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C linical D isorders and Management .................................................................................................. 279
FIGURE 8.32. Management of acute visceral ischemia. Abbreviations: IMA, inferior mesenteric artery;
SMA, superior mesenteric artery.
A
B
FIGURE 8.33. Acute ischemic colonic infarction. (A) Grossly, there is sloughing of the mucosa, and (B)
microscopically, the vessels in the submucosa and serosa are filled with microthrombi. (Figures courtesy
of Linda Ferrell, MD.)
Investigation
Endoscopy
Sigmoidoscopy may show a carcinoma in the upper
rectum, sigmoid, or descending colon. In diverticulitis, the
examination is painful and no tumor is seen. Colonoscopy
may be indicated in some cases.
Radiological Studies
Plain films demonstrate distended colon with its typical
haustral markings and absence of air in the rectum. CT
scan with rectal contrast enema is usually a conclusive
examination. In general, barium enema should not be performed in a patient with left lower quadrant tenderness
280 ................................................................................................................ Small and L arge Intestine
and inflammatory mass. However, if abdominal tenderness is absent, a careful barium enema may yield useful
information. If this is done, the radiologist should be
instructed that a limited examination is needed to show
only the site and nature of the obstruction and not a full
study of the colon. If too much barium with significant
head pressure is used, two catastrophic complications can
follow:
1. Perforation of the cecum or at the site of diverticulitis,
causing barium peritonitis.
2. Barium loading of the colon proximal to the obstruction, a problem that complicates surgical treatment.
Management
The goals of treatment are rapid decompression of the
bowel, removal of the underlying lesion, and restoration
of bowel continuity. Specific management details in obstruction due to diverticulitis and volvulus are discussed
below.
When obstruction is due to cancer, the management
decision depends on the condition of the patient, the condition of the bowel (e.g., distension, fecal loading), and the
lesion site. Three questions must be asked:
1. Should decompressing ileostomy or colostomy precede
resection?
2. Should resection be performed and an end-colostomy
created with a plan for anastomosis in a second
operation?
3. Could primary resection and anastomosis be accomplished in one operation?
In general, the safest operation should be chosen.
Whenever the lesion can be removed without compromising the resection necessary to treat the cancer, primary
resection without anastomosis is preferred. Some prefer to
perform resection with intraoperative colonic lavage and
primary anastomosis. Another option is to perform anatomosis with the use of a coloshield, a device that provides
intraluminal bypass to divert the fecal stream from the
anastomosis, thereby reducing anastomotic leak rate.
When the obstructing lesion is proximal or in the splenic
flexure, extended right hemicolectomy with ileocolostomy
is the preferred operation.
SIGMOID VOLVULUS
Clinical Picture
Intermittent suprapubic colicky pain and striking abdominal distension are the usual presenting symptoms. The
patients, usually elderly and from nursing homes, may
have longstanding constipation and may, indeed, have
had prior attacks of sigmoid volvulus that resolved
spontaneously.
Radiologic Studies
Plain abdominal films show an extremely dilated single
loop of bowel arising from the pelvis, typically with a
coffee bean shape (see Figure 8.16). Barium enema, if necessary, must be performed with caution. It shows obstruction at the rectosigmoid with a characteristic bird’s beak
deformity and spiral narrowing of the bowel.
Management
Sigmoidoscopic Reduction
Sigmoidoscopic reduction should be attempted only when
strangulation has not occurred. This is best assessed
with flexible sigmoidoscopy. The presence of dusky or
black mucosa is a contraindication to sigmoidoscopic
decompression. Otherwise, the procedure is performed by
advancing a rigid sigmoidoscope to a point a few centimeters below the obstruction, then passing a welllubricated large rectal tube through the sigmoidoscope
and gently pushing it through the obstruction. The resulting decompression may be somewhat explosive, and
the surgeon and surgical assistants should place themselves appropriately to escape the deluge.
If successful decompression is possible, elective
sigmoid resection should be planned after bowel preparation. In very elderly patients, expectant management may
be appropriate after the first episode.
If sigmoidoscopic decompression is unsuccessful
or if strangulation or perforation occurs, an emergency
operation is needed. The goal is to resect the sigmoid
and perform an end-descending colostomy. In selected
patents with megacolon, total colectomy may be the best
option.
