Arteriovenous malformation of the rectum: report of a case

We report herein the case of a 38-year-old man found to have a rectal arteriovenous malformation (AVM). The patient was admitted to our hospital for investigation of fresh anal bleeding and general malaise. Barium-enema examination showed a slightly elevated lesion in the rectum, and a selective superior rectal angiogram subsequently revealed an AVM in the peripheral region of the superior rectal artery, which was presumed to be the cause of the anal bleeding. Colonoscopic examination disclosed a submucosal tumor-like lesion in the left posterior wall of the rectum, 3cm above the anal verge. After marking the boundaries by clipping, transanal resection of the lesion was performed. Histological examination revealed an irregularly expanded arteriovenous aggregation in the submucosal layer. The patient had a favorable postoperative course, and no residual AVM was seen on a postoperative selective inferior mesenteric arteriogram. There have been no signs of recurrence in the 2 years since his operation.     

Late rectal bleeding following combined X-ray and proton high dose irradiation for patients with stages T3-T4 prostate carcinoma

PURPOSE: Dose escalation for prostate cancer by external beam irradiation is feasible by a 160 MeV perineal proton beam that reduces the volume of rectum irradiated. We correlated the total doses received to portions of the anterior rectum to study the possible relationship of the volume irradiated to the incidence of late rectal toxicity. METHODS: We have randomized 191 patients with stages T3 and T4 prostatic carcinoma to one of two treatment dose arms. These were: 1) 75.6 Cobalt-Gy-equivalent (CGE), 50.4 Gy delivered by 107-25 MV photons followed by 25.2 CGE delivered perineally by protons (Arm 1) or 2) 67.2 CGE delivered by 10-25 MV photons (Arm 2). RESULTS: With a median follow-up of 3.7 years, post-irradiation rectal bleeding (grades 1 and 2 only, none requiring surgery or hospitalization) from telangiectatic rectal mucosal vessels has occurred in 34% of 99 Arm-1 patients and 16% of 92 Arm-2 patients (p = 0.013). Dose-volume histograms (DVHs) for the anterior rectal wall, the posterior rectal wall and the total rectum in 41 patients treated on Arm 1 were calculated from the three dimensional dose distributions. Rectal bleeding has occurred in 14 or 34% of the 41 DVH-analyzed subset of Arm-1 patients. Both the fractional volume of the anterior rectum and the total dose received by fractional volumes of the anterior rectum significantly correlate with the actuarial probability of bleeding. CONCLUSIONS: Clinicians planning dose escalation to men with localized prostate cancer should approve with caution treatment plans raising more than 40% of the anterior rectum to more than 75 CGE without additional effort to protect the rectal mucosa because this late sequela data indicate that more than half of these men will otherwise have rectal bleeding.     

Early local recurrence of rectal cancer showing extremely rapid growth after curative surgery: report of a case

We report herein the case of a 59-year-old woman who developed a local recurrence of rectal cancer which showed extremely rapid growth. The patient had undergone a curative low anterior resection with total mesoexcision, and was discharged on postoperative day 25 after an uneventful recovery. However, 2 months after the operation, she developed bleeding from the rectum during defecation, the quantity of which gradually increased. A colonoscopy performed during the fifth postoperative month revealed a circular tumor at the suture line. The tumor was unresectable because it had firmly invaded not only the sacrum, but also the right ureter. Despite the administration of 5-fluorouracil and leucovorin, the patient died of cancer 18 months after her initial surgery. Considering that local recurrence of rectal cancer does not usually occur within 1 year after surgery, this case is unusual because the local recurrence developed very early and showed extremely rapid growth, occupying the entire lumen of the rectum by the time it was detected by colonoscopy during the fifth postoperative month.     

