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endoscopy. But now the bowel is obstructed and distended. ‘Run’ the
bowel to identify any skip lesion that is more proximal and make sure
there is a passage through it, i.e. it is non-obstructing. Record any
proximalskiplesioninyournotesbutleavethemuntouched.Yourtaskis
todealwiththeacuteSBO.ObstructioninCDisveryrarelycompleteor
strangulating,therefore,yourbestoptionistocloseuptheabdomen
andstartthepatientonsteroids—thussparinghisbowel.
Rarely you’ll be calledto operate upon anacutely obstructed patient
who failed conservative treatment. Here the operative options are:
resectionof theileocecal region,stricturoplasty ora temporaryproximal
loop ileostomy. When the last of these options is adopted the
inflammationis medically treated until theacutephase resolves and an
electiveoperationcandealpermanentlywiththeaffectedbowel.
AcuteappendicitisinCD
Ifyouoperateforsuspectedacuteappendicitis( Chapter23)and
encounter changes that are compatible with CD of the terminal
ileumandcecum(e.g.serosalinflammation,thickenedmesentery),
whatthen? If the cecum is involvedbut the appendix appearsnormal,
thebestoptionisprobablytoleaveitaloneasappendectomymayresult
in an enterocutaneous fistula.The patient is thentreated with steroids.
An ileocecal resection in that situation may provide you with the
histological diagnosis but is unnecessary or could at least have been
postponed for several years. Almost every patient with an ileocolic
resectionwilldeveloprecurrentCrohn’sinflammationoftheanastomosis,
usually within a year; yet another reason not to be blasé about the
resection. But let’s not forget that CD patients may develop acute
appendicitis—whichistreatedwithanappendectomy.Inanycase,
itisextremelyimportantthatthepatientbemadeawarewhetherthe
appendixhasbeenremovedorstilllurksinhisbelly!
PerinealCrohn’sdisease
About a fifth of the CD population will develop an anal fistula
and/or an abscess at some time. About half of the abscesses and
fistulae appear to be similar in character to those that affect the nonCrohn’spopulation.Inthetypical‘perinealCrohn’s’,theabscessislarge
withsignificantindurationoftheperianalarea.Thefistulaistypicallyhigh,
abovethe externalsphincter,andhas extensions.Not uncommonly,the
external opening is far awayfrom theanal orifice,not theusual 3-4cm
seen in cryptogenic fistula. There may be more than one external
opening. There may be an undermining ‘sea of pus’. There is often
associated proctitis — a reason to do rectoscopy as part of the preoperative evaluation. Pain can be significant and, if so, perform
rectoscopy in the operating room. The diagnosis of CD may have
been established previously and what you see around the anus is
obviouslyachronicprocess.
Theanorectuminthesepatientsisbestevaluatedandmanagedunder
general anesthesia. Do not attempt to do more than adequate
drainage,whichstillmayrequirequitean extensiveincision.Avoid
incising close to the anus, because the wounds may not heal; incise
liberallyover the peripheral abscess and externalopeningfor adequate
drainage. Place a loose draining Seton if the internal opening is
identifiedandcanbeintubated.Yourtaskistoprovidesourcecontrolof
the abscess which can be difficult with inadequate incisions. Let the
peripheralextensionof the fistula tract guide you.Justavoidbringing
theincisiontooneartheanalorifice.
Clostridium difficile colitis (CDC — pseudomembranous
colitis)
Clostridiumdifficile isa Gram-positivebacillus. Itistheprimarycause
ofpseudomembranous colitisandis associatedwith antibiotic use.It is
importanttorememberthatonedoseofantibioticsisallittakesto
developcolitis.Clostridiumdifficile hastwo potent toxinsthat mediate
colitis and diarrhea. Patients present with profuse diarrhea that is foul
smelling,plusclinicalandlabfeaturesofSIRS.
The clinical spectrum of CDC is broad, ranging from mild diarrhea
whichcanbetreatedasanoutpatienttosepticshock.Mostpatientshave
abenignabdominal exam;however,inseverecasespatientsmayhave
peritonitis.
The diagnosis is made by sending a stool sample to detect the C.
difficile toxin and a bedside sigmoidoscopy revealing the typical
pseudomembranes.InseverecasestheCT revealsmassivecolonic
wallthickening.Sometimes(10-20%ofthetime)pseudomembranes
maynotbepresentintherectum,butfoundinthemoreproximal
colon,sodon’tbefooledbyanormalproctosocopy.