CECAL VOLVULUS
Clinical Presentation
The presentation of cecal volvulus is distal small bowel
obstruction. The patient may have a history of similar past
attacks.
Investigation
Plain films of the abdomen show distal small bowel
obstruction with a dilated cecum in the epigastrium or the
left upper quadrant. Barium enema is usually diagnostic,
showing the level of obstruction and the ileocecal junction
to the right of the cecal bubble (see Figure 8.17).
C linical D isorders and Management .................................................................................................. 281
Management
After fluid resuscitation, all patients should undergo an
operation. The goals of surgery are to decompress the
obstruction and fix the cecum in the right lower quadrant,
either by creating a pocket in the parietal peritoneum and
suturing the cecum to the peritoneum or by using tube
cecostomy. If strangulation has occurred, right hemicolectomy is the definitive procedure.
FISTULAS OF THE SMALL INTESTINE
About 95% of external small bowel fistulas develop as a
complication following surgery. In the remaining 5%,
spontaneous fistulas may occur as a result of primary
disease, such as Crohn’s disease, actinomycosis, tuberculosis, or neoplasm. Postoperative small bowel fistulas occur
as a result of either suture-line dehiscence, unrecognized
intraoperative bowel injury, or because the small bowel is
incorporated into a suture during closure of the abdominal wall. Suture-line dehiscence is apt to occur in previously irradiated bowel. The fistula may be a high-output
fistula (producing more than 500mL/24 h) or a lowoutput fistula.
Clinical Picture
The typical picture is a patient who, 2 or more days
postabdominal surgery, develops sepsis with fever and
leukocytosis. Abdominal pain and tenderness are present.
The incision becomes red and, when opened, intestinal
contents discharge through the wound. The discharge of
succus entericus may excoriate the skin of the abdominal
wall. After drainage of the wound, the sepsis subsides
unless there is associated intra-abdominal abscess or
abscesses. A high-output fistula from the duodenum
or jejunum can lead to severe fluid and electrolyte
abnormalities.
Investigation
Laboratory Studies
Leukocytosis is common and, in high-output fistula,
hemoconcentration and electrolyte abnormalities may
occur. Low serum albumin levels may indicate preexisting
malnutrition.
Radiological Studies
Plain abdominal films are likely to be less helpful than CT
scan and ultrasound, which are the best way to look for an
intra-abdominal abscess. The location of the fistula and
whether or not distal obstruction is present may be
detected by oral or rectal administration of contrast
medium. In regard to the fistulous tract, information
about the number of fistulas and whether or not there is
associated abscess is best obtained with a fistulogram by
injecting hypaque into the fistula tract.
Treatment
A well-planned management approach is indicated,
including:
1. Replacement of fluids and electrolytes. Restoration
of lost fluids requires estimating the existing deficit and
measuring continuing losses. An ileostomy bag or a
suction system is used to collect fistula output. Careful
daily input-output charting and daily weighing of the
patient are essential.
2. Reduction of fistula output. This is done through
institution of nasogastric suction, use of H
2
-receptor
antagonists, or, in the case of a high-output fistula, use of
subcutaneous injection of the longacting somatostatin
analogue octreotide.
3. Control of fistula and wound care. As much as possible, fistula output should be drained directly into a bag
or by a suction catheter to limit skin damage. Various
pastes may be applied to the surrounding skin to prevent
excoriation.
4. Drainage of any associated abscess. Drainage is best
handled by interventional radiology using CT-guided
insertion of a catheter into the abscess cavity through the
fistulous tract. If the fistula cannot be drained successfully
in this way, operative drainage is necessary.
5. Supplemental nutrition. Total parenteral nutrition
may need to be instituted,providing 2500 to 3000 kcals/day.
6. Operative treatment. Operative treatment is indicated when a fistula fails to heal, usually due to the presence of:
a. Undrained pus.
b. Foreign body.
c. Distal obstruction.
d. Short fistulous tract.
e. Active disease (e.g., Crohn’s disease, malignancy) at
the site of perforation.