Transanal endoscopic microsurgery--experiences at the Zurich University Hospital

The advantages of TEM (transanal endoscoic microsurgery) are minimally invasive, exact and full thickness excision of tumors in the rectum and a very low morbidity with excellent comfort for the patient. In a retrospective study all transanal endoscopic operations at Zurich University hospital in the last 5 years have been analyzed (n = 18). 11 adenomas and 5 carcinomas of the rectum have been resected with TEM (one mucosectomy, 16 full wall resections and one segmental resection of the rectum). In the group of the carcinomas there were four preoperatively known carcinomas, one T1 carcinoma was discovered postoperatively in the analyzed tissue. Among the four known carcinomas was one T1 carcinoma, two T2 carcinomas (one of them was thought to be a T1 preoperatively) and one T3 carcinoma. One patient with T2 carcinoma wanted specifically a minimally invasive procedure, the other one with T2 carcinoma was an older patient who didn't qualify for laparotomy. The patient with T3 carcinoma also had a malignant lymphoma. The operation was tolerated well by all the patients. There was one case of peritoneal perforation treated laparscopically and one case of postoperative bleeding. An incontinence of gas in one patient disappeared after 3 months. There was no adjuvant treatment in the group of the T1 carcinomas. One patient with a postoperative T2 carcinoma did not want a chemotherapy. The other two patients with T2 and T3 were polymorbid. Among the resected adenomas there was no case of recurrence. One T2 carcinoma recurred. These results show that transanal endoscopic microsurgery (TEM) is an excellent technique to treat ademomas and T1 carcinomas of the rectum with the advantages of full thickness excision under good vision, a minimal rate of recurrence and maximal patient comfort. The indications for transanal microsurgery are rare. The techically demanding operation is not always simple and should be performed in larger centers only.     

Diffuse cavernous hemangioma of the rectum complicated by invasion of pelvic structures. Report of two cases

PURPOSE: We present two cases of diffuse cavernous hemangioma of the rectum that invaded the pelvic structures. METHODS: Two young women suffering from intermittent rectal bleeding were studied using computed tomography and magnetic resonance imaging. RESULTS: Beside the rectal hemangioma, computed tomography and magnetic resonance imaging revealed that the pelvic ureter and the iliac vessels were each eroded by the tumor that produced symptoms in these two patients. CONCLUSION: Computed tomography and magnetic resonance imaging permit direct visualization for tumor staging and also for recognition of any pelvic structure invasion, which facilitate preoperative assessment of diffuse cavernous hemangioma of the rectum.     

A prospective cohort study on the relationship between onion and leek consumption, garlic supplement use and the risk of colorectal carcinoma in The Netherlands

The association between onion and leek consumption, garlic supplement use and colon and rectum carcinoma among men and women was evaluated in the Netherlands Cohort Study, a large-scale prospective cohort study on diet and cancer. Onions, leeks, and garlic belong to the Allium genus and contain large amounts of potentially chemopreventive compounds. The Netherlands Cohort Study was started in 1986 among 120 852 men and women, aged 55-69 years. Dietary intake was measured with a 150-item food frequency questionnaire. After 3.3 years of follow-up, 150 and 143 incident male and female cases of colon carcinoma, and 93 and 57 cases of rectum carcinoma, respectively, with complete dietary data were available for analysis. Dietary data were available for 1525 men and 1598 women of a randomly selected subcohort, that was followed up to estimate person-time in the entire cohort. In men, the adjusted rate ratios (RRs) in multivariable analysis for colon and rectum carcinoma in the highest compared to the lowest onion consumption categories were 0.87 (95% confidence interval [CI] = 0.48-1.65), and 0.66 (95% CI = 0.28-1.52), respectively. The RRs for proximal colon carcinoma were lower than for distal colon carcinoma. Leek consumption was not associated with colon and rectum carcinoma incidence in men. None of the RRs were significantly different from unity and no trends in the RRs were detected. A lower risk was found for rectum carcinoma in women consuming less than 0.25 onions per day (RR=0.36, 95% CI = 0.13-0.99), but the trend in the RRs was not statistically significant (P = 0.25). All other RRs for colon and rectum carcinoma associated with onion consumption were slightly higher than one. Leek consumption was not associated with colon and rectum carcinoma incidence. The use of garlic supplements was not associated with colon and rectum carcinoma in men and women combined. This study does not support an inverse association between the consumption of onions and leeks, or the use of garlic supplements and the incidence of male and female colon and rectum carcinoma.     