The treatment consists of vigorous rehydration, stopping the
‘responsible’antibioticagentandbowelrest.First-linetherapyincludes
oralmetronidazole,withoralvancomycinasasecond-linetherapy.
In patients with ileus the delivery of vancomycin to the colon might
require an enema in order to be effective. Metronidazole is equally
effectiveintravenously.
Immunosuppressed patients who develop pseudomembranous colitis
mayhavesignificantrisk ofmortality.Rising lactate,anincreasingWBC
count, worsening renal function and the need for the initiation of preoperativepressorsareominoussigns.
Figure 26.2. Surgeon: “Anyone ready to serve as a s**t donor for this poor patient.”
Studentoftheyear:“Sir,whataboutanautotransplant?”
Surgical intervention before systemic decompensation improves
survival.Theonlysurgicaloptioninthissettingisatotalcolectomy
withanendileostomy.Thecolonwillappeardeceivinglynormalatthe
time of operation. This should never fool the surgeon into performing
anythinglessthanatotalcolectomy.Somereportshaverecentlybeen
publishedsuggestingthatperforminga loop ileostomy with direct
instillation of vancomycin into the colon might be an effective
methodofmanagingthesepatients.These reportsare relativelynew
and should be considered with caution. Patients who are septic and
requiring systemic pharmacologic or respiratory support are not
candidatesforantecolicirrigationviaaloopileostomy.
Fecal transplant is gaining popularity for the management of
refractoryorrecurrentC.difficilecolitis.Ourresultsaremixed,butwe
do not see a role for fecal transplant in those patients who have
progressed on to toxic megacolon Most are being performed as an
outpatient in the gastroenterologist’s office. (Anyway, we are seeking
donors—toapplypleaseemailus...[ Figure26.2].)
Thefollowingsectiononneutropenicenterocolitisandischemiccolitishas been added by us.
TheEditors
Neutropenicenterocolitis
This is a transmural inflammation of the large bowel in
myelosuppressed and immunosuppressed patients — usually suffering
from myeloproliferative disorders, receiving chemotherapy or following
solid organ or bone marrow transplantation. Profound neutropenia
appearsto bethe commondenominator.Theprocess involvesmucosal
damage and alteration in bacterial flora, which then invade the bowel
wall.Thececumisprimarilyaffectedbuttheprocessmayextendtothe
ascendingcolonandeventheileum.Thepresentationmaymimicacute
appendicitis; watery or bloody diarrhea is present in only half of the
patients.Rightlowerquadranttenderness,apalpablececum,peritoneal
signs and features of ileus may be present. Neutropenia is a
pathognomonic laboratory finding. Plain abdominal X-rays are usually
non-specific,revealinganassociatedileusbutmayshow‘thumbprinting’
of the right colon and intramural air (pneumatosis) — denoting severe
involvement of the cecal wall. A CT scan of the abdomen is the
diagnostic procedure of choice, showing thickening of thececum
andfreeairifanunderlyingperforationexists.
Management should be initially supportive, including broad-spectrum
antibiotics effective against colonic Gram-negative bacteria and
anaerobes; granulocyte colony-stimulating factor (G-CSF) may be
considered.Clinicaldeterioration,evidenceoffreeperforationand,rarely,
severelower gastrointestinalhemorrhage maynecessitate operation.At
laparotomy, normal-looking serosal surfaces may hide mucosal
breakdownandnecrosis.Therefore,thewholeinvolvedsegmentofcolon
shouldbe resected;anastomosis shouldbe avoidedin thesedebilitated
patients. Mortality is obviously high. The key is to recognize the
conditionandavoidanoperationinthemajorityofpatients.
Ischemiccolitis
Ischemiccolitis isapoorly definedentity,which encompassesa wide
variety of conditions. Paradoxically, occlusion of the named arteries
supplying the colon is not associated with ischemic colitis but local
vascular changes in the wall of the colon may play a role. Thus, a
patient with sigmoid colon gangrene following repair of an
abdominal aortic aneurysm and ligation ofthe inferiormesenteric
arteryhascolonicischemia—notischemiccolitis.