The key decision is choosing the timing of surgery. If
sepsis is controlled and adequate nutrition established, the
operation should be delayed 8 to 12 weeks. During that
time, about a third of patients spontaneously heal their
fistula. If the fistula persists, reoperation is necessary to
resect the fistulous segment. If this is technically difficult,
the fistula may be bypassed. The latter procedure is rarely
needed if the second operation is delayed 8 to 12 weeks
after the onset of the fistula.
DIVERTICULITIS OF THE COLON
Diverticulitis is the second most common disease of the
colon and the second most common cause of colonic
obstruction following colon cancer.
282 ................................................................................................................ Small and L arge Intestine
Clinical Presentation
Uncomplicated Diverticulitis
Uncomplicated diverticulitis typically presents with
acute onset of nausea, vomiting, fever, and left lower
quadrant (LLQ) pain similar to the pain of acute appendicitis but on the wrong side. Diarrhea alternating
with constipation is a typical antecedent complaint.
Physical examination reveals LLQ tenderness and
mass. The mass is best appreciated with bimanual
examination with one finger in the rectum and the other
hand palpating the abdomen. Leukocytosis with a shift to
the left will be present. Sometimes, patients may complain
of dysuria.
Complicated Diverticulitis
Diverticulitits may cause complications, which include
obstruction of the sigmoid, localized perforation with
pericolic abscess, free perforation with generalized
peritonitis, and colovesical fistula.
1. Colonic obstruction due to diverticulitis. Colonic
obstruction is always associated with acute flare-up of
diverticulitis and the signs and symptoms of sigmoid
inflammation, as well as left-sided colon obstruction with
distension and late-onset vomiting.
2. Pericolic abscess. The patient is more ill, and impressive signs of localized peritonitis and tender mass may
be present in the LLQ of the abdomen. High fever and
leukocytosis with bandemia are common. Nausea and
vomiting, including signs of large bowel obstruction, may
be present.
3. Generalized peritonitis. Free perforation of
colonic diverticula with fecal peritonitis is a serious,
life-threatening illness. Generalized peritonitis could
also be secondary to perforation of a previously localized
pericolic abscess, in which case the peritonitis is purulent.
The findings in both are those of generalized peritonitis
with severe sepsis with or without accompanying septic
shock.
4. Colovesical fistula. This is rarely an acute problem
and manifests itself with recurrent attacks of polymicrobial urinary infection and history of pneumoturia.
Investigations
Laboratory Studies
Leukocytosis with a shift to the left occurs. In severely
septic patients, gram-negative bacteria may be grown in
blood culture. Mild dehydration may be present. Anemia
and severe electrolyte imbalance are not characteristically
seen.
R
ADIOLOGICAL STUDIES
Plain Films of the Abdomen Obstruction associated
with diverticulitis involves the left colon. When pericolic
abscess is present, the picture is that of ileus. When perforation has occurred, free air may be present in the
peritoneum.
CT Scan CT scan is the most useful study to investigate septic process in the lower abdomen. Sigmoid
thickening and effacement of pericolic fat are seen in
diverticulitis. Pericolic abscesses are readily visualized
and their accessibility for percutaneous drainage
determined.
Rectal Contrast Studies Barium enema is contraindicated in acute diverticulitis. The use of water-soluble
enema has now been largely replaced by CT scan. Barium
enema is a useful study 2 or 3 weeks following resolution
of acute diverticulitis and may show multiple diverticula
and a sinus tract with or without communication to an
abscess cavity outside the colon.
E
NDOSCOPY The role of sigmoidoscopy is limited, and
colonoscopy should be avoided. If rigid sigmoidoscopy
is performed, the scope cannot be passed beyond the
rectosigmoid, where erythema and edema may be visible.
The examination is painful.
Surgical Management
Uncomplicated Diverticulitis
Patients with mild attacks can be treated on an outpatient
basis with clear fluid diet and broad-spectrum oral antibiotics or triple antibiotics (i.e., ampicillin, an aminoglycoside, and metronidazole). Patients with more severe
symptoms should be admitted to hospital and treated with
intravenous fluids and intravenous antibiotics. Resolution
of symptoms occurs within 5 to 10 days. Rarely is operation required unless the condition has recurred three or
more times. Full colon investigation is done 2 to 3 weeks
after discharge from hospital.
