Patients’ comorbidities reduce the clinical value of emergency colonoscopy: results of a retrospective cohort study

Background and study aims Urgent endoscopy is often used to diagnose and sometimes treat acute upper gastrointestinal syndromes (hemorrhage, toxic ingestion, and occlusion). However, its suitability concerning the management of lower gastrointestinal conditions in emergency circumstances is controversial. Patients and methods We studied the role of emergency colonoscopy in diagnosis and treatment of all consecutive patients presenting with acute lower gastrointestinal symptoms referred to our hospital on an emergency basis. All patients were first managed by physicians from the emergency room and/or the intensive care unit (ICU); the treatments included fluid resuscitation, blood transfusion, and antibiotic or cardiotonic as needed. Bowel cleansing was performed to purge the colon of clots, stool, and blood when clinically possible; alternatively, a bowel enema was used. Patients only underwent a computed tomography (CT) scan prior to the colonoscopy in clinically relevant situations. Colonoscopy was performed within 6 – 36 hours after hospitalization or the beginning of the clinical symptoms (hemorrhage, sepsis, colon distension) or occlusion, as assessed by abdominal CT scan. Results From 2010 to 2015, 603 patients underwent urgent colonoscopy; among them, 214 (36 %) presented with lower GI bleeding, while 264 (44 %) had symptoms suggestive of intestinal ischemia; almost half (49 %, n = 295) of the patients were hospitalized in the ICU. Patients received therapies, such as clips (15 %), epinephrine injections (5 %), bipolar coagulation (7 %), or devolvulation (3 %) using colonoscopy or antibiotic therapy when needed. No perforation was observed after colonoscopy and only three cases of hemorrhage recurrence were documented as complications after the procedure. Overall, 192 patients died within 1 month after colonoscopy due to four independent risk situations, as follows: septic shock, heart transplantation, multiorgan failure, and ischemic colitis. Only 67 (35 %) underwent urgent intestinal surgery when ischemic colitis was identified, and this did not have a significant effect on the mortality rate. Conclusions Urgent bedside colonoscopy is feasible and safe for routine use. The highest advantage was observed in patients with red blood hemorrhage, diarrhea, and colon distension when symptoms were not associated with multiorgane failure, heart transplantation, or septic shock. As revealed by colonoscopy and pathological features, ischemic colitis is associated with a bad prognosis, and patients experience a higher rate of early mortality regardless of whether they undergo urgent colon surgery.

Peritoneal fluid changes in horses subjected to small colon distension

Intestinal devitalization in cases of small colon obstruction may be difficult to detect based only in clinical signs. The purpose was to serially evaluate blood and peritoneal fluid of horses subjected to small colon distension. Seventeen adult horses were allotted in three groups. In the small colon-distended group (DG, n=7) a surgically-implanted latex balloon was inflated to promote intraluminal small colon distension. In the shamoperated group (SG, n=5), the balloon was implanted but not inflated, and no surgery was done in the control group (CG, n=5). Blood and peritoneal fluid were sampled before and after (6 samples with a 30-minute interval) intestinal obstruction for cytological and biochemical analyses. No significant changes in clinical signs occurred within groups or across time during the experimental period. There were no statistical differences among SG and SG groups in hematologic and blood chemistry variables. Although total protein concentration and lactate dehydrogenase (LDH) activity in peritoneal fluid remained most of the time within reference values during the experimental period in all groups, increases from baseline values were detected in SG and DG groups. Such increases occurred earlier, progressively and with greater magnitude in the DG when compared with the SG (P<0.05). Increases from baselines values were also observed in total nucleated cells and neutrophils counts in the DG (P<0.05). In conclusion, distension of the equine small colon induced progressive subtle increases in total protein and LDH concentrations in the peritoneal fluid during the first hours. Serial evaluation of these variables in peritoneal fluid may be useful for early detection of intestinal devitalization in clinical cases of equine small colon obstruction.

Colorectal and rectocolonic reflexes in canines: involvement of tone, compliance, and anal sphincter relaxation

Distention of the proximal colon may have inhibitory or excitatory effects on the rectum and vice versa. The reflexes between the proximal colon and the rectum have not been well studied due to difficulties in accessing the proximal colon. The aim of this study was to investigate the reflex responses and their mechanisms between the proximal colon and the rectum in consideration of distention-related changes in tone and compliance of these regions as well as anal sphincter relaxation in a canine model. Proximal colon/rectal tone, compliance, and anal sphincter relaxation were investigated in six dogs chronically implanted with a proximal colon cannula while in the fasting state and during proximal colon distention or rectal distention. It was found that: 1) both rectal distention and proximal colon distention significantly and substantially decreased the compliance of the opposite regions, and guanethidine abolished proximal colon distention-induced changes in rectal compliance; 2) rectal/proximal colon distension decreased proximal colonic/rectal tone, and guanethidine abolished both of these inhibitory effects; 3) the anal sphincter was more sensitive to rectal distention than proximal colon distention; and 4) the minimal distention pressure required to induce anal inhibitory reflex was lower for rectal distention than proximal colon distention. It was concluded that distention-related changes in tone and compliance suggest the long inhibitory reflexes between the proximal colon and the rectum with the sympathetic involvement in rectal responses. The anal sphincter is more sensitive to the distention of the rectum than that of the proximal colon.

