COLORECTAL ISSUES
| COLORECTAL ISSUES IN THE ICU—Sonia Ramamoorthy, MD, Assistant Professor of Surgery, Colon and Rectal Surgery,
University of California, San Diego, School of Medicine
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| Clinical challenges: history taking compromised by sedation, intubation, pain medication, neurologic deficit; physical examination
compromised by postoperative status of intensive care unit (ICU) patient and concomitant medications; laboratory
and radiographic results compromised; also chronic conditions, eg, lupus; in ICU, catastrophic abdominal events tend
to be diagnosed in advanced stage (rapid course; need high index of suspicion); clinicians need to audit their ICU and themselves
(eg, neurologic ICU may see more pseudo-obstructions from medication)
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| Common ICU problems: colitis (ischemic and infectious); mainly pseudo-obstruction and lower gastrointestinal (GI)
bleeding
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Ischemia
| Case: man, 54 yr of age, postoperative day 2, abdominal aortic aneurysm repair, with increasing abdominal pain; not responding
to analgesics; bloody stools, abdomen distended, no physical findings, laboratory studies equivocal, some acidosis,
nonspecific bowel gas pattern on x-rays; differential diagnosis ischemic colitis
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| Ischemic colitis: fits into larger category of acute mesenteric ischemia; abdominal emergency; although uncommon in
ICU, too frequently ruled out; mortality 60% to 80%; increasing incidence despite medical advances; mainly seen in
postoperative cardiothoracic patients, coronary patients with intra-aortic balloon placement, and renal failure patients;
neurologic ICU most common population; multiple etiologies
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| Different forms of occlusive ischemia: arterial occlusion in acute setting due to embolic or thrombotic phenomena
(eg, atrial fibrillation sends clot into lower aorta); ischemic colitis occurs in large intestine; venous occlusion (patients
with hypercoagulable states)
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| Acute mesenteric ischemia: cause leads to compromised bowel flow and release of inflammatory mediators that
break down gut barrier; bacterial translocation; microcirculation damage; ischemic reperfusion injury leads to irreversible
intestinal necrosis; patient goes on to multiorgan failure and demise
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| Work-up: by time patient develops acidosis, team “behind 8-ball”; anticipated laboratory results, eg, lactate levels, nonspecific
and not sufficiently sensitive indicators of intestinal ischemia; acidosis may occur in only 50% of patients, so
need to put total picture together (history, laboratory findings, and physical examination) and have high index of suspicion
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| Other tests: work-up includes acute abdominal series; determines need for surgery; free air, hematosis in colon indicating
transmural infarction of bowel, portal venous air; all ominous signs of need for immediate surgery; maintain adequate
perfusion pressure and avoid pressor extremes; if patient develops signs of sepsis, broad-spectrum antibiotics indicated;
nasogastric (NG) tube decompression; use rigid sigmoidoscope to view distal sigmoid colon; in more stable patient, use
angiography (gold standard for diagnosing intestinal ischemia)
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| Management: first resuscitate patient; may require Swan-Ganz catheter placement and echocardiography to evaluate
cardiac output; laboratory work-up; try for any history; in stable patient, angiography; if patient unstable, operate; may
undergo bowel resection; second-look laparotomy; in operating room, aim for diagnosis of cause, whether thrombotic,
embolic, or nonocclusive
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Clostridium difficile Colitis
| Case: woman, 30 yr of age, lung transplant for cystic fibrosis 2 yr ago, transferred to ICU for hypotension; initially admitted
for pneumonia; started on antibiotics; developed diarrhea and correctly diagnosed (via stool studies) for Clostridium difficile
colitis; did not respond to treatment; progression to fulminative colitis indicated; transferred to ICU; suffered disorientation,
diarrhea, and electrolyte abnormalities; poor vital signs; colitis; abdominal distention; tympanitic and tender to
palpation; white blood cell (WBC) count elevated (60,000/mm3 )
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| C difficile: spore-forming gram-positive anaerobic bacteria; normally found in 1% to 3% of patients; in hospitalized patients,
10% to 20%; in neonates, 40%; not all strains pathologic; elaboration of protein exotoxins A and B makes strain
pathologic; grow culture and expose C difficile cells to normal tissue (takes 48 hr); history most common for recent antimicrobial
