Gastrointestinal bezoars: Review of the literature and report of a rare case of pumpkin seed rectal impaction.

In science, bezoar is a mass of hair or undigested vegetable matter, found in a human or animal's intestines, similar to a hairball. Usually, it is found trapped in every part of the gastrointestinal system and must be distinguished by pseudobezoar which is an indigestive object voluntarily introduced into the digestive tract. The term Bezoar is from Arabic bazahr, "bezoar" or ultimately from Middle Persian p'tzhl padzahr, "antidote, bezoar"ægagropile o egagropile It should be a universal antidote that works against any poison, and could neutralize any poison. Otherwise, the name could derive from a kind of Turkish goat whose name is just bezoar. Authors report a case of fecal impaction by pumpkin seeds bezoar with abdominal pain: a difficulty to void with subsequent rectal inflammation and hemorrhoid enlargement was observed. The patient underwent a successful manual disimpaction. Guidelines do not require IRB approval Authors examined the literature about occlusion from bezoar The most common causes of occlusion from bezoar are: a previous gastric surgery such as a gastric band (for weight loss) or gastric bypass, a reduced stomach acid (hypochlorhydria) or decreased stomach size, a delayed gastric emptying, typically due to diabetes, autoimmune disorders, or mixed connective tissue disease. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. Rectal impaction is common after ingestion of seeds while a true occlusion is rare. Although several cases of phytobezoars composed of various types of seeds are reported in literature, bezoars of pumpkin seeds have rarely been reported.

Harry Potter's Occlusion: Report of a Case of Pumpkin Seed Bezoar Rectal Impact.

Bezoar is a term from Arabic "bazahr" or ultimately from Middle Persian "p'tzhl" (padzahr, "bezoar antidote" or less commonaly ægagropile or egagropile (2-4). It was believed to have the power of a universal antidote that works against any poison, and a glass containing a bezoar could neutralize any poison poured into it. In science, it is a mass of hair or undigested vegetable matter found in a human or animal intestines, similar to a hairball. Otherwise, the name could derive from a kind of Turkish goat whose name is just bezoar. Usually, it is found trapped in every part of the gastrointestinal system and must be distinguished by pseudobezoar, which is an nondigestible object voluntarily introduced into the digestive tract. The most common causes are a previous gastric surgery such as a gastric band (for weight loss) or gastric bypass, a reduced stomach acid (hypochlorhydria) or decreased stomach size, and a delayed gastric emptying, typically due to diabetes, autoimmune disorders, or mixed connective tissue disease. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. Rectal impaction is common after ingestion of seeds, while a true occlusion is rare. Although several cases of phytobezoars composed of various types of seeds are reported in the literature, bezoars of pumpkin seeds have rarely been reported. The authors report a case of fecal impaction by pumpkin seed bezoars with abdominal pain: a difficulty to void with subsequent rectal inflammation and hemorrhoid enlargement was observed. The patient underwent a successful manual disimpaction.

HIV screening in patients with anal condylomatosis. An overview about ethical and legal issues.

Although there is a strong evidence of prevalence of condylomata in the HIV-positive population, literature on HIV prevalence in HIV-unscreened population diagnosed with condylomata is still unconclusive. Our aim is to review literature about HIV screening and diagnosis of anal condylomata in order to evaluate medical aspects, ethical and legal issues concerning the management of this disease. We undertook an online search on Pubmed for the keywords "HIV", "screening" and "anal condylomata" and 23 papers were analysed, 2 being randomized controlled trial, 11 comparative studies and 10 reviews. A total of 1270 patients were reviewed. All authors strongly recommend HIV testing in patients with clinical evidence of anal condylomata. In undeveloped countries with high prevalence of HIV, a proctological evaluation could be a could represent an unexpected therapeutic option for HIV infected male patients to prevent anal cancer. Clinical trials and prospective studies are necessary to validate this interesting hypothesis. KEY WORDS: Anal condylomatosis, HIV screening, Papilloma virus.

Treatment and outcomes of patients with chronic radiation proctitis. A single-center experience and review of the literature.

