Steven J. Morris

Colonoscopic Evaluation of Rectal Bleeding: A Study of 304 Patients

We studied 258 patients with rectal bleeding and 46 patients with anemia and occult blood in the stool. All 304 patients had negative proctosigmoidoscopies, single-contrast barium studies that were negative or showed diverticula only, and colonoscopic evaluation. In the 258 patients, the overall incidence of finding significant lesions by colonoscopy was 41.5%. Twenty-nine patients (11.2%) had carcinoma and 17 patients (6.6%) had cecal telangiectasia. In the 46 patients, the overall incidence of finding significant lesions was 19.6%. Three patients with carcinoma were found in this group. A significant number of both benign and malignant lesions were detected by colonoscopy proximal to the splenic flexure. Colonoscopy should be done in patients with rectal bleeding or anemia and occult blood in the stool who have had negative proctosigmoidoscopies and single-contrast barium studies interpreted as normal or showing diverticula.

Cholecystoduodenocolic fistula secondary to carcinoma of the gallbladder

A 55-year-old white man was admitted to the Miami Veterans Administration Hospital with complaints of diarrhea, weight loss, and weakness. One year prior to admission the patient developed intermittent right upper quadrant discomfort, and four months prior to admission he developed 8-10 black, watery, bowel movements per day. He lost 60 pounds over one year prior to admission despite persistance of a good appetite. He denied nausea, vomiting, fever, or history of gallbladder, liver, or ulcer disease. Physical examination revealed a cachectic, chronically ill appearing man in no acute distress. He was afebrile with a pulse of 80/rain, BP 150/80 mm Hg without orthostasis. The liver was 10 cm by palpation. There was a firm RUQ mass which could not be felt separately from the liver edge. Stool was guaiac positive. Laboratory data included: hemoglobin 3.8 g/100 ml, hematocrit 16 volume %, and leukocytes 9800/mm 3. Peripheral smear disclosed hypochromic, microcytic cells. Electrolytes, glucose, BUN, prothrombin time, and partial thromboplastin time were normal. The albumin was 2.6 g/100 ml, cholesterol 94 mg/100 ml, bilirubin 0.4 mg/100 ml, alkaline phosphatase 121 mU/ml, SGOT 18 mU/ml, and amylase 40 Somogyi units. Hospital Course. A barium enema examination revealed a fistula between the area of the hepatic flexure and the duodenum with no colonic mass demonstrated. The fistula on the upper-gastrointestinal tract was seen to enter the second part of the duodenum (Figure 1). Colonoscopy was performed and several fistulous tracts were visualized in the transverse colon, but the surrounding colonic mucosa appeared normal. Upper-gastrointestinal endoscopy revealed a submucosal mass in the second portion of the duodenum with a central fistula. Biopsies of this area showed inflammatory changes. Laparotomy disclosed a mass in the right upper quadrant with fistulous connections between a noncalculous gallbladder, duodenum, and colon (Figure 2). Sections of the mass showed mucinous adenocarcinoma of the gallbladder with invasion and fistulization to the duodenum and colon. Surgery included radical excision of the gallbladder bed, cholecystectomy, partial gastrectomy, vagotomy, duodenectomy, proximal pancreatectomy, right hemicolectomy, and resection of the proximal 8 in. of the jejunum. An anticolic antiperistaltic gastrojejunostomy (Polya), end-to-side choledochojejunostomy, and an ileotransverse colostomy were performed. Four months postoperatively the patient continues to gain weight and feel well.

Diarrhea after gastrectomy and vagotomy.

Development of diarrhea in a patient following gastric surgery can be a confusing problem. The clinician is forced to consider and exclude causes that may be independent of the surgery as well as those that are unique to the postgastrectomy state. An orderly approach is mandatory for appropriate workup and management.