Search

Ascariasis is a helminthic infection of global distribution, and intestinal obstruction is its most common gastrointestinal complication. This is a case of a 7-year-old boy admitted to Pediatric Surgery because of intestinal obstruction caused by ascariasis. On admission, the patient presented with colicky abdominal pain, bile-stained vomiting and meteorism. On physical examination, the patient was thin, pale, and dehydrated. An abdominal examination showed distention and diffuse tenderness. After admission, the patient had fecal vomiting and expulsion of worms through the mouth. Laboratory-test results showed leucocytosis, eosinophilia, hypoalbuminaemia, and hypochloremia. Abdominal radiographs and ultrasound studies were indicative of small-bowel obstruction due to roundworms, which led to the performance of an exploratory laparotomy. On bowel exploration, an intraluminal mass, 10 by 6 cm in diameter, consisting of roundworms in the middle third of the ileum was found. A longitudinal enterotomy was performed, and the worms were meticulously extracted manually. Postoperatively, broad-spectrum antibiotics and antihelminthic drugs were administered. Our case of intestinal obstruction caused by ascariasis is the first to be reported in Serbia, according to the Serbian literature.

We herein report the case of a 51-year-old man with gastrojejunocolic fistula. It is one of the late severe complications of gastrectomy and gastrojejunostomy and is considered to be induced by a stomal ulcer due to inadequate resection of the stomach and incompleteness of vagotomy. The main clinical presentation of this condition is chronic abdominal pain, weight loss, diarrhea, gastrointestinal bleeding and fecal vomiting. The diagnostic workup should include barium enema, gastroscopy and sometimes colonoscopy and abdominal tomography for excluding and ruling out the possibility of malignant extraluminal disease. The historical approach of the treatment of this rare entity was 2–3-phased operations which included colostomy. However today, medical management has recently been recommended as the first-line therapy, with parenteral and enteral support treatments. The preferred surgical approach is single-stage gastrocolic resection and anastomosis and this has been favored to minimize mortality.

Gastrocolic fistula is a fistulous communication between the stomach and the colon. It is a passage between the gastric epithelium and the colonic epithelium. This uncommon complication is caused by benign and malignant diseases of the stomach or the colon. Its clinical manifestations include weight loss, diarrhea and fecal vomiting; occasionally, anemia, poor oral intake, fatigue and dizziness; and very rarely, gastrointestinal bleeding. In this paper, an unusual case of gastrocolic fistula accompanied by hematochezia, which was revealed to have been caused by colon cancer invasion, is described.

Crohn's disease is a rare cause of gastrocolic and duodenocolic fistulas. Only 83 examples (27 gastric, 52 duodenal, four both) have been described. Weight loss, abdominal pain, and diarrhea are common features but fail to distinguish a fistula from active inflammatory bowel disease. Fecal vomiting is pathognomic but is present in one third of gastrocolic and only 2% of duodenocolic fistulas. Diagnosis is most readily made by contrast radiography, with barium enema being more sensitive than barium meal. Although several gastrocolic fistulas have been successfully treated with long-term 6-mercaptopurine, surgery is the mainstay of therapy. An isolated duodenocolic fistula should not be regarded as the primary indication for operation because most are asymptomatic. Ileocolonic resection with simple gastric or duodenal repair is safe and effective in most cases. An ileocolonic anastomosis should be positioned away from the stomach or duodenum or protected with omentum to prevent recurrent fistulization. A number of fistulas appear to have arisen from gastric or duodenal Crohn's, but the vast majority originate from diseased colon.

Ileus comes from the Greek word for twisted. The early classical literature suggests that this term was used for what we now call sigmoid volvulus. The Romans translated this word as volvulus. During later classical times, investigators used ileus and volvulus in describing conditions other than sigmoid volvulus. Roman investigators used ileus to describe midgut volvulus, intussusception, and incarcerated hernias because the symptoms of these conditions were similar. During the Renaissance, ileus, volvulus, and intussusception were synonymous and were closely linked to the volgar terms iliac passion and Miserere Mei. The sine qua non of ileus was the clinical triad of abdominal pain, obstipation, and fecal vomiting. Autopsies in the 16th, 17th, and 18th centuries exposed the various causes of these symptoms. Ileus became the clinical diagnosis whereas such terms as intussusception were used to describe autopsy findings. Physicians classified diseases by symptoms not by cause. During the 19th century, emphasis switched to the pathologic basis of disease. The classification of intestinal obstruction became one of cause. Ileus was abandoned because its classical definition did not encompass all forms of intestinal obstruction. In the last 50 years, ileus has been relegated to mean nonmechanical obstruction that does not initially require operative treatment. Thus, ileus which was the twisted intestine of Ascelpiades, the Miserere Mei of Pare and the iliac passion of Barrough, has come in the 20th century to mean nonmechanical intestinal obstruction.

