PRESSURE ACTIVITY OF THE COLON AND RECTUM IN DIVERTICULAR DISEASE BEFORE AND AFTER SIGMOID MYOTOMY. (E.) Attisha, R. P. (Western Gen. Hosp., Edinburgh, Scotland) and A. N. Smith. J Surg 56(12):891-894, 1970.

Brit

Intraluminal pressure of the colon and rectum was determined in 29 untreated patients with diverticular disease, 14 patients with sigmoid myotomy (1-6 months after surgery), and 9 normal subjects. There was no significant difference in basal pressure activity (recorded as mean motility index) in the three groups tested (normals, 151; diverticular disease, 343; after sigmoid myotomy, 130). There was an increase of the motor activity of the bowel following ingestion of a meal in all groups and patients with diverticular disease (740) responded more than controls (263). Prostigmine increased both amplitude and frequency with a resulting increase in motility index, both for normals and groups with diverticular disease (normals, me an index, 791; diverticular disease, 2856; after sigmoid myotomy, 1183). Wave amplitudes increased after food and prostigmine, while after myotomy, marked decrease in number of waves occurred. Atropine (0.4-0.6 mg) given to patients under treatment with prostigmine caused a decrease in mean motility index from 2852 to 1400. (In subjects already myotomized, the decrease was from 1260 to 200). Propantheline bromide (3.5 mg) virtually abolished all prostigmine effects in diverticular disease group, before and after surgery. There seemingly is some residual smooth-muscle activity (however weakly present) in the colon or at zones close to myotomy site.

3460

COLONIC ILEUS. (E.) Decker, G. A. G. (Johannesburg Hosp., Union of South Africa) S Afr J Surg 7(4):143-147, 1969.

and A. D. Smith.

The clinical evaluation, subsequent management, and progress of 11 patients with colonic ileus is presented. The radiological picture was that of large bowel distension, but none of the symptoms or signs were diagnostic. It is suggested that a barium enema be done on admission to confirm the presence of organic stenosis before laparotomy. Although the mechanism of colonic ileus is obscure, the possibility of a spastic segment causing a dilatation of the colon is ruled out in the three patients on whom laparotomies were performed. The 8 patients not operated on responded to intravenous fluids and nasogastric suction.

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GASTROENTEROLOGY VOL. 5

LARGE INTESTINE

Seven cases of extensive perineal ulceration (4 of them with cutaneous ulceration elsewhere also) were seen in 207 cases of Crohn's disease. Perineal ulceration was the most common site, and in all of these patients (4 male, ages 32 66; 3 female, ages 1069) it was the initial site. Parastomal ulceration was present in 2 patients and metastatic in 3. Macroscopically, the ulceration was characterized by florid granulation tissue with marked destruction of the surrounding tissues. The skin edge was edenatous and there was a typical dusky cyanosis of the surrounding skin. Though the ulceration is usually associated with severe Crohn's disease of the gastrointestinal tract the condition has to be differentiated from tuberculosis by demonstrating the typical sarcoid granulomatous reaction in the absence of central caseation in a biopsy of the ulceration, together with a normal chest radiograph and a negative Mantoux test to a dilution 1 in 100. The first stage in treatment is usually the removal of the adjacent bowel if it is involved in the disease as the ulceration will never heal when the bowel is still present no matter what local treatment is employed. Treatment including oral zinc sulfate and repeated curettage is recommended.

The colonic absorption of sodium, potassium, and water in 4 patients with diffuse untreated proctocolitis (ages 27 69 yr, 3 of them male with proctocolitis involving the entire colon) was compared with that of 13 healthy male medical students (ages 19 23 yr). The colon was perfused with an isotopicallylabeled solution instilled through a tube introduced by mouth. In the 4 patients, the mean rate of absorption of sodium was reduced to 1/3, and of water to 1/7; while potassium was secreted into the colonic lumen at a mean rate of more than 4 times that found in the healthy subjects. Sodium and potassium ions moved more rapidly into the lumen of the ulcerated colon and the rate of movement of sodium out of the colonic lumen was diminished. patients and healthy subjects alike, the net transport of water was closely correlated with that of sodium. The diarrhea of proctocolitis can be explained in part at least by the impairment of the colon in its ability to absorb the salt and water delivered to it from the ileum and by an increase in the secretory function and a decrease in the absorptive function of the diseased colon. 3464

In

AN IN VITRO SYSTEM FOR STUDYING MUCUS SECRETION AND OTHER PHYSIOLOGICAL ACTIVITIES IN HUMAN INTESTINAL MUCOSA. (E.) Johansen, P. G. (Roy. Child. Hosp. Res. Found., Melbourne, Australia). Experientia 26 (2) 130-131, 1970.