Ogilvie sindromas: klinikinis atvejis

Kastė Mateikaitė1, Paulius Žeromskas2, Kęstutis Strupas21 Vilnius universiteto Medicinos fakultetas, M.K.Čiurlionio g. 21, LT-03101 Vilnius2 Vilniaus universiteto Santariškių klinikų Gastroenterologijos,urologijos ir abdominalinės chirurgijos klinika, Santariškių g. 2, LT-08661 VilniusEl paštas: [email protected] Ogilvie sindromas – tai reta sunki būklė, atsirandanti dėl sutrikusios storosios žarnos parasimpatinės inervacijos. Jai būdingas ūmus ir smarkus storosios žarnos išsiplėtimas be mechaninės obstrukcijos. Šis sindromas dažnai pasitaiko kritinių būklių pacientams. Pateikiame storosios žarnos ūminės tariamosios obstrukcijos klinikinį atvejį, kuris pasitaikė nevaikštančiam, išsėtine skleroze sergančiam slaugos namų pacientui. Tiesinė pilvo rentgenograma leido įtarti laisvą orą po diafragmos kupolu, todėl buvo atlikta laparotomija. Žarnyno perforacijos nebuvo, tačiau rasta išsiplėtusi storoji žarna. Ketvirtą pooperacinę parą pacientas buvo išrašytas iš ligoninės, rekomenduotas agresyvesnis obstipacijų gydymas ir prevencija. Konservatyvus gydymas ar invazinė dekompresija dažnai yra veiksmingi metodai. Jeigu Ogilvie sindromas diagnozuojamas ir gydomas per vėlai, ligonis gali mirti dėl perforacinio peritonito. Pagrindiniai žodžiai: storoji žarna, Ogilvie sindromas, storosios žarnos tariamoji obstrukcija, obstipacijos Ogilvie’s syndrome: case report Kastė Mateikaitė1, Paulius Žeromskas2, Kęstutis Strupas21 Vilnius University Faculty of Medicine, M.K. Čiurlionio 21, LT-03101 Vilnius, Lithuania2 Clinic of Gastroenterology, Urology and Abdominal Surgery, Vilnius University HospitalSantariškių Klinikos, Santariškių 2, LT-08661 Vilnius, LithuaniaE-mail: [email protected] Ogilvie’s syndrome is a rare but serious condition caused by parasympathetic dysfunction of large bowel. It is characterized by acute and massive colon distension without mechanical obstruction. This syndrome most often appears as a complication of other clinical conditions. We present a case of acute colonic pseudo-obstruction occurring in constipated bedridden, male nursing home resident with multiple sclerosis. Free air trapped in the subdiaphragmatic locations was suspected in plain abdominal radiogram and the laparotomy was performed. No intestinal perforation was found. Massively distended colon was observed. The patient was discharged at the fourth postoperative day and more aggressive prevention and treatment of constipation was recommended. In conclusion, early treatment with expectant management or invasive decompression is often successful. However, this condition can be fatal, if diagnose and treatment are delayed. Keywords: large bowel, Ogilvie’s syndrome, colonic pseudo-obstruction, constipation

A therapeutic time window for anti-CD11d monoclonal antibody treatment yielding reduced secondary tissue damage and enhanced behavioral recovery following severe spinal cord injury

Object The purpose of this study was to investigate the therapeutic time window for antiinflammatory treatment within the first 24 hours of spinal cord injury (SCI). The authors have shown that an anti-CD11d antibody treatment attenuates leukocyte infiltration and improves neurological function when administered beginning 2 hours after SCI. A more clinically relevant time for the initiation of treatment after SCI, however, is 6 or more hours postinjury. Methods In Study 1, the T-4 vertebrae in four groups of rats were injured by a 50-g clip-induced compression method, and the anti-CD11d antibody (1 mg/kg) was intravenously administered starting 2, 6, 12, or 24 hours postinjury. All groups received subsequent doses at 24 and 48 hours, and animals were killed at 72 hours. The anti-CD11d antibody treatment starting at 6 hours postinjury caused significant attenuation of leukocyte infiltration, reactive oxygen species–associated enzymes, and secondary tissue damage. Based on these findings, Study 2 included two groups of rats receiving the aforementioned injury and treatment beginning at 6 hours postinjury (with subsequent treatments at 24 and 48 hours) with the anti-CD11d or a control antibody (1B7); these rats were then observed for 5 weeks. Basso-Beattie-Bresnahan (BBB) scores were significantly higher in anti-CD11d–treated rats (mean BBB score 8.9 ± 0.1) than controls (mean BBB score 7.7 ± 0.1) 5 weeks postinjury. Increases in mean arterial pressure during colon distension were smaller in anti-CD11d–treated rats (19.5 ± 3.7 mm Hg) than in controls (37.4 ± 4.7 mm Hg). Conclusions These findings suggest that antiinflammatory treatments that reduce secondary tissue damage after SCI may be delayed until 6 hours postinjury and still be effective.