n/a

Gastrocolic fistula has long been established as a distinct clinical entity. Although it is rare in occurrence, many isolated cases have been reported in the literature. The condition exists only as a complication to other primary gastrointestinal or intra-abdominal lesions. The characteristic symptoms of gastrocolic fistula are fecal vomiting in the absence of symptoms of intestinal obstruction, eructation of foul gas, a fecal odor to the breath, general weakness, extreme loss of weight, and persistent diarrhea with undigested food particles in the stools. The diagnosis can safely be made when fecal vomiting occurs in the absence of intestinal obstruction. However, because of the variable symptomatology resulting from the different primary lesions, clinical diagnosis sometimes becomes difficult and roentgen study may be required. By means of the barium meal, barium enema, and double contrast enema the diagnosis of gastrocolic fistula can be established easily and definitely. Case Report A 37-year-old whi...

Gastroileostomy is a relatively uncommon surgical error; but with the increasing frequency of vagotomy and gastroenterostomy employed in the surgical treatment of complicated chronic duodenal ulcer, the incidence of gastroileostomy may become more prevalent. The symptoms of gastroileostomy consist of severe weight loss, pain, diarrhea with the passage of undigested food in the stool, vomiting and in about one-fifth of the cases fecal vomiting, hemorrhage and symptoms of an ileac or marginal ulcer. The symptoms may commence immediately after the operation or may be delayed for years, particularly if the gastroileal stoma is not functioning. Roentgenologic examination is frequently diagnostic of this condition. A direct communication from the stomach to the right colon may be demonstrated. Serial barium meal films may show refilling of the stomach after all the barium has initially left. Six cases of gastroileostomy have been presented in some detail. In none of these was there operative mortality and the patients' symptoms disappeared promptly following surgery. Gastroileostomy can and should be avoided by positive identification of the ligament of Treitz when a gastroenterostomy is performed.

1. 1. One should suspect a fistula in the presence of a persistent diarrhea following an operation for gastric or duodenal ulcer, associated with loss of weight, fecal vomiting and eructation of foul smelling gas, intestinal obstruction being ruled out. 2. 2. Jejunal ulcer occurred in 1 to 3 per cent of all ulcer cases for which a gastroenterostomy had been performed. Of these, 10 per cent ultimately developed gastrocolic fistulas. 3. 3. Once an ulcer patient, always an ulcer patient, regardless of the type of surgical treatment. 4. 4. Postoperative gastric cases should be impressed that they must continue under strict medical supervision the rest of their lives. Habits are restricted, particularly the use of tobacco, and perhaps, alcohol.

‘EXT to appendicit,is, intestinal obstruction is the most common emergency encountered on the He laid especial emphasis on the vaIue of this procedure in recognizing postoperative ileus requiring reoperation. Since that time he has pubhshed several reports of further observations on the same subject, his most recent report? incIuding a review of the Iiterature which indicated that the method was being adopted at other cIinics, and was pro\-ing itseIf to be a vaIuabIe diagnostic aid in dealing with this common abdomina1 emergency. general surg;caI service of the Los AngeIes County General Hospital. The mortality is between 40 and 50 per cent, which is consistent with the statistics of other similar institutions. This very high mortality is particuIarIy unfortunate when we reaIize that the pathology in most cases of intestina1 obstruction can be corrected by relativeI\ simpIe surgica1 procedure, and if the diagnosis could be estabIished and the treatment instituted within the first few hours of the disease rather than within the first few days, the mortaIity_ couId be made comparabIe to that ot acute appendicitis. The big probIem in intestinn1 obstruction is one of earlier diagnosis. unquestionably Our conceptron of the disease has too Iong been based on a clinical picture drawn from its terminn stages and not from its earliest manifestations. Even Cope, in his exceIIent monograph “The EarIy Diagnosis of the Acute Abdomen,” mentions fecaI vomiting as a point for differentia1 diagnosis when considering intestinal obstruction, and yet m-e know that fecal vomiting is a symptom of obstruction of man37 hours’ standing and is extremely grave in its prognostic significance. In attempting to reduce the mortalit?; then, we must certainIy direct our efforts toward earlier diagnosis, and anything that shows promise along that Iine commands our earnest consideration. The use of the flat roentgen-ray plate in the diagnosis of intestinal obstruction was first suggested by Case in 1914.~