Neural activity in areas V1, V2 and V4 during free viewing of natural scenes compared to controlled viewing

BACKGROUND AND PURPOSE: The three-dimensional (3D) dose distribution in combination with 3D anatomy of 13 patients treated for cervical carcinoma with intracavitary brachytherapy was analyzed. The aim of this study was to determine the correlation between a dose value obtained from the integral dose volume histogram (DVH) of the rectum and (a) the Nederlands Kanker Instituut (NKI) point of reference for the rectum dose (R) and (b) the highest dose to the frontal rectum wall in the transverse CT slice near the top of the vagina through point R. RESULTS: The correlation between the DVH rectum dose value for 2 cm3 in the highest dose region and the rectum dose at point R was poor (regression coefficient 0.50). On the contrary, however, the correlation between the DVH rectum dose value for 2 cm3 in the highest dose region and the maximum rectum dose value in a transverse CT slice through point R was good (regression coefficient 0.90). CONCLUSIONS: The maximal rectum dose value obtained from a transverse CT slice near the top of the vagina through point R was found to be a more representative point for the rectal dose burden and might therefore show a good correlation with complications. The point of reference for the rectal dose (R) was found not to be a reliable estimation of the maximal dose in the rectum.     

Per anal suturing of a bleeding ulcer to achieve successful hemostasis of massive hemorrhage associated with ulcerative colitis: report of two cases

We report herein the cases of two patients with ulcerative colitis complicated by massive hemorrhage who were successfully treated by per anal suturing of a bleeding ulcer. A 40-year-old woman and a 22-year-old man had suffered from extensive colitis for 8 and 2 years, respectively, and both followed a similar clinical course. They were admitted under emergency conditions and, despite treatment with intravenous high-dose prednisolone and thereafter with intraarterial injections of prednisolone, suffered several attacks of massive hemorrhage with hypovolemic shock. Emergency subtotal colectomy with ileostomy and rectal mucous fistula were performed, but recurrent massive hemorrhage occurred during the early postoperative period. Bleeding from a discrete ulcer in the rectum was subsequently located, and both patients underwent per anal suturing of the ulcer. No recurrent bleeding occurred thereafter, and an ileoanal anastomosis was performed several months later. Massive hemorrhage is a rare complication of ulcerative colitis which is most often resolved by subtotal colectomy without proctectomy. Although bleeding associated with ulcerative colitis usually occurs diffusely, these case reports serve to demonstrate that massive bleeding can also result from a discrete ulcer. We advocate that this condition be treated by an endoscopic or local hemostatic procedure.     

Perforated rectal lymphoma in a renal transplant recipient: report of a case

PURPOSE: We report the case of a renal transplant recipient with rectal lymphoma manifested by sudden onset of abdominal pain from a perforated rectum who was treated successfully with prompt surgical resection and reduction of immunosuppressants. METHODS: An emergent anterior resection with Hartmann's procedure was done. Immunosuppressants were drastically reduced by discontinuation of cyclosporine. RESULTS: Pathologic examination showed diffusely infiltrated large-cell malignant lymphoma with an immunoblastic feature. The patient has been followed-up for four years, with no tumor recurrence or graft rejection. CONCLUSION: Rectal lymphoma, although rare, should be kept in the list of differential diagnoses for transplant recipients who exhibit lower gastrointestinal bleeding, intestinal obstruction, or abdominal pain.     

Susceptibility to vaccine-preventable diseases in a sexually transmitted disease clinic population

OBJECTIVE: To determine whether general practitioners (GPs) had received Australian guidelines on early detection, screening and surveillance for colorectal cancer or rectal bleeding, and whether their reported practice conformed with these guidelines. DESIGN: Cross-sectional postal survey of self-reported practice. PARTICIPANTS AND SETTING: 213 GPs in practice in the southern metropolitan area of Perth, Western Australia, were randomly selected from the Fremantle Regional Division of General Practice database and surveyed in March 1997. RESULTS: Replies were received from 155 (73%) of the GPs, and 110 reported receiving guidelines (from the Australian Gastroenterology Institute [AGI], 44; Gut Foundation of Australia [GFA], 40; others, 6; and not specified, 20). GPs who reported receiving guidelines were significantly more likely to screen for colorectal cancer (99/110; 90%) than those who reported not receiving guidelines (33/45; 73%) (P = 0.008). The commonest method to investigate people with identifiable risk factors for colorectal cancer was colonoscopy. Reported screening frequencies in asymptomatic patients with above-average risk (family history of colorectal cancer or past history of adenomatous polyps or colorectal cancer) were significantly higher than recommended by AGI and GFA guidelines (P < 0.05). Up to 24% of GPs investigated altered bowel habit or bleeding per rectum with faecal occult blood testing. CONCLUSIONS: Most GPs report having received guidelines. Reported screening frequency was higher than recommended for most above-average-risk patients, which will result in excessive consumption of resources without benefits for cancer prevention.     