Colonic Obstruction due to Diverticulitis
Patients with colonic obstruction should be admitted to a
hospital. They are given intravenous fluids and nasogastric
suction is instituted. Broad-spectrum antibiotic or triple
antibiotic therapy is administered intravenously. Adequate
analgesia is provided with meperidine or pentazocin.
Morphine should be avoided because it increases colonic
pressure. Typically, symptoms resolve in 5 to 10 days.
Surgery is not indicated if this is the first, and perhaps even
the second, attack. If it is the third attack, or if obstruction
fails to resolve in 12 to 14 days, sigmoid resection is necessary. The safest operation is the Hartmann procedure
C linical D isorders and Management .................................................................................................. 283
A
FIGURE 8.34. Hartmann procedure. (A) The affected sigmoid colon is resected, (B) the descending
colostomy is then constructed, and the rectal stump closed in layers. (Adapted from Schwartz SI, ed:
Principles of Surgery, 6th ed. New York: McGraw Hill, 1994:1282.)
B
(Figure 8.34), in which the sigmoid is resected; the rectal
stump closed, and end-descending colon colostomy constructed. The colostomy would then be taken down and
colorectal anastomosis performed in a second operation 2
to 6 months later. Some surgeons advocate colonic lavage
performed on the operating table and resection with
primary colorectal anastomosis to avoid a second
operation.
Pericolic Abscess
Pericolic abscesses can be drained with a CT-guided
percutaneous catheter if they are 4 cm or larger and readily
accessible (Figure 8.35). The drainage procedure, done
in conjunction with antibiotic therapy, resolves symptoms
in most patients. The catheter is removed when drainage
is 10 mL or less per day, and the patient is discharged to
await definitive colectomy in about 6 weeks time. At any
time during the treatment, if sepsis worsens or fails to
resolve, an emergency Hartmann procedure is performed
and the abscess is drained. During operation on patients
like these, it may be wise to insert a ureteric catheter
in place in the left or both ureters to aid in identification
of the ureters and thus help prevent inadvertent injury.
Generalized Peritonitis
Generalized peritonitis is a complication that requires
rapid resuscitation, institution of nasogastric and
intravenous antibiotic therapy, and emergency laparotomy. The diseased segment with perforation is resected;
the abdomen is washed with multiple liters of saline; the
rectal stump is closed or, if long enough, brought out as a
mucous fistula; and end-colostomy is constructed. During
operation for severe diverticulitis complicated with percolitic abscess or perforation—where the pelvis is frozen
and safe dissection of the diseased sigmoid is difficult—
the descending colon should be divided just above the
diseased bowel and end-colostomy and mucous fistula
constructed. Closed-suction drainage of the pelvis is also
instituted.
Treatment of colonic perforation is associated with a
high incidence of intra-abdominal abscesses postoperatively. These patients require vigilant abdominal examination and CT scan if a septic picture develops. They are, of
course, kept on broad-spectrum antibiotics postoperatively. Any intra-abdominal abscess that develops might be
amenable to percutaneous drainage. Otherwise, surgical
drainage will be necessary.
284 ................................................................................................................ Small and L arge Intestine
A
A
B
FIGURE 8.35. Drainage of pericolic abscess in diverticulitis. (A) The pelvic CT scan, performed with
water-soluble contrast material in the rectum and sigmoid, demonstrates a 6–cm mass (letter A) with
an air-fluid level adjacent to a thickened sigmoid segment (arrow). This mass represents an extramural
pericolic abscess. (B) After a drainage catheter was placed percutaneously in the abscess cavity using
CT guidance, contrast injected into the abscess demonstrated a connection with the sigmoid colon
(arrow). (Courtesy of Henry I. Goldman, MD.)
Colovesical Fistula
CROHN’S DISEASE
Patients who develop colovesical fistula are treated with
elective resection after mechanical and antibiotic bowel
preparation. The colovesical fistula is taken down. Usually,
the fistula is exceedingly small but may be large enough to
require closure of the bladder with nonabsorbable sutures.
Sigmoid resection with primary colorectal anastomosis is
then performed.
C linical D isorders and Management .................................................................................................. 285
Crohn’s disease may present as a chronic disease or as
an acute abdomen simulating acute appendicitis. The
distinction between Crohn’s disease and chronic ulcerative
colitis is generally evident, based on the different manifestations and treatment responses of the two diseases (Table
8.10), but occasionally the distinction may be difficult.
