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Colonic Pseudo- o bstruction (Ogilvie Syndrome)

Introduction Acute colonic pseudo-obstruction, also known as Ogilvie syndrome, is a nonmechanical, functional obstruction of the large intestine. It has become a well-known clinical entity, but in many regards it is poorly understand and difficult to manage. In 1948 a British surgeon, Sir Heneage Ogilvie, first described acute colonic pseudo-obstruction in two patients who had colonic dilatation without an obvious mechanical cause. Both patients had extensive…

Colonic Volvulus

Introduction In this chapter, we review the presentation, diagnostic strategy, and treatment algorithms for colonic volvulus. Colonic volvulus is the torsion of a mobile loop of bowel with an elongated mesentery and a narrow pedicle. The twisting of the bowel around its mesenteric blood supply leads to acute luminal obstruction and decreased blood flow to the bowel wall that can progress to ischemia, infarction, and, eventually,…

Large Bowel Obstruction

Introduction A large bowel obstruction results from a narrowing of the colorectal lumen that restricts passage of gas and stool. It is a relatively common surgical emergency. Because the condition may be the result of many combinations of causes, locations, and settings, each case is unique, making the choice of treatment challenging. The most common cause of large bowel obstruction is colorectal adenocarcinoma, which accounts for…

Lower Gastrointestinal Hemorrhage

Introduction Lower gastrointestinal hemorrhage refers to blood loss originating distal to the ligament of Treitz that is symptomatic and necessitates hospital admission. It is a serious and potentially life-threatening situation. Although rectal hemorrhage can be seen in any age group, most patients requiring admission to the hospital are elderly and have coexistent medical problems. Because of these comorbidities, management is complex. Many patients stop bleeding spontaneously,…

Surgical Treatment of Diverticulitis and its Complications

Introduction Surgical management of patients presenting with complications of diverticular disease can be elective, semi-elective, or an emergency, depending on the severity of the disease and patient comorbidities. A laparoscopic sigmoid resection is the preferred procedure in the elective setting, whereas two-stage procedures (e.g., the Hartmann procedure [HP] and primary resection with anastomosis and diversion [PRA]) are better choices in the semi-elective and emergency setting. Performing…

Diagnosis and Management of Acute Colonic Diverticulitis

Introduction Colonic diverticula are false diverticula—that is, pockets composed of mucosa and submucosa that have herniated through weaknesses in the colon wall at the points where intramural vasa recta penetrate the inner circular muscle of the bowel ( Fig. 48-1, A and B ). The generally accepted pathophysiology of diverticulitis centers on a diverticular microperforation causing a bacterial infection. A possible alternative mechanism suggesting that diverticulitis…

Cytomegalovirus Ileocolitis and Kaposi Sarcoma in HIV/AIDS

Introduction An unusual outbreak of Kaposi sarcoma (KS) and Pneumocystis carinii pneumonia among young homosexual men was first reported by the Centers for Disease Control and Prevention (CDC) in 1981. By the end of 1982, the term acquired immune deficiency syndrome (AIDS) was born. In 1983, two research groups published their findings of the retrovirus thought to be responsible for AIDS. Initially referred to as human…

Pseudomembranous Clostridium Difficile Colitis

Introduction Clostridium difficile was originally described as a component of the normal intestinal flora of newborn infants by Hall and O’Toole in 1935, who also demonstrated that this organism produced a toxin extremely lethal to mice. However, the “ C. difficile era” began in 1974 when Tedesco et al reported high rates of pseudomembranous colitis in patients exposed to clindamycin at Barnes Hospital in St. Louis, Mo.…

Cecal Ulcer

Introduction Solitary ulcer of the cecum was first described by Cruveilhier in 1832. The subject of cecal ulcers is confusing and complicated because they are uncommon and have multiple causes. A variety of terms, including solitary cecal ulcer, acute cecal ulcer, and benign solitary cecal ulcer, have been used to describe these lesions. Case inclusion varies. For example, Ong et al, in a recent review of “solitary…

Management of Perianal Crohn Disease

Introduction Perianal disease is the presenting symptom in 5% of patients with Crohn disease, but overall up to 80% of patients experience anal symptoms. An understanding of the pathophysiology of the anal disease is basic to appropriate management and successful control of symptoms. The purpose of this chapter is to present a rational approach to dealing with perianal disease in patients with Crohn disease. Pathophysiology The…