Ontogeny of the endocrine cells of the intestine and rectum of sea bass (Dicentrarchus labrax L.): an ultrastructural study

Several endocrine cell types were ultrastructurally characterized during the differentiation of the intestine and rectum of sea bass (Dicentrarchus labrax L.) larvae. Only one cell type (type I) was found in the posterior region of the undifferentiated gut of 5-day-old larvae (phase I). Types V and VI were found in both the intestine and rectum, types II, III and IV in the intestine, and types VII and VIII in the rectum of 9- and 12-day-old larvae (phase II), the rectum alone showing signs of functional differentiation. In phase III larvae, in which both the intestine and rectum were differentiated, types IX, X, XI, XII, XIII, XIV and XV were found in the intestine, only types X, XI and XII being seen in the rectum. Besides these, a new cell type, XVI, was observed in the intestine of 55- and 60-day-old larvae (phase IV), in which the digestive tract was completely differentiated. The endocrine cells appearing in phases I and II showed very scarce secretory granules and the ultrastructural features of undifferentiated cells. Some endocrine cell types in the earliest developmental stages were related to some of those found later. A maturational process of the endocrine cell types paralleled the differentiation of the intestine and rectum, with an apparent increase in the number of secretory granules accompanying organelle development.     

A case of metastatic carcinoma to the retina]

The authors report a case of metastatic carcinoma to the retina. The patient was a 61-year-old man who had an operation for a well-differentiated adenocarcinoma of the rectum. Ophthalmoscopic examination disclosed a single, white, elevated mass lesion surrounded by serous retinal detachment located in the upper part of the macula of the right eye. A few retinal hemorrhages existed around the lesion. Fluorescein angiography revealed partially obscured retinal vessels due to compression by the tumor and arteriovenous anastomosis. Postmortem pathologic examination confirmed metastases to the brain, lung and retina. Microscopic examination showed a retinal lesion and tumor cells in the right eye. Tumor cells, similar to the carcinoma of the rectum, were present only in the neurosensory retina and did not invade the pigmented epithelium or choroid.     

Hyperhidrosis as the only symptom of post-influenza diencephalitis

A prospective study to evaluate sexual dysfunction following resection of the rectum was performed in 21 male patients. Following proctocolectomy for inflammatory bowel disease (9 patients), the incidence of sexual dysfunction was 11%, and it was always partial. Following abdominoperineal excision of the rectum for carcinoma (7 patients), the incidence of sexual dysfunction was 50%, and it was total in 16%. After anterior resection with low colorectal anastomosis (5 patients), the incidence of sexual dysfunction was 40%. The risk of dysfunction following operations on the rectum increased with the age of the patient and was minimal below the age of 50 years. In patients with inflammatory bowel disease, careful dissection close to the rectum should avoid damage to the pelvic nerves, and the incidence of sexual dysfunction should be low.     

Synthesis and characterization of 8-methoxy-2''- deoxyadenosine-containing oligonucleotides to probe the syn glycosidic conformation of 2''-deoxyadenosine within DNA

