcinoma of the anus is a relatively uncommon GI malignancy. When it does occur, it metastasizes in only a small minority of patients. Spread of anal squamous cell carcinoma to the brain is exceedingly rare, and has been previously reported only three times in the medical literature. We report the case of a 67 year old male who was diagnosed on presentation with a poorly differentiated anal squamous cell carcinoma that already had a solitary metastasis to the liver. While the tumors were initially responsive to chemoradiotherapy, the patient's primary and liver lesions recurred. The patient then underwent synchronous abdominoperineal resection for the primary lesion and a liver lobectomy for the metastasis. Soon thereafter, the patient developed focal neurologic symptoms and was found to have an intracranial lesion that on biopsy demonstrated metastatic squamous cell carcinoma. This case highlights the fact that patients with a previous history of anal squamous cell carcinoma can occasionally develop cerebral metastasis. Furthermore, cerebral metastases from anal squamous cell carcinoma portend a dismal prognosis even in the face of aggressive medical and surgical therapy.

Extrapulmonary small cell carcinoma of the anal canal: a case report and review of the literature.

Purpose. Extrapulmonary small cell carcinoma affecting the anal canal is a rare and poorly understood entity which can, in its early stages, masquerade as benign anorectal disease such as hemorrhoids. Methods. We report a case of this rare malignancy which initially presented with hematochezia and anal pain. We also review the literature with regard to previously described cases and management strategies including the role of surgery. Results. Despite aggressive multidisciplinary treatment consisting of chemotherapy and radiation, the disease progressed rapidly with dissemination occurring only three months after completion of treatment. Because of the aggressive nature of this tumor, the treatment options for this almost universally fatal malignancy are often palliative in nature. Conclusion. Chemoradiotherapy is likely the most reasonable approach to extrapulmonary small cell carcinoma of the anal canal given its aggressiveness.

The impact of anastomotic leak and intra-abdominal abscess on cancer-related outcomes after resection for colorectal cancer: a case control study.

PURPOSE: This study was designed to analyze the impact of anastomotic leak and intra-abdominal abscess on cancer recurrence and survival in patients who underwent resection for colorectal cancer. METHODS: Data for patients who underwent resection for colon or rectal cancer were retrieved from a prospective colorectal cancer database. Patients with inflammatory bowel disease, familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, palliative resection, or perioperative mortality were excluded. Patients with postoperative anastomotic leak or intra-abdominal abscess were matched at a 1:2 ratio to patients from the same database who had no leak or abscess. Matched characteristics were age, gender, cancer stage, tumor histology, and operation occurring within three years of each other. Survival and cancer recurrence at five-year follow-up were evaluated with the Kaplan-Meier method and log rank test. RESULTS: In patients with colon cancer, comparison of the 59 patients with a leak or an abscess with 118 matched controls showed no differences in demographic or treatment characteristics, recurrence, or mortality. In patients with rectal cancer, comparison of the 97 patients with a leak or an abscess with 194 matched controls showed that at five-year follow-up the complication group had higher rates of overall mortality (46.8 vs. 28.9, P < 0.01), cancer-specific mortality (28.7 percent vs. 18.0 percent, P = 0.03), overall recurrence (28.6 vs. 15.7, P = 0.01) and local recurrence (11.0 percent vs. 5.0 percent, P = 0.04). CONCLUSION: Anastomotic leak and intra-abdominal abscess were not associated with worsened 5-year survival or recurrence in patients who underwent resection for colon cancer. However, these complications were associated with increased overall and cancer-specific mortality and increased overall and local recurrence in patients who underwent resection for rectal cancer.