Ischemiccolitisdevelopsintwodifferentclinicalsettings:
•
Spontaneous: in patients with underlying cardiac failure, chronic
lung disease, renal failure, diabetes, and collagen disease —
probablyrelatedtodiseasedintramuralvessels.
•
Shock-associated: in patients who have experienced sustained
shockregardlessofetiology(e.g.rupturedaorticaneurysm).
Typically, thecolonic process involvesa varying depthof penetration.
Transientmucosalinvolvementmayormaynotprogresstopartialthicknessnecrosis,whichmayrecoverwithorwithoutastricture,
orprogresstofull-thicknessgangrene.Althoughmostcommoninthe
‘watershed’areaofthesplenicflexureandtheleftcolon,thediseasecan
involveanypartofthecolonandtherectum,andrarelytheentirecolon;
althoughusuallyfocalitmaybepatchyordiffuse.
Patients with spontaneous ischemic colitis present typically with
non-specific abdominal pain and lower gastrointestinal bleeding
(hematochezia).Thosewithshock-associatedischemiccolitisdevelop
thesefeaturesontopoftheirunderlyingcriticaldisease.
Aswithmesentericischemia( Chapter24),theclinicalpicture—as
wellaslaboratoryfindings—isentirelynon-specificasisthecommonly
associated ileus. Abdominal X-rays may demonstrate an ileus and
colonic dilation proximal to the area of ischemia or a dilated ischemic
colon.In therare,advanced transmuralcases, pneumatosiscolior free
gas may be seen. Findings on CT include colonic wall thickening, free
fluidandpneumatosiscoli.LowerGIendoscopy(oftenbedside)isthe
best diagnostic test, visualizing a spectrum of hemorrhagic and
ischemic changes which, although non-specific and may be confused
withCD colitis(see above),are highlysuggestiveinthespecific clinical
setting.
Treatment
Clinical and radiographic evidence of colonic perforation or an
endoscopic picture of dead bowel (black, paralyzed) necessitates a
laparotomyandresectionoftheinvolvedsegment,butthisisinfrequently
needed.Non-transmural ischemiais managednon-operatively with
supportivemeasuresandbroad-spectrumantibiotics,aslongasthe
patientisnotdeteriorating.Increasingorpersistingabdominalpain,
fever, ileus, leukocytosis, acidosis and progressive changes on
abdominalimagingmaycallforcolonicresection.
Although most patients recover from the acute insult, some may
progresstodevelopachronicischemicstricture—butthisisbeyondthe
scopeofourstory.
The differentiation between ischemic colitis and colonic ischemia is inconsequential to the
managementinmyopinion.Jon
Finalwords
Acute colitis from any cause needs careful monitoring and a team
approach to ensure optimumcare. As with mostsurgical emergencies,
interventionwhenthepatientisnotsepticwithperitonitisispreferable,so
gettoknowthesepatientsearlyintheirhospitalcourseandkeepaneye
on them. Both laparoscopic and open approaches are appropriate,
depending on the severity of the colitis and the overall health of the
patient.Temporizingprocedures,primarilytotalcolectomywithend
ileostomy,areusuallyappropriate.Leavetherectumalone!Youwill
have the opportunity to come back and deal with that much maligned
organinthefuture.
“Wesuffer anddie throughthe defects thatarise inour
sewerageanddrainagesystems.”
WilliamA.Lane
1
Dr.P.O.Nyströmcontributedtothischapterinthepreviouseditions.
Chapter27
Colonicobstruction
JonathanE.Efron
The only time human beings wish they could fart and
defecateiswhentheyarenotabletodoso.
This chapter is mainly concerned with the most common cause of
acuteobstructionofthecolon—whichiscancer;thenextmostfrequent
etiologyis diverticulardisease. Youalready know thatobstruction due
tothese conditions occursmostlyin the left colon— where the stoolis
moresolidandthecolonatitsnarrowest.We’llalsodiscussthecondition
that mimics obstruction: pseudo-obstruction (Ogilvie’s syndrome).
Finally, we’ll deal with volvulus of the colon affecting the sigmoid and
cecum.