BACKGROUND: Rectal motor activity is incompletely understood. The aim of this study was to characterize the patterns of rectal motor activity and to examine their diurnal variation and their relationships to proximal colonic activity and to meals. METHODS: We performed a 30-h ambulatory motility study by recording pressure activity at multiple sites in the colon in 18 normal subjects. RESULTS: During 288 h of recording, discrete bursts of tonic and phasic activity were seen in the rectum of all subjects at night and during the day lasting > or = 3 min, with a predominant frequency of 3 waves/min: periodic rectal motor activity (PRMA). Nocturnally, the number of cycles and the proportion of time occupied by this activity were greater (p < 0.001) and the inter-cycle interval was shorter (p < 0.008) compared with daytime, but the cycle duration was similar. Only 4 versus 5% (nocturnal vs daytime) of cycles propagated aborad, whereas 36 versus 14% (p < 0.01) propagated retrogradely, 16 versus 47% (p < 0.01) occurred simultaneously, and 44 versus 34% were confined to the rectum. There was considerable intra- and intersubject variability. PRMA was not related to meals or to anal motor activity, but 81% of nocturnal and 94% of daytime cycles occurred within 5 min of a motor event in the more proximal colon. CONCLUSIONS: PRMA is a characteristic feature of the normal rectum and is more frequent at night. The temporal association with motor events in the proximal colon suggests that PRMA is triggered by the arrival of stool or gas in the rectum. Because most cycles are either segmental or are propagated retrogradely, PRMA may serve as an intrinsic braking mechanism that prevents untimely flow of colonic contents, particularly during sleep.     

Regulation of prostaglandin endoperoxide H2 synthase in term human gestational tissues

The distribution in the chicken intestine of neuropeptide-immunoreactive (IR) ganglion cells and nerve fibres was investigated immunohistochemically. There were four kinds of ganglion cells: vasoactive intestinal polypeptide (VIP)-, substance P (SP)-, galanin (GAL)- and somatostatin (SOM)-IR cells in the submucous plexus (SMP) of the whole intestine and in the myenteric plexus (MYP) in the small intestine excluding VIP-IR ones. These peptide-containing fibres were found consistently but their distribution was variable in the mean areas in different regions of the intestinal wall. They seemed to be intrinsic. Comparing the jejunum and rectum in density and variation, the characteristics of innervation were as follows: villi in both intestines received more VIP-IR fibres than the other three which showed no significant difference. Crypts were surrounded with SP-IR fibres; these were denser than the other three in the jejunum compared with the rectum. The mean areas of SOM- and GAL-IR fibres were four and six times larger than those in the rectum, respectively. The SMP was supplied with the six kinds of neuropeptide-IR fibres, and VIP-IR fibres were dominant in both sides. Areas of VIP-, SP- and SOM-IR fibres were about two times greater than in the jejunum. The area of VIP-IR fibres in the circular muscle was significantly larger than that of the other four in both intestines; their density in the rectum was bout two times higher than in the jejunum. The mean area of SP-IR fibres in jejunal circular muscle was 14 times larger than that in the rectum. The MYP was supplied with seven kinds of neuropeptide-IR fibres except that methionine enkephalin-IR was absent from the rectum. Of these seven fibres, SP- and VIP-IR fibres in the jejunum had the largest areas. However, GAL-IR fibres in the jejunum were about four times denser than in the rectum. We conclude that the jejunum is characterized by the dense distribution of neuropeptide-IR fibres in crypts and MYP whereas in the rectum they occur in SMP and circular muscle. Fig. 15 summarizes the connections described in the present study.     

Role of electrocoagulation in treatment of cancers of the rectum

The authors describe the technics of a wide local electrocoagulation which was used in the treatment of 42 malignant tumors of the rectum: 27 adenocarcinomas and 15 malignant villous tumors. This not disabling technic, avoiding colostomy, is generally harmless even in old and poor risk patients. The mortality rate was 7 p. 100 in the adenocarcinomas series, nul in the malignant villous tumor series. The five year survival rate was 66 p. 100 in the first series and 80 p. 100 in the second. One third of the patients bearing adenocarcinomas developed recurrences, among which some were treated either by large surgery, iterative electrocoagulation, or radiotherapy after colostomy. The indications depend on the size and the site of the tumor. Electrocoagulation is found possible only for T1 or T2 tumors of the posterior and lateral walls of the rectum, provided that they are located at less than 10 cm from anus and above the sphincter.     