Management of Crohn Colitis

Crohn disease can affect any segment of the intestinal tract, and the colon will be involved in approximately half of afflicted patients. Crohn disease of the colon can entail disease of the large bowel alone or of the large bowel plus the terminal ileum. The behavior of the disease varies and can be categorized as predominantly inflammatory, stricturing, or penetrating. Furthermore, disease of the anal canal…

Medical Management of Crohn Disease

Introduction Crohn disease (CD) is a chronic, relapsing, idiopathic inflammatory condition that primarily affects the gastrointestinal tract. The severity and location of CD are variable. CD, a transmural inflammation of the bowel characterized by skip lesions that may involve any section of the gastrointestinal tract, is sometimes complicated by strictures and fistula formation. In about 50% of cases, CD affects the terminal ileum and colon; in…

Unhealed Perineal Wound

Introduction Excision of the rectum via a combined abdominal and perineal approach (i.e., an abdominoperineal resection [APR]) has been a time-honored technique for the management of rectal cancer and inflammatory bowel disease (IBD). However, achieving prompt and satisfactory healing of the perineum after such an approach is still a challenge. A wound that has not healed by 6 months after the surgery is considered an unhealed…

Continent Ileostomy

Introduction The continent ileostomy has an interesting history. It began as a revolutionary concept and technique, only to fall out of routine use because of technical issues and ultimately a better alternative: the ileal pouch–anal anastomosis (IPAA). Indications for a continent ileostomy still exist, although the operation is now rarely performed. It has undergone multiple modifications, is technically demanding, and is associated with a relatively high…

Pouchitis and Functional Complications of the Pelvic Pouch

Introduction Despite recent advances in medical therapy, approximately 25% to 30% of patients with ulcerative colitis (UC) will need surgery for refractory colitis or colitis-associated neoplasia. For these patients, a total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the standard surgical option. During the past four decades, IPAA has been constantly shown to reduce the risk of UC-associated neoplasia and to improve quality of life. On…

Pelvic Pouch: Complications and Their Management

Introduction When a total proctocolectomy is required, the ileal pouch–anal anastomosis (IPAA) procedure is favored over an end ileostomy because the IPAA allows continence with defecation by the normal route. The procedure can be performed with favorable results for patients with ulcerative colitis and familial adenomatous polyposis, as well as in some patients with indeterminate colitis and highly selectively in patients with Crohn disease that is…

Management of Acute Toxic Colitis and Megacolon

Introduction Toxic colitis and megacolon fall within the spectrum of inflammatory bowel disease (IBD). Toxic colitis, also referred to as acute, fulminant, or severe colitis, is a potentially life-threatening form of IBD. Patients display gastrointestinal symptoms in conjunction with signs of systemic toxicity. In its rare, extreme manifestation—toxic megacolon—toxic colitis is accompanied by radiographic evidence of nonobstructive colonic dilatation in excess of 6 cm. Systemic toxicity…

Chronic Ulcerative Colitis: Surgical Options

Introduction Despite major advances in the medical treatment of ulcerative colitis (UC), surgery is still frequently required. Because the aim of surgery is to cure the disease, elimination of all colorectal mucosa is ideal. This operative strategy may need to be modified depending upon patient-, disease-, and treatment-related factors, which may have an impact on short- and long-term outcomes, as well as quality of life. Evolution…

Medical Treatment of Ulcerative Colitis and Other Colitides

Ulcerative Colitis Ulcerative colitis (UC) is a chronic idiopathic inflammatory disease that affects the mucosa of the colon. Even though the cause of the disease is unknown, certain risk factors such as cigarette smoking cessation, use of nonsteroidal antiinflammatory drugs (NSAIDs), and infections have been identified. The incidence of UC in the United States is 12 cases per 100,000 persons. The disease can present at any…

Preoperative Preparation of the Patient for Colon and Rectal Surgery

Introduction The goal of preoperative assessment and preparation for a patient undergoing colon and rectal surgery is to minimize the risk of perioperative complications and optimize outcomes. Advancing age, obesity, and comorbidities such as cardiopulmonary disease and malnutrition are all factors that contribute to perioperative risk and are becoming more prevalent. Although these factors do not preclude surgery, they complicate preoperative assessment and increase the risk…