use (within last 2 mo); human factor in transmission makes hand washing important; epidemics in ICU
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| Treatment: metronidazole (Flagyl) oral or intravenous (IV) and vancomycin in oral and enema form; depends on particular
hospital’s customary approach
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| Diagnosis: ominous signs may be present; computed tomography (CT) quick and almost 100% sensitive for pseudomembranous
colitis; most clinicians start therapy without waiting for toxicology results
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| Study: University of Pittsburgh over 12-yr period retrospectively studied C difficile colitis for incidence and mortality;
found both increasing (doubled from 1988 to 2000); mortality ≈15%, compared to overall hospital mortality (3%); 75%
of patients with C difficile who went on to colectomy were postoperative patients; most commonly posttransplant (lung
most common organ); other group postoperative vascular and cardiothoracic surgery; colectomy associated with bad outcome
from C difficile colitis
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| Summary: treat early, especially high-risk patients; follow closely for signs of fulminant colitis; involve infectious disease
specialists when patients do not respond to treatment in 24 to 48 hr; involve surgeons early
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Gastrointestinal Bleeding
| Risk factors: for GI bleeding in ICU include any patient with history of shock or hypoperfusion to intestine; sepsis; respiratory
failure; prolonged NG intubation leading to gastritis or ulceration; coagulopathies; alcoholism or liver disease
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| Lower GI bleeding: originates distal to ligament of Treitz; 20% to 30% of GI bleeding comes from lower GI tract; resolves
spontaneously in ≈80% of patients; high rebleeding rate (20% to 50%); mortality increases as patients require
more blood; cut-off point ≈3 units (where mortality rate jumps); etiology includes diverticular disease, arteriovenous
(AV) malformations, vascular ectasias, and anorectal disease; less often, inflammatory bowel disease (IBD), polyp disease,
and cancer
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| Work-up: laboratory results needed to resuscitate; history and physical examination important to discover etiology (eg,
does patient have baseline coagulopathy?); tender abdomen with bleeding may indicate colitis; painless bleeding more
indicative of diverticular disease, AV malformation, or cancer; anorectal pain indication for rigid sigmoidoscopy
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| Treatment: resuscitation, localization, and treatment; to resuscitate, use blood and fluids; NG tube lavage to rule out upper
GI source; transfuse as necessary; unstable patient requires surgery; for stable patient, speaker prefers colonoscopy
(diagnostic and therapeutic); bowel preparation not usually needed; if unable to locate, try red blood cell (RBC) scan or
angiography (therapeutic for brisk bleeding)
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Colonic Pseudo-obstruction
| Case: man, 74 yr of age, admitted to ICU after spinal surgery complicated by pneumonia; afebrile; abdomen increasingly
distended; diminished bowel sounds; no bowel movement for 3 days; WBC count mildly elevated; x-ray showed only dilated
large bowel with no evidence of obstruction, but cecum 9 cm; obvious case of colonic pseudo-obstruction (seen frequently
in ICU); mortality 15% to 30%; etiology multifactorial
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| Management: noninvasive; correct electrolytes; limit narcotics; increase mobility; serial x-rays; pharmacologic interventions
include use of erythromycin (promotility agent) and neostigmine; invasive treatments include colonoscopic decompression;
last option surgical decompression
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| LAPAROSCOPY FOR COLORECTAL CARCINOMA: A GLOBAL PERSPECTIVE OF TRIALS AND DATA FROM
USA AND CANADA —Steven D. Wexner, MD, Chairman, Department of Colorectal Surgery, Cleveland Clinic Florida,
Weston
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| Benefits of laparoscopy: bowel function returns more rapidly after laparoscopy than with open procedure; early finding
based on Level-I data; benefit of laparoscopy found also in pulmonary function; 1988 study showed significant difference
and recovery of 80th percentile in respiratory volume and functional vital capacity in laparoscopic group; pain
another area to benefit
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| Clinical Outcome of Surgical Therapy (COST) study: 2 studies; first was feasibility study; second study in
Journal of the American Medical Association (JAMA) in 2002; randomized controlled study of 449 patients with single-