Comparison of the oral, rectal, and vaginal immunization routes for induction of antibodies in rectal and genital tract secretions of women

To determine which mucosal immunization routes may be optimal for induction of antibodies in the rectum and female genital tract, groups of women were immunized a total of three times either orally, rectally, or vaginally with a cholera vaccine containing killed Vibrio cholerae cells and the recombinant cholera toxin B (CTB) subunit. Systemic and mucosal antibody responses were assessed at 2-week intervals by quantitation of CTB-specific antibodies in serum and in secretions collected directly from mucosal surfaces of the oral cavity, rectum, cervix, and vagina with absorbent wicks. The three immunization routes increased levels of specific immunoglobulin G (IgG) in serum and specific IgA in saliva to similar extents. Rectal immunization was superior to other routes for inducing high levels of specific IgA and IgG in rectal secretions but was least effective for generating antibodies in female genital tract secretions. Only vaginal immunization significantly increased both specific IgA and specific IgG in both the cervix and the vagina. In addition, local production of CTB-specific IgG in the genital tract could be demonstrated only in vaginally immunized women. Vaginal immunization did not generate antibodies in the rectum, however. Thus, generation of optimal immune responses to sexually transmitted organisms in both the rectal and the genital mucosae of women may require local immunization at both of these sites.     

Endoscopic management of uterine perforation with the ENDO-UNIVERSAL surgical stapler

The management of an uterine perforation occurring during a D & C, in which a bleeding could not be stopped by coagulation per laparoscopiam is described. The closing of the bleeding injury in the uterus wall was performed by ENDO-UNIVERSAL-clip-instrument. The wound was closed and the bleeding stopped. The possibility to manage an uterine perforation with this simple method is reported and discussed.     

Identification and sequence of human PKY, a putative kinase with increased expression in multidrug-resistant cells, with homology to yeast protein kinase Yak1

The authors report a clinical case of endometriosis the abdomen rectum muscle, in woman 28 years old, after a cesarean section delivery. On the basis of literature on the topic, the following are taken into consideration, the incidence, the pathogenesis, the clinical characteristics of this kind of pathology and the aspects which might facilitate the diagnostic approach and correct therapeutic to be given or follow. Parietal endometriosis is an extremely rare disease with incidence in feminine population of 0.03-1%. The pathogenesis is still ill-known. Lack of the classical symptoms and the unusual site can make diagnosis difficult. Pathognomonics but not always present are the presence of tumescence palpable of the abdominal wall near or proximity of preceding surgical scar, the cyclic character of painful symptomatology, the augmentation of volume and the bleeding in period menstrual or premenstrual. The ultrasonography, the computerized axial tomography, the nuclear magnetic resonance can facilitate the preoperative diagnosis but they do not always furnish reports of certainty. The aspirate-needle in ultrasonography control can furnish one of orientation diagnosis. The diagnosis of certainty is founded on the histologic examination after biopsy or excision. The treatment of the abdominal wall endometriosis is surgically essential. The excision of tumescence, easy usually, it is the only means to obtain the definitive recovery. The medical therapy postoperative is adjuvant in the treatment of unrecognized pelvic centres of endometriosis.     

Ths significance of metastases to the adrenal glands in adenocarcinoma of the colon and rectum

A study to determine the frequency of metastases to the adrenal glands following carcinoma of the colon and rectum was undertaken. Patients with, or without, adrenal spread were compared regarding age, sex, race and survival time. The over-all metastatic pattern was analyzed to determine its usefulness for predicting the presence of metastases to the adrenal glands. Autopsy reports and clinical records of patients with adrenal spread were reviewed regarding the extent of tumor involvement in the glands and possible adrenal insufficiency. Of 457 patients with adenocarcinoma of the colon and rectum who underwent autopsy, 63 or 14% had metastasis to the adrenal glands. Of these, 29 had bilateral involvement. Patients with bilateral metastases had a lower median age than did those without adrenal spread. No correlation was found between adrenal metastatic status and sex or race. Although survival time was found to be shorter for patients with bilateral metastases of the adrenal glands, adrenal insufficiency did not seem to be the reason for this shorter survival time. In retrospect, however, the presence of adrenal insufficiency could not be ruled out in several of these patients. Eight sites were studied with regard to whether or not metastatic involvement in a specific site might indicate a higher risk for simultaneous metastases to the adrenal glands. It was found for all sites that, when involved, there was a higher frequency of metastases to the adrenals than if free of tumor. Metastases especially above the diaphragm indicated a considerable risk for adrenal involvement. Different sites were combined in groups and studied in the same way. It was found that the more sites involved, the higher the relative chance of metastases to the adrenals. It was suggested that the results presented may be useful in predicting the relative chance of adrenal metastases in patients with advanced carcinoma of the colon and rectum.