Journal Meeting

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• 2003.02.19

Journal Meeting
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Barium - textbooks

• If suspect perforation use water-soluble contrast
  rather than barium
• Barium peritonitis is a disastrous complication
  that causes severe infection and subsequent
  intraperitoneal fibrosis (Schwartz 1999)

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Barium perforation (intraperitoneal) - humans

• Zheutlin(1952) 3 cases and questionnaire to 100
  institutions
• total 53
• mortality 50
• some survived with no surgery
• many survivors had no clinical adhesions

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Summary

• Barium gives better picture
• Gastrografin has limitations oesophagus,
  stomach (false negatives)
• Barium extravasation into peritoneum
• 10- 25 mortality in adults
• Operate early and lavage
• Suspect leak in alimentary tract
• gastrografin first
• if negative use barium (esophagus, stomach)

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Perforated gastric/duodenal ulcer

• Mortality rate 20
• 33 of cases, sudden attack of epigastric pain.
• Shortly after onset
• relatively free of pain
• mild tenderness
• diminished or absent peristalsis
• Few hours later
• Vomiting
• Tenderness over epigastrium ? whole abdomen
• Spasm
• Upright abdominal x-ray taken 6 h after
  perforation
• Free air about 50 of cases
• Meglumine diatrizoate (Gastrografin) through NG
  tube will demonstrate the perforation.

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Reference

• Zheutlin N, Lasser FC, Rigler LG. Clinical
  studies on effect of barium in the peritoneal
  cavity following rupture during a barium enema.
  Surgery 195232967-69.
• Cordone RP Brandeis SZ Richman H. Rectal
  perforation during barium enema. Report of a
  case. Dis Colon Rectum 198831563-9.

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Ischemic colitis

• the most common ischemic injury of the GI tract
• one of the most common disorders of the large
  bowel in the elderly
• AAA surgery in the early 1960s
• increasing percentage of older people in the US
• being seen with increasing frequency

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Ischemic colitis

• broad spectrum
• benign reversible colonopathy
• fulminant colitis
• colonic gangrene
• different outcome
• size of the occluded vessel
• various aggressive and defensive factors
• aggressive extent, severity, rapidity of onset,
  bacterial luminal load
• defensive collateral circulation, mucosal
  resistance

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Predisposing factors

• atherosclerosis
• shock
• congestive heart failure
• 3 to 6 of pt underwent aortoiliac surgery
• patency of the inferior mesenteric artery
• preoperative shock
• intraoperative blood loss
• extended decrease in sigmoid intramural pH
• previous pelvic radiation therapy

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Clinical course

• Typical presentation
• elderly
• no predisposing/precipitating factors
• acute, cramping abdominal pain of abrupt onset
• abdominal distention
• bloody diarrhea
• Outcome
• 2/3 spontaneous recovery
• 1/2 exploratory laparotomy
• Complication
• chronic ischemic colitis
• perforation and peritonitis
• stricture

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Locations
occur anywhere in the colon (table 1).
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Diagnostic approaches

• Nonspecific laboratory testing WBC ?
• Plain radiographic studies
• Early bowel dilatation or a gasless abdomen
• Severe wall thickening, thumbprinting
• Advanced
• free air in the abdominal cavity
• air within the bowel wall
• air in the portal venous system

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Diagnostic approaches (2)

• Colonoscopy safe and effective
• Acute petechiae, pallor, hyperemia, necrosis
• Subacute ulceration and exudation
• Chronic stricture, decreased haustration, and
  mucosal granularity
• CT
• irregular thickening of the submucosa
• narrowing of the lumen
• plain film thumb-printing sign
• US
• segmental thickening of the colon
• target lesions
• typical five-layered structure of the bowel wall
  
• Doppler D.D. ischemic colitis/inflammatory bowel
  disease (both have wall thickening)

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Diagnostic approaches (3)

• Angiography
• not routinely used
• rarely show any significant vascular occlusions
• information provided is seldom decisive
• used in clinical situations
• ascending colon/terminal ileum
• thrombosis/embolism of the SMA

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Treatment

• Conservative
• IV hydration
• bowel rest
• antibiotic therapy
• correction of precipitating processes
• contraindicated medicine
• vasoconstricting drugs
• corticosteroids may cause silent perforation

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Treatment (2)

• Indication of surgical intervention
• frank peritonitis
• transmural infarction/perforation of the colon
• ongoing clinical deterioration
• bleeding from deep ulcerations
• methods
• resection of the ischemic segment
• exteriorization of the remaining ends

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Reference

• When to suspect ischemic colitis. Satyaprasad V.
  Alapati, MD Anastasios A. Mihas, MD
• VOL 105 / NO 4 / APRIL 1999 / POSTGRADUATE
  MEDICINE