Mihaela Batke

Mechanical Obstruction of the Small Bowel and Colon

Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.

Adynamic ileus and acute colonic pseudo-obstruction.

Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.

Endoclips to Facilitate Cannulation and Sphincterotomy During ERCP in a Patient with an Ampulla Within a Large Duodenal Diverticulum: Case Report and Literature Review

Cannulation and sphincterotomy of the ampulla may be technically challenging at endoscopic retrograde cholangiopancreatography (ERCP) when the ampulla is located within a duodenal diverticulum because of obscuring of the ampulla and approaching it from an awkward angle. Successful application of endoclips to expose and facilitate cannulation of an ampulla within a duodenal diverticulum has been reported for three cases of diagnostic ERCP [1, 2] and one case of therapeutic ERCP [3]. A second case is hereby reported of clinically beneficial, successful, therapeutic ERCP using endoclips.

Invasive cancer in a diminutive rectal polyp amidst internal hemorrhoids detected by rectal retroflexion.

A diminutive rectal polyp amidst internal hemorrhoids, detected by rectal retroflexion during colonoscopy, was shown to harbor invasive rectal adenocarcinoma by colonoscopic biopsy. Initially this lesion had appeared to be a relatively innocuous prominent anorectal mucosal fold and was recognized as a diminutive polyp only after careful rectal retroflexion during colonoscopy. This report emphasizes that lesions just above the anorectal junction with atypical endoscopic features for internal hemorrhoids should be carefully examined at rectal retroflexion and that polyps or suspicious lesions amidst internal hemorrhoids identified during colonoscopy should be snared or at least biopsied, even if small. This case report also illustrates how easily an early cancer in a diminutive colonic polyp can be missed when in difficult areas of colonoscopic inspection, such as behind a colonic fold or immediately above the anus.

Recurrent ischemic colitis associated with oral contraceptive therapy

In an interesting article Mosli et al. methodically reported the risk factors associated with ischemic colitis, as well as characterizing the clinical features, endoscopic findings, complications and prognosis of this disease. They noted a female predominance, but interestingly reported no association with oral contraceptive (OC) use or hormone replacement therapy (HRT). However, they acknowledged that this lack of association might have resulted from the underreporting of OC use or HRT, because patients often failed to voluntarily disclose their use of these agents, and physicians must therefore directly query patients about such use. We emphasize the clinical relevance of this omission by reporting a case of recurrent severe ischemic colitis after failing to discontinue OC medications after the first episode.

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy (EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass (RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status post RYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.

Consideration of endoclips to help cannulate an ampulla hidden in a duodenal diverticulum at ERCP.

We thank Drs. Nadir and Chuang for their thoughtful letter [1] in response to our recent single case report [2] of successful deployment of two endoclips at ERCP to expose an ampulla of Vater, initially inaccessible due to the ampulla lying within a large diverticulum, with consequent successful cannulation, sphincterotomy, and stone retrieval. They report one case in which an endoclip was deployed to evert and expose an ampulla that was initially inaccessible within a large duodenal diverticulum, and deployed a second endoclip for stabilization that inadvertently caused greater instability of the ampulla. Despite this difficulty, they were able to use the sphincterotome to evert the ampullary opening and successfully cannulate for therapeutic ERCP. We have two comments. First, despite their difficulties, the outcome was successful cannulation after multiple unsuccessful attempts before deploying the endoclips. Second, we experienced a similar problem of instability during cannulation after deploying one endoclip which resolved after deploying a second endoclip. This finding argues for carefully placing endoclips to achieve stability. Endoclips should currently be considered only when (1) cannulation is otherwise impossible due to ampulla location within a diverticulum, (2) ERCP is required for potentially life-saving endoscopic therapy, and (3) the endoscopist is highly skilled in both ERCP and endoclip deployment. This technique should currently be considered experimental with use restricted to these circumstances due to insufficient outcomes data.

Letter to the editor: Recurrent ischemic colitis associated with oral contraceptive therapy.

In an interesting article Mosli et al. methodically reported the risk factors associated with ischemic colitis, as well as characterizing the clinical features, endoscopic findings, complications and prognosis of this disease. They noted a female predominance, but interestingly reported no association with oral contraceptive (OC) use or hormone replacement therapy (HRT). However, they acknowledged that this lack of association might have resulted from the underreporting of OC use or HRT, because patients often failed to voluntarily disclose their use of these agents, and physicians must therefore directly query patients about such use. We emphasize the clinical relevance of this omission by reporting a case of recurrent severe ischemic colitis after failing to discontinue OC medications after the first episode.

Clostridium difficile is the most common identifiable cause of infectious colitis

Background: Clostridium difficile is a significant cause of nosocomial diarrhea. We sought to determine the role of bacterial pathogens in patients with infectious colitis in our community. Methods: We reviewed the records of patients who were tested positive for C. difficile toxin A or B by enzyme-linked immunosorbent assay, or had a positive stool culture for a bacterial pathogens. Results: A total of 1374 patients had positive C. difficile toxin assays; 67 had positive cultures for other bacterial pathogens. Of the patients with C. difficile, 568 were outpatients, whereas 804 were inpatients. Four hundred eighty-eight (83%) of outpatients were extended-care facility residents. Detection of C. difficile toxin was preceded within 2 months by a urine culture in 32.6% of the outpatients; half of these had a positive urine culture. Conclusions: C. difficile is the most common identifiable bacterial pathogen among patients with infectious colitis in our community. Patients with C. difficile toxin detection were likely to have a suspected urinary tract infection. We speculate that empiric antibiotics for urinary tract infections may contribute to the higher C. difficile toxin detection in these patients.