A 64-year-old man with fecal vomiting is the 20th patient recorded with a cholecysto-duodeno-colic fistula and the second to have a concomitant gallstone ileus. All 20 cases have been due to complicated cholelithiasis. A survey reveals the cardinal features to be that of vomiting (often feculent), air in the biliary tree on roentgenograms, and the invariable demonstration by barium enema of a colonic fistula.

• The symptoms, diagnosis, and management of three patients with gastrocolic fistula secondary to benign peptic ulcer disease are reviewed. To our knowledge, this brings the total of such cases reported in the literature to 50. The most frequent symptoms were abdominal pain, weight loss, diarrhea, and vomiting followed by anemia, foul eructations, and fecal vomiting. Barium meal demonstrated the fistula in about 70% of the patients, whereas barium enema examination demonstrated the fistula in nearly all of them. The diagnostic workup should rule out the possibility of a malignant cause for the fistula. The surgical management of these patients consists of the one-stage, when possible, resection of the involved portion of the antrum and the fistula of the transverse colon with appropriate reconstruction of gastrointestinal continuity. An increased awareness of the benign cause of some gastrocolic fistulas is necessary to avoid unduly extensive surgery in these cases. ( Arch Surg 114:1426-1428, 1979)

A 27-year-old woman with a long history of scleroderma developed megacolon and severe fecal vomiting as a result of intestinal atony. Evacuation of fecal impaction with water-soluble contrast enema resulted in prompt relief of fecal vomiting and gradual return of bowel function.

History. —Mrs. P., aged 72, a patient of Dr. Best, has had fair health for many years with the exception of obstinate constipation. Nov. 1, 1913, she was seized withsevere abdominal pain and nausea. Later on she had considerable distention and great tenderness over the abdomen. The tenderness was general and there was no resistance or tumefaction at any point. November 2 decided symptoms of obstruction showed themselves. High enemas given that day failed to produce much result, except one fairly large stool with some gas. Large doses of calomel and other cathartics had been given previously. Finally fecal vomiting appeared with hiccoughing. Operation. —November 3 a laparotomy was performed. As the urine was almost entirely suppressed, November 2 and the morning of November 3, chloroform and oxygen were used. A median incision was made and the first thing noticed was a marked distention and congestion of the small intestine.

Since the writings of Victor Bonney, 1 considerable interest has been manifested in jejunostomy as a treatment of acute intestinal obstruction and paralytic ileus. It has been advocated especially in those severely toxic cases in which a more radical operation to relieve obstruction would be dangerous to life. Bonney writes: I hold strongly that all cases of paralytic intestinal obstruction (whether primary or secondary to an organic obstruction or to peritonitis), when advanced to the stage of fecal, or short of fecal, intestinal vomiting, should be treated by jejunostomy. By making an opening into the jejunum in a case of fecal or intestinal vomiting, the source of the vomit is directly tapped and free drainage of the toxic material is established. No patient should be allowed to die with fecal vomiting if it is possible to perform this operation. Its effect in many cases has been remarkable; in all of

To the Editor:— The report of a case of intestinal obstruction, caused by the ingestion of half of a dried peach, which, swallowed unchewed, passed undigested into the small intestine completely occluding the lumen of the bowel, is of great interest. This patient of Drs. Andrews and Walker of Great Falls, Mont., (The Journal, August 7) is probably not an isolated case. In the forenoon of April 25, 1934, I was called to see an obese edentulous woman, aged 70, who had had severe abdominal pains all through the night. Great distention, fecal vomiting, fever and a very rapid pulse made the diagnosis of intestinal obstruction imperative. She was admitted to the hospital and an attempt was made to improve her desperate condition, but she died in a few hours. Myocardial degeneration and chronic nephritis barred an operation and contributed to the outcome. The postmortem examination disclosed a fusiform swelling