Acute Presentation
Acute ileitis may present as an acute abdomen, mimicking
acute appendicitis in abdominal findings and leukocytosis. Some patients, however, have, in addition, anemia that
is not usually seen in acute appendicitis.
Tr e at m e n t
An emergent operation, usually through a right lower
quadrant incision, is performed for presumed acute
appendicitis. The appendix is normal, but the terminal
ileum is grossly inflamed with thickening of the bowel wall
and mesentery. Mesenteric lymph nodes may also be
enlarged. The condition could be Crohn’s disease or ileitis
due to other causes, particularly Yersinia enterocolitica.
About 15% of cases initially presumed to be due to Yersinia
are determined to be chronic Crohn’s disease.
Appendectomy should be performed to remove acute
appendicitis as a possible diagnosis during future attacks.
However, it may be unwise to perform appendectomy if
granulomatous inflammation is present at the base of the
appendix in the cecum because of the risk of postoperative fistula formation. Resection of the diseased ileum may
be necessary if obstruction is present.
Chronic Crohn’s Disease
Clinical Presentation
Onset of disease is usually insidious. Chronic diarrhea and
abdominal pain are the presenting symptoms in 90% of
cases. Patients may describe a course characterized by
exacerbations and remissions. Diarrhea is frequent, with
loose bowel movements occurring sometimes 10 to 15
times/day. The stool usually contains no blood unless
Crohn’s colitis is present. Fatigue, weight loss, malaise, and
fever are frequent symptoms. Other presenting symptoms
include fever of unknown origin, recurrent anorectal
lesions, or iron-deficiency anemia. Patients may also
present with obstruction, abdominal abscess, or occasionally, with one or more of the extra-intestinal manifestations described earlier.
286 ................................................................................................................ Small and L arge Intestine
TABLE 8.10. Comparison of Crohn’s Disease and Chronic Ulcerative Colitis
Crohn’s disease Chronic ulcerative colitis
Distribution Small intestine in 90% Small intestine involved only in
Ileocolitis in 40%–60% backwash ileitis
Large bowel alone in 25%–30% Rectum usually involved
Rectum infrequently involved
Pathology Transmural granulomatous Inflammation limited to mucosa
inflammation
Extensive superficial ulceration Longitudinal ulcers, transverse fissures
Bowel wall and mesentery No thickening of bowel wall or
thickened mesentery
Pseudopolyps uncommon Pseudopolyps common
Clinical features Diarrhea less severe, less bloody Severe diarrhea, usually bloody
Gross bleeding uncommon Gross bleeding characteristic
Bowel obstruction common Bowel obstruction rare
Severe perianal disease common Perianal disease uncommon
Toxic megacolon uncommon Toxic megacolon more common
Fistula formation common Fistula formation rare
Perforation rare Perforation common
Radiology Skip areas Continuous involvement
Cobblestone mucosa Finely granular mucosa with ulcers
Fistulas and strictures common Fistulas and strictures uncommon
Endoscopy Rectal sparing common Rectum usually involved
Cobblestone mucosa with Erythematous mucosa with contact
linear ulcers and skip lesions bleeding and discreet ulcers
Treatment response Less responsive to medical Good response to medical treatment
treatment in 85%
High recurrence rate after Cured by colectomy and mucosal
surgical resection proctectomy
Malignancy <10% after 20 years 20%–25% after 20 years
Investigation
LABORATORY FINDINGS Anemia is a frequent finding,
and leukocytosis is present if sepsis has developed. An elevated sedimentation rate is a feature of active disease.
Hypoalbuminemia is common. Steatorrhea is present
when the ileum is extensively involved. A number of malabsorption tests may be abnormal, including the D-xylose
absorption test, and hydrogen and
111
indium and
99m
technitium have been used semiquantita-
14
CO2breath tests. Both
tively to measure tracer activity in fecal leukocytes and to
perform scintigraphy to establish disease location and
extent.
ADIOLOGICAL STUDIES
R
Plain Films of the Abdomen Plain films often are
negative or show nonspecific gas patterns within the small
intestine unless an obstruction is present.