Human rectal mucosa was obtained by suction biopsy from patients with cystic fibrosis for in vitro stud

MAY 1970

ies on the excessively viscous mucous secretions and the electrolyte abnormalities in the serous secretions. Trowell's technique was the most satisfactory culture method, using a media based on 199 or Trowell's T8, containing 4 mg/ml glucose, and usually 10% fetal calf serum. Antibiotics were added to the culture medium, and various additives such as insulin and hydrocortisone were tested and the criterion for satisfactory survival was based on histological exar ination. Biopsies from 40 patients with cystic fi brosis and from normal controls were compared in this study using histochemical methods and autoradiography for examining mucous production. No consistent histologic or chemical differences were demonstrated.

The records of 20 patients who suffered from ischemia and gangrene of the colon after they had undergone abdominal aortic resection were examined to determine the etiology of and treatment for these complications. Interruption of the arterial blood supply to the left colon results is ischemia and diarrhea, unexplained toxicity, or hypotension that occurs postoperatively suggests ischemia and immediate treatment (usually colectomy if gangrene is present) is advised. Prophylactic measures include avoiding trauma to the collateral circulation of the colon, implanting the inferior mesenteric artery into the wall of the graft, or insuring patency of the internal iliac vessels.

Perforation of the anterior wall of the ascending colon (at its midpoint) as a complication of exchange transfusion is described in a female infant born at 36 weeks gestation. Abdominal distention, vomiting of bile-stained mucus, and passage of normal meconium stool were the earliest findings and abdominal radiographs suggested the presence of intramural gas in the gut and necrotizing enterocolitis. Repeat abdominal radiographs revealed pneumoperitoneum and the previous diagnosis (of necrotizing enterocolitis) with perforation was confirmed. Following exploration of the abdomen (revealed murky fluid and meconium, necrotic ascending colon with midpoint perforation), an uneventful right hemicolectomy was perfom ed. The pathological specimen (ascending colon, appendix, and a portion of the terminal ileum) vas characterized by a necrotic oval perforation of the antimesenteric border of the colon and the surrounding mucosa was edematous, ulcerated, necrotic and covered by bile-stained exudate. Authors believe this to be the first case in the American literature that was diagnosed correctly before operation and successfully treated by surgery.

389

Vitamin B12 absorption was studied in 22 ileostomy patients at various intervals after operation (with panproctocolectomy) for ulcerative colitis. Low Schilling-test values (5 to 10%) were found in 11 patients and normal values (>10%) in 11 patients. No correlations between lowered vitamin B12 absorption and preoperative length of case-history, and low absorption values and length of resected ileum segment were observed. Low vitamin B12 absorption

values were observed in 8 of 10 'short-term ileostomy patients' (tests performed within one yr or less) while low values were found in 3 of 12 'long-term ileostomy patients'. Vitamin B12 was normal (>200 pg/ml) in all 22 patients including those with lowered vitamin B12 absorption (similar results were found in patients observed for more than 3 yr). Folic acid in serum and blood, hemoglobin, serum iron, transferrin, and serum creatinine were at nor

mal levels in all patients. Defective vitamin B12 absorption seemingly is due to bacterial imbalance in the terminal ileum after ileostomy.

Possible events considered as emotionally and psychologically disruptive were listed following interview of 158 ulcerative colitis patients and 69 regional enteritis patients (study groups) and 105 irritable colon patients and 735 healthy individuals (comparison groups) in Baltimore. Social and cultural discontinuities, geographic mobility, and job changes were studied, with little difference between groups although the study groups had a significantly different family background (more patients in the study group were only children and generally came from smaller families) than the comparison groups. These findings agree with the results obtained when more intensive psychiatric interviewing was used.

nisone (40 mg p.o. daily for 7 days) was given in divided dose; after 7 days the dosage was reduced to 20 mg. Within 48 hr of the beginning of treatment, the swelling in the oral mucosa subsided, the pinpoint pustular lesions regressed, the rough and granular appearance of the buccal mucosa changed, and hyperemia was reduced. There was less eversion of the lower lip and also a slight improvement in the bowel condition, with a drop in the daily number of stools to four. After 3 months, the mouth lesions remained healed but the colitis remained slightly active with an average of 4 stools daily. The patient's general condition was good and is maintained only on prednisone (15 mg/day).

Cytogenic examinations were conducted to study chromosomal aberrations in 9 patients suffering from severe ulcero-hemorrhagic colitis. A high degree of aneuploidy (up to 44%) and structural aberrations (up to 17.5%) were observed in all patients and aneuploidy had a pronounced hypodiploid character. Chromosomal structural aberrations affected both adhesions and chromosomes in the form of dicentric chromosomes and adhesions between chromosomes. There was a parallelism between the degree of chromosomal aberrations in somatic cells and severity of disease. Aberrations seemingly are due first of all to mutagen influence of the X-rays which had been received during X-ray examinations, to antibiotics, and to other drugs as well as partially to considerable metabolic aberrations which exist in patients.