Colonicobstructionisatruesurgicalemergency.Thereareonly
two emergencies that should make a surgeon run, either to the
operatingroomorelsewhere,andthatisfireandbleeding.Allother
emergencies need to be assessed, evaluated, and ‘scheduled’ to
allow time for resuscitation of the patient. Colonic obstruction is at
timesgroupedinoursubconsciouswithotherbowelobstructionsandthis
may lead to a state of complacency. But a patient with complete
colonic obstruction anda competent ileocecalvalve has a limited
time before perforation or necrosis occurs, significantly changing
the outcome for both you and the patient. So be aware that these
patientsrequireactiveandattentivemanagement.
Clinicalapproach
A52-year-oldmalewithnopastmedicalorsurgicalhistorypresentstoyouremergencyroom
withsignificantabdominal distensionandpain.Hehas nothadabowelmovement orpassed
gasforthelast3days.Youremergencyroom,unlikemostintheUnitedStates,hasdecidedto
consultyoubeforeobtaininganywork-up(ohyes,youareallowedtoseeapatientwhohasn’t
undergoneaCTasyet!).
How do you approach this problem if you are the initial individual
evaluatingthepatient?
Because you are a highly accomplished andcompetent surgeon you
start with a history and physical examination. This history should
include questions like: Has he had a change in his bowel habits?
Bloodinthestool?Anyweightloss?Acrucialquestiontobeasked
is did he have a colonoscopy in the past — when and with what
findings?Inpopulationsundergoingroutinescreeningcolonoscopy
(startingattheageof50),obstructingcoloncarcinomahasbecome
a rarity! You should enquire about a family historyof colon and rectal
cancer,whetherhehashadanyfeversorchillsoranacuteonsetofpain
anddiscomfort,and whether he has noticed ifthisdistensionhas been
going on for a longer period of time. The routine questions about
diabetes,cardiachistory,oranymedicalproblemsingeneralshouldalso
ofcoursebeexplored.
Nowyoudoathoroughphysicalexamination,culminatingwiththe
everlesspopularrectalexam.Therectalexamisadyingartandisoften
skipped completely by residents. However, given his significant
abdominaldistensionandpainitisessentialtodeterminethatnothingin
thedistalpartoftherectumcouldbecontributingtothis—anadvanced
rectalcancerforexample.
So you find out that this patient has had a significant change in his
bowelmovements overthe lastseveral months(no, hehasnever been
colonoscoped — it has been offered to him by his doctor but he
declined).Hehasnoticedthemgettingsmaller,almosttoapointofbeing
pencil thin. Over the last week, he has not passed any bowel
movements. And he has not passed flatus for the last 3days. He has
intermittentcrampypain,butnonauseaorvomiting,andhisdiscomfortis
significantandconstant.
Onphysicalexam,heistachycardicwithapulseof110buthisblood
pressureisnormal.Theabdomenissignificantlydistendedandtympanic.
Itistender to palpation, predominantly on the rightside,buthe has no
rebound or guarding. Examination of the groins shows that he has no
evidence of ahernia. The emergency room is being incredibly efficient
and tells you that lab test results are all within normal limits with the
exceptionofhishemoglobinwhichis7.2g/dL.Whatwouldbeyournext
step?
Obviously we would like to proceed with some sort of testing to
determinethecauseofthedistensionandpainbutitshouldbeobvious
to most that this patient is suffering from a colonic obstruction;
additionally, given his significant distension, the fact that he has
had no nausea or vomiting suggests that his ileocecal valve is
competent.Inmyhospital,asinmosthospitalsintheUnitedStates,the
emergency department may have already obtained a CT scan before
theyconsulted you. However,thismightbe a problem insomeonewith
colonicobstructionandacompetentileocecalvalve.OralGastrografin
®
contrastgiventothesepatientscanresultinasignificantbuild-up
offluidandgaswithinthecolon(thevalveiscompetentonlyinone
direction...),increasingtheriskofcolonicischemiaandperforation
— taking those patients that are not acutely ill and making them
criticallyso.
Therefore, when faced with this question of what to do next, I
would recommend a good old-fashioned abdominal X-ray — both
flatandupright.Thiswill give you an idea as to whether the patient’s
ileocecalvalve is competent (e.g. no significantsmallbowel distension)
ornot.Ifoneseessignificantcolonicdistensionwithoutdistension
or air fluid levels in the small bowel or stomach, one can safely
assume,giventhehistoryandphysicalexam,thatthispatienthasa
colonicobstruction.
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