ARIUM CONTRAST STUDIES Barium studies often
B
establish the diagnosis. Barium enema should be the initial
examination because, not only will it detect the presence of
Crohn’s colitis, but it also provides the best image of the
terminal ileum (Figure 8.36). Following barium enema, the
small bowel should be investigated with barium swallow
and small bowel follow-through or enterocylosis. Positive
findings include edema of the mucosa; edema of the entire
wall, which manifests as a separation between adjacent
loops of bowel; and aphthous ulcers, which progress to
create denuded areas that give the characteristic cobblestone appearance. A characteristic radiological finding is
the string sign, due to thickening of the bowel wall and
luminal narrowing (Figure 8.37). Signs of more advanced
disease include strictures, fistulas, and abscesses. Also characteristic in Crohn’s disease are skip lesions, where affected
segments of bowel are separated by segments of normal
bowel. When extramural complications are suspected, CT
scan provides the most information.
B
A
FIGURE 8.36. Diagnosis of chronic Crohn’s colitis. (A) A barium enema in a patient with ileocolic
Crohn’s disease demonstrates a normal appearance of the rectosigmoic and extensive ulceration and
nodularity of the transverse and ascending colon (arrows), typical of Crohn’s disease. The terminal
ileum appears normal (arrowhead). (B) The small bowel barium examination illustrates the presence of
Crohn’s disease in the terminal ileum (arrowheads), while the cecum in this patient appears normal.
(Courtesy of Henry I. Goldman, MD.)
C linical D isorders and Management .................................................................................................. 287
FIGURE 8.37. String sign in Crohn’s colitis. This small bowel
barium examination illustrates the string sign, due to extensive
transmural ileal Crohn’s disease (arrows). The ileum is extremely
narrowed and widely separated from adjacent bowel segments
because of both transmural thickening and reactive mesenteric
fat. (Courtesy of Henry I. Goldman, MD.)
FIGURE 8.38. Cobblestoning in Crohn’s disease. In Crohn’s
disease of the colon, the presence of linear and transverse ulcers
characteristically produces a cobblestone pattern (arrows). In this
patient, the pattern is manifest primarily in the transverse colon.
(Courtesy of Henry I. Goldman, MD.)
Endoscopy Both colonoscopy and upper GI endoscopy
may be necessary. Colonoscopy should attempt to examine
the terminal ileum by intubation of the ileocecal valve.
Pancolonoscopy is generally contraindicated during severe
bouts of colitis for fear of precipitating toxic megacolon, a
complication that is sometimes seen in CD but is more
common in CUC. Colonoscopy should be preceded by
careful evaluation of the perianal region. The presence of
perianal fissures, fistulas, or abscess is most suggestive of
CD. The rectum is relatively spared. Colonic involvement,
if present, is segmental, with cobblestoning from intersections of longitudinal and transverse ulcers (Figure 8.38).
The terminal ileum is involved in some 80% of cases of CD.
Multiple biopsies of affected areas should be obtained,
particularly areas of stenosis or stricture formation. The
diagnostic role of capsule video endoscopy is now under
evaluation.
Clinical Management
MEDICAL THERAPY
Nutritional Therapy CD is treated medically; surgery
is reserved for complicated cases (see below). Nutritional
therapy is important as a supplement to other medical
therapy and to help induce growth in children. Both elemental diet and total parenteral nutrition are useful.
Medical and surgical approaches are summarized in Table
8.11.
Aminosalicylates These include sulfasalazine and a
growing number of 5-aminosalicylic acid (mesolamine)
derivatives. Sulfasalazine has been shown by several
controlled prospective trials to provide effective therapy,
particularly in patients with Crohn’s colitis and ileocolitis.
TABLE 8.11. Essentials: Treatment of Crohn’s Disease
Medical
䊏
Sulfasalazine
䊏
Mesalamine (5-ASA) 500–1000 mg tid
䊏
Corticosteroid 0.25–0.75 mg/kg
䊏
Clarithromycin 250 mg bid
䊏
Growth hormone
䊏
6-mercaptopurine 15 mg/wk
䊏
Azathioprine
Surgical
䊏
Ileal obstruction: right hemicolectomy
䊏
Acute refractory disease: conservative resection
䊏
Chronic stricutre: stricturoplasty
288 ................................................................................................................ Small and L arge Intestine
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