Severe ischemic cytomegalovirus proctocolitis with multiple perforation.

Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.

Morning colonoscopies are associated with improved adenoma detection rates.

BACKGROUND: Higher adenoma detection rates are associated with decreased risks for subsequent colorectal cancers. Studies have suggested that adenoma detection rate (ADR) may be affected by timing of colonoscopy due to endoscopist fatigue later in the day. The aim of our study is to assess the influence of the timing variables on ADR. METHODS: Univariate analysis and multivariate logistic regression analysis were performed on a prospective colonoscopy database, comparing ADR for colonoscopies performed in the morning shift (AM) and in the afternoon shift (PM) over a 1-year period. Each shift lasted 4 h. Only elective outpatient completed colonoscopies with adequate bowel preparation, performed by four certified staff endoscopists, were included. Surveillance colonoscopies for cancers were excluded. ADR was defined as the detection of at least one histologically confirmed polyp during colonoscopy. RESULTS: A total of 533 colonoscopies were included. ADR was 25 % in the cohort. Mean age was 59 (SD 14.1). Two hundred and seventy (50.6 %) were done in the AM and 263 (49.4 %) were done in the PM. ADR was 29 % in the AM group compared to 21 % in the PM group (p = 0.03). Excluding time needed for polypectomy, the mean time taken for scope withdrawal was significantly longer in the morning group (12 min) compared with the afternoon group (10 min) (p = 0.002). The longer withdrawal time in the morning was significantly associated with increased ADRs (OR 1.104, 95 % CI 1.063-1.147) (p < 0.0001). CONCLUSION: Timing of colonoscopy is an independent predictor for ADR. Colonoscopies performed in the morning have a longer mean withdrawal time, thus leading to a significantly higher ADR. As endoscopists concentration decreases as the day progresses, this may account for the shorter time spent on colonoscopies on the afternoon.

Unusual cause of pneumomediastinum in a laparoscopic extraperitoneal inguinal hernia repair.

Pneumomediastinum is an extremely rare complication after laparoscopic inguinal hernia repair. Very few cases have been reported in the surgical literature to date and most reports indicate pneumoperitoneum from the transabdominal preperitoneal approach as a causative factor. This case report describes a patient in whom an elective total extraperitoneal inguinal hernia repair was complicated by a pneumomediastinum without concomitant pneumoperitoneum, and identifies the tracking of air along the anterior extraperitoneal space and endothoracic fascia as a cause. Previous case reports were reviewed and possible etiologies are discussed.