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The patient’s colitis had been diagnosed at 10 years of age, and after 18 years of medical treatment, her diarrhea was still disabling (Day/Night = 8/1). Sigmoidoscopy revealed chronic changes of proctocolitis without obvious ulceration. A biopsy showed histological changes consistent with chronic ulcerative colitis. Colonoscopy was not performed (1974). A barium enema had demonstrated a smooth stricture of the transverse colon.

The patient, aged 9 years, was first seen by the author within a few days of the first episode of diarrhea and rectal bleeding (1972). Within 1 week, a significant proctocolitis to 20cm was apparent. Treatment with intermittent courses of prednisolone and maintenance with sulphasalazine was supervised by the attending gastroenterologist. In 1982, colonoscopy revealed total chronic colitis with pseudopolyp formation, and biopsies were consistent with ulcerative colitis. The patient’s family rejected proctocolectomy at this time. An exacerbation of the colitis resulted in a short hospital stay in 1988. Follow-up colonoscopies revealed slow progressions of the colitis with pseudo polyps, contraction and rigidity of the distal colon. No dysplasia was identified in random biopsies. Colonoscopy (9.23.94) identified chronic active disease in the right colon and more acute inflammation in the left colon and rectum. The patient was advised to undergo restorative proctocolectomy but declined. Thirteen months later, cystoscopy was performed to investigate dysuria and hematuria. Inflammatory changes were present in the bladder. Sigmoidoscopy now revealed an obstructing carcinoma in the upper third of the rectum (Figure 62.1).

The patient had been aware of constipation for a period of 4 months and, for 6 weeks, had noticed a frequent and frustrated desire to defecate. During this latter period, a small amount of bleeding and mucus appeared with the stools. On examination, distention of the left and right colon was palpable. Rectal examination revealed a large firm mass in the pelvis, and flexible sigmoidoscopy revealed edema of the mucosa at 15 cm where the further lumen could not be visualized due to angulation of the rectum. A limited barium enema demonstrated a stenotic lesion in the rectosigmoid (Figure 63.1).

The patient was admitted to hospital with a respiratory infection which had been treated with erythromycin. The patient also suffered from bronchiectasis and asthma. Prednisolone and trimethoprim were administered in view of poor lung function. Ten days after admission, there had been no bowel action for 3 days. At the time of the initial surgical consultation, the abdomen was distended with absent bowel sounds. The patient was afebrile with a pulse rate of 110 and a white cell count of 57,400. During the next 4 days, the patient’s bowel function varied from diarrhea to no bowel action or flatus in a 24 hour period. Abdominal distention persisted. Radiological investigation revealed a grossly dilated colon (Figure 64.1) without evidence of mechanical obstruction. The diagnosis remained obscure. On the fifth day of admission, the patient complained of severe abdominal pain in the right upper quadrant. The abdomen was distended with localized tenderness. A computerized tomography (CT) examination revealed a small collection of free gas adjacent to the transverse colon.

In 1986, the patient was suffering chronic abdominal pain and was investigated in the Department of Surgery at the Aga Khan University Karachi, where a diagnosis of ileocecal Crohn’s disease was made. The patient lived in isolation 1000km from Karachi, and her family in Australia preferred that further treatment occur in Sydney. Investigations indicated the need for operation, which was performed (12.22.86). Right hemicolectomy with 75cm of ileum was performed for an inflammatory mass of the cecum, cecoileal fistula, and two small bowel strictures. The histology was nonspecific chronic inflammation. Tests for tuberculosis were negative. Recovery was satisfactory and the patient returned to Pakistan until 1990 when she presented with colicky abdominal pain, diarrhea, and marked loss of weight. Endoscopic and x-ray investigations now demonstrated an enteroduodenal fistula and an inflammatory stricture at the ileocolic anastomosis. Extensive tests for tuberculosis (TB), performed in Pakistan, were negative. The patient returned to Australia for further surgical treatment. The Mantoux test was positive and there was a calcified focus in the mid zone of the right lung. A 10-day period of total parenteral nutritional (TPN) therapy was administered prior to operation.

The patient had suffered from recurrent abdominal pain for 1 year. The pain, central and in the right iliac fossa, had been worse for 1 week, requiring daily attention from the family doctor. On admission to the hospital, clinical examination revealed a long mass lying transversely in the upper abdomen. A contrast enema confirmed the diagnosis of intussusception (Figure 66.1). The apex reached the splenic flexure.

The patient had noted the recent onset of abdominal distention with 2 episodes of acute lower abdominal pain within 2 months. These symptoms were accompanied by a loss of weight. The stools had become black in color over a period of 7 days. Examination revealed a large nontender spherical mass occupying the right lower abdomen. A barium enema demonstrated dilatation of the terminal ileum with distortion of the mucosal pattern. A computerized tomography (CT) examination revealed a mass in the lower abdomen 10 × 10 × 8cm extending into the cecum and ascending colon. A collection of contrast appeared within the mass, suggesting a bowel perforation was present. Colonoscopy revealed a large polypoid mass in the medial aspect of the proximal ascending colon and cecum, which obscured the ileocecal valve.

The patient had noticed a few weeks of minimal dark red bleeding from the rectum and was examined by colonoscopy. There was diffuse low grade colitis (Figure 68.1) affecting the colon with a loss of vascular pattern and diminution of the haustral indentation. In the lower third of the sigmoid colon (at 20cm), there was nodularity of the mucosa with associated hyperemia and small submucosal hemorrhages. Biopsy of this area revealed non- Hodgkin’s lymphoma (NHL) of a diffuse type. Immunochemistry was positive for the B cell marker L26. Other biopsies of the mucosa showed nonspecific chronic inflammation. Staging investigation by gallium and computerized tomography (CT) scans revealed no other foci of lymphoma. Surgical treatment was advised in preference to chemotherapy.

The patient presented with a history of bright blood on the stool for only a few days. He otherwise felt well. On rectal examination, a large firm polypoid lesion was palpable on the left anterior aspect of the lower third of the rectum 5 cm from the anal verge. It was moveable on palpation. Colonoscopy revealed no other pathology in the colon.

The patient had, for some years, been diagnosed as suffering from an irritable bowel. For a “few months,” she had noticed rectal pain on defecation which had become severe and was aggravated by her bowel frequency. She was not aware of any swelling, but there was a sense of blockage during a bowel action. On examination, there was a smooth, rounded, nontender mass on the left side of the anal canal, extending just above the anorectal junction and bulging into the lumen beneath intact mucosa. It extended into the ischiorectal fossa and was readily palpable in the perianal region. Flexible sigmoidoscopy was normal to 30cm. Transrectal ultrasound (TRUS) revealed a poorly echogenic mass deep to the mucosa within the sphincter muscle. At this examination, fine needle aspiration biopsy was performed. Histologically, this revealed a “smooth muscle tumor” with no evidence of malignancy.