Krishna C. Gurram

POEM Procedure: What the Radiologist Needs to Know for This New Surgical Intervention for Achalasia

Achalasia is a debilitating condition resulting from the failure of appropriate lower esophageal sphincter relaxation. Traditionally, the treatment of choice for achalasia has been a Heller myotomy, performed either via laparotomy or laparoscopically. The latter method has gained wide popularity in its documented lower postoperative morbidity. Recently, however, a new technique has been developed that can be performed by both thoracic surgeons and endoscopists-Per-Oral Endoscopic Myotomy. This procedure offers an alternative to invasive surgery and provides excellent outcomes with minimal recovery time.1 This article would help familiarize radiologists with this new technique, as well as both normal and abnormal postoperative appearances.

Clostridium difficile extraintestinal abscess: a rare complication

Extraintestinal Clostridium difficile is rare. A 74-year-old man with a history of ulcerative colitis presented after a fall. Trauma work-up showed liver cirrhosis. Two days later he developed abdominal pain, distension, diarrhoea and leucocytosis. Stool tested positive for C. difficile. CT abdomen showed pancolitis with toxic megacolon. Total abdominal colectomy and ileostomy with a rectal stump was performed. He was discharged, but was readmitted with sepsis. CT abdomen showed a 10.4×7.2 cm fluid collection in the pelvis. C. difficile stool was negative. CT-guided abscess drainage grew C. difficile. Barium enema was negative for communication from the rectal stump to the abscess. The patient was treated with metronidazole for 2 weeks. In summary, extraintestinal C. difficile can develop from recent antibiotics use, gastrointestinal surgery and microperforations from toxic megacolon. We recommend abscess drainage, concomitant treatment with metronidazole and or vancomycin, and reimaging of abscess location 2–4 weeks after cessation of antibiotics.

Mo1228 Deflating the Pipes: A New Way of Colonic Decompression

Introduction The standard endoscopic treatment of a symptomatic colonic pseudo-obstruction is by placing a 14Fr, 175cm long colonic decompression tube. We wanted to assess the effect of large bore orogastric Ewald stomach evacuator tubes (32Fr) placed rectally for decompression due to its large size, easy accessibility, and obviating the need for proximal colonic intubation. Methods This is a retrospective case series assessing the effectiveness, safety and outcomes of rectally placed orogastric tubes used for decompression of colonic pseudo-obstruction, ileus and volvulus from 2013 to 2014 at a single institution. Clinical outcomes were measured by symptom resolution with >50% reduction of distention on imaging. Results Twenty one patients with colonic pseudo-obstruction, ileus and volvulus were evaluated. The average age was 68.7 ± 12.2 (SD) years of which 13 (59%) were men. Eleven patients had medical etiologies causing distention while 6 patients were postoperative. Seventeen patients (81%) had associated comorbidities including cardiovascular (80%), pulmonary (28%), sepsis (14%), and were ventilator dependent (19%). Twelve patients (57%) failed medical therapy including neostigmine, erythromycin and metoclopramide. Eighteen (85.71%) patients were taking medication including narcotics, benzodiazepines and calcium channel blockers, either alone or in combination. The mean distention diameter was 9.2 ± 3 (SD) cm. Fifteen (71%) patients had improvement after the first procedure while 2 (9.5%) patients had improvement after more than one procedure. Three (17.6%) had a recurrence while 4 (19%) patients had no improvement. Overall success rate was 80.9%. The average time for improvement was 1.58 days with no procedure related complications. Conclusion Large bore gastric tubes placed rectally provide an alternative to the conventional colonic decompression tubes with good initial successful decompression without any complications.