Chronic radiation proctitis is a frequent complication after radiotherapy for pelvic malignancies. It is reported that 1 to 5% of patients develop chronic radiation proctitis even with recent advances in external radiotherapy. Hematochezia, mucus discharge, urgency and tenesmus are common symptoms and they can vary in severity but bleeding is often the most debilitating to the patient. Different options are reported for treatment of this condition that always should keep in differential diagnosis in patients with history of pelvic radiotherapy. Treatments range from easy, with topic administration of formalina, to expensive and requiring specialized equipment such as hyperbaric oxygen therapy. Surgery is reserved to patients with failure of conservative treatments due to the high risk of leakage and high morbidity up to 60%. KEY WORDS: Argon beam, Bleeding, Formalin, Radiation, Proctitis, Sucralfate enema.

Successful transanal removal of unusual foreign body self-inserted in the rectum A case report and review of literature.

Foreign bodies in the rectum are a true proctological emergency. The incidence of these cases is increasing in recent years mostly due to auto-erotic acts and behavior disordes and is mainly observed in young patients. Most patients with rectal foreign bodies present to the emergency room usually exhausted after efforts of removingothe object at home. Many endoscopic and surgical techniques to get such removal have been described in the literature and the reported variety of in foreign bodies is as large as the number of techniques used to remove them. Authors report a case of unusual foreign body in the rectum that required multiple attempts to be removed and an original solution. KEY WORDS: Emergency surgery, Rectal foreign body, Transanal Extraction.

Percutaneous endoscopic gastrostomy (PEG), in elderly patients with dementia and anorexia. Medical and ethical issues regarding placement.

BACKGROUND AND AIMS: Ethical and medico-legal issues reviews of Percutaneous Endoscopic Gastrostomy (PEG) placement in elderly patients is an important topic of international medical literature. PEG is often inappropriately placed in patients with not spontaneous oral feeding intake, cause of unrealistic expectations. We performed a critical review of the literature for placement of PEG in geriatric patients. METHODS: A literature review was performed about the positioning of the PEG in geriatric patients with dementia and severe anorexia. This assessment has served to develop an algorithm that would be able to provide adequate indications for PEG placement in this patient population. RESULTS: We obtained appropriate indications about PEG placement, below: 1) Esophageal obstructions (like esophageal or neck cancer) 2) neurological deficits correlated dysphagia (like ictus sequelae) 3) refusal to swallow without concomitant terminal illness (like protracted pseudo dementia caused by severe depression) 4) chronic gastric decompression in patients with benign/malignant obstruction who do not wish or can't have a nasogastric tube placed. CONCLUSIONS: When compared with controls matched for age, elderly patients with cognitive impairment who have feeding gastrostomy do not demonstrate improved survival. KEY WORDS: Anorexia, Dementia, Elderly, Percutaneous Endoscopic Gastrostomy.

Gallstone ileus: A possible cause of bowel obstruction in the elderly population.

INTRODUCTION: Gallstone ileus (GI) is characterized by a mechanical occlusion of the ileal lumen as a result of migration of one or more gallstones in the intestinal tract. Less than 1-4% of all cases of intestinal obstruction are derived from this etiology (1,2,3). CASE REPORT: We present a case of small intestinal obstruction owing to a large gallstone in lower ileum in a 66 years old woman. The diagnosis was made by computed tomography, and treated successfully with an enterotomy, with a removal of a 5 cm gallstone, carried out through a longitudinal incision on the antimesenteric border. Post-operative course presented no adverse effects. CONCLUSION: Gallstone ileus should be considered in case of bowel obstruction in the elderly population. Abdominal CT scan is the preferred investigation for a timely diagnosis.

Umbilical metastasis mimicking symptomatic hernia: Report of a case of Sister Mary Joseph Syndrome.

INTRODUCTION: An umbilical mass can be the first symptom of an intra-abdominal neoplasia, and this condition is also defined as Sister Mary Joseph Syndrome. CASE PRESENTATION: An eighty-year-old patient presented with a complicated umbilical hernia. CT scan abdomen revealed a pancreatic neoplasm and an umbilical biopsy confirmed diagnosis of metastasis. Patient started chemotherapy by Oncologists. CONCLUSIONS: In this paper the Authors suggest a histopathological evaluation of umbilical fat in all cases of newly emerging umbilical hernia in the adult population.

Intersphincteric anal lipofilling with micro-fragmented fat tissue for the treatment of faecal incontinence: preliminary results of three patients.

Faecal incontinence is a very debilitating problem. Many techniques have been proposed to treat this condition, with controversial results. Autologous transplant of fat tissue is an established procedure used for the repair of tissue damage, and recent studies revealed the potentiality of tissue regeneration by human adipose-derived stem cells. We treated this condition with the injection, in the intersphincteric anal groove, of lipoaspirate processed by an innovative technology (Lipogems). The aim of the study was to evaluate the efficacy of Lipogems injection for the treatment of faecal incontinence. In February 2014 we treated 3 patients with faecal incontinence. The surgical procedure required three phases: lipoaspiration, processing of lipoaspirate with the Lipogems system, and injection of the obtained product in the intersphincteric anal groove. An accurate proctological examination followed at 1 week, 1 month and 6 months after treatment. Each patient reported an improved Wexner incontinence score at 1 month after the procedure. We observed an increase of resting pressure (by at least 10 mm Hg) and thickness of the internal anal sphincter respectively at ano-rectal manometry and by ultrasound (US) evaluation at the sixth month of follow-up. Our preliminary results are encouraging, but multicentric studies with longer follow-up are needed to validate this novel technique for treatment of faecal incontinence.

A case of HPV and acquired genital lymphangioma: over-lapping clinical features.

Lymphatic malformation or lymphangioma is a benign proliferation of the lymphatics accounting for 4% of all vascular malformations and 26% of all benign vascular tumors. There are several reports about genital lymphangiomas mimicking venereal lesions, such as genital warts. Hereby we described a case of a 24 year old man affected by multiple vesicles and warts in genital area. All hematological and biochemical parameters, Human Immunodeficiency Virus (HIV) and Treponema Pallidum tests, C1-Inhibitor and C1-Q values were within limits. An accurate fulguration and wide excision of bigger lesions were performed. Histological examination showed numerous dilated lymphatic vessels in the superficial dermis with infiltration of inflammatory cells, that is a histopathological picture compatible with genital lymphangioma. Considering our clinical suspicion of condylomatosis, HPV (Human Papilloma Virus) Polimerase Chain Reaction (PCR) Genotyping, named INNOLiPA test, was performed, that revealed a genital infection by HPV - genotype 6. We think that our case can be considered an example of HPV infection and acquired genital lymphangioma overlap clinical syndrome. The patient presented any lesions one year after the procedure at follow-up examination.

Fast track for elderly patients: is it feasible for colorectal surgery?

BACKGROUND: Fast-track program has been applied in several surgical fields. However, currently many surgical patients are elderly over 70 years of age, and discussion about the application of such protocols for elderly patients is inadequate. MATERIALS AND METHODS: The present study was designed to consider the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients. A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection were randomly assigned to receive either the fast-track care program (n = 40) or the conventional perioperative care protocol (control group, n = 36). The fast track protocol included no preoperative mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise. The length of postoperative hospital stay, the length of time to regain bowel function and the rate of postoperative complications were compared between the two groups. RESULTS: The length of time to regain bowel function, including the passage of flatus [32 (24-40) h vs 42 (32-52) h], and to start a liquid diet (13 [10-16] h v/s 43 [36-50] h) were significantly shorter in patients receiving the fast track care protocol compared with those receiving the conventional care protocol. A shorter duration of postoperative hospital stay was recorded in patients receiving the fast-track program than in those receiving conventional care [6 (5-7) days v/s 9.5 (7-12) days]. A reduced percentage of patients who developed general complications was also observed in the fast-track group (5.0% v/s 18%). CONCLUSION: Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients older than age 70 years. The fast-track recovery program resulted in a more rapid postoperative recovery, earlier discharge from hospital and fewer general complications compared with a conventional postoperative protocol.

Internal Delorme vs. STARR procedure for correction of obstructed defecation from rectocele and rectal intussusception.

PURPOSE: "Outlet obstruction" is a complex functional disorder compelling patients to exhausting uneffective attempts to void. This study was designed to compare the effectiveness and a safety of the endorectal proctopexy (internal Delorme) vs STARR procedure in two groups of patients. METHODS: A total of 66 patients with rectocele and associated mucosal prolapse or anorectal intussusception between January 2006 and June 2010 were randomly assigned to Group # 1 Endorectal proctopexy with levatorplasty (ERPP) and Group # 2 STARR. Patients were assessed one week, six and twelve months after the operation. Operative time, postoperative pain, day of discharge and late complications was recorded. The time of recovery of work was also assessed. The continence score was updated with a constipation questionnaire. Quality of life after the operation and the overall grade of satisfaction were assessed and compared with radiological findings. All patients were reassessed after one year. RESULTS: The results in the two groups of patients show no significant difference between ERPP and STARR: the improvement in symptoms is similar but significant and well definite in both groups with a low incidence of postoperative complications. STARR procedure is just faster to perform even if more expensive. Dyspareunia slightly improved mainly in ERPP group, due probably to scar distention. CONCLUSION: The results of our experience indicate a significant improvement of symptoms with both techniques. The overall incidence rate of postoperative complications is low and similar between the two groups. As economical consideration, ERPP is less expensive.

Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial.

Anal fissure is a tear in the lining of the anal canal distal to the dentate line, which most commonly occurs in the posterior midline. Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion. One hundred and forty-two consecutive patients with a chronic anal fissure with hypertonicity of internal sphincter on proctological examination were selected for this study from October 2008 to October 2010. Patients enrolled for the study were randomized to two groups by using a computer-generated list. Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia. Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks. Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure. All patients were required to record pain after the first defecation, on 3rd and 7th postoperative day on a self-administered VAS scale in cm (0-10). Sixty-eight patients were randomly assigned to LIS, 74 to the conservative approach. Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077. As regards post-operative pain, 43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless. In the topical nifedipine group 43 (58.1 %) after 3 days since treatment and 35 (47.3 %) after 7 days had pain. In the LIS group 22 (32.3 %) after 3 days and 9 (13.2 %) after 7 days referred pain. There was no statistical difference between LIS and topical nifedipine group concerning side effects. Lateral internal sphincterotomy is an effective, less painful, fast recovery treatment for chronic anal fissure. Incontinence rate is overestimated and often the fear of a continence disturbance, albeit with a low incidence following surgery, may obscure the need to relieve symptoms which may be so severe as to make the patient's life intolerable.

2 L PEG plus ascorbic acid versus 4 L PEG plus simethicon for colonoscopy preparation: a randomized single-blind clinical trial.

BACKGROUND: The 2 L polyethylene glycol (PEG) lavage solution has been proved to be similarly safe and effective as 4 L PEG formulations, in spite of the reduced volume. OBJECTIVE: To compare low-volume PEG-based solution combined with ascorbic acid with high-volume PEG-based solution combined with simethicon in terms of efficacy and patient tolerability. METHODS: This was a single-blind prospective randomized trial. Patients were randomized to receive either 2 L PEG plus ascorbic acid (PEG+Asc) or 4 L PEG plus simethicon (PEG+Sim). The primary endpoint was overall colon cleansing evaluation, assessed by blinded investigators using Aronchick score. Secondary end points included patient compliance and tolerability and adverse events. RESULTS: Sixty patients received PEG+Asc and 60 received PEG+Sim. Overall bowel cleansing score was considered adequate in 81.67% of the PEG+Asc and 80% of the PEG+Sim groups, respectively. Excellent and good ratings were recorded in 11.6% and 38.3% receiving PEG+Asc as compared with 26.6% and 23.3% of patients receiving PEG+Sim. Patient tolerability and safety were similar with both the preparations. CONCLUSIONS: According to our data, low-volume PEG+Asc has comparable efficacy, safety, and tolerability as high-volume PEG+Sim; therefore, it can be considered as a good alternative solution for bowel preparation. More improvements are necessary to achieve the target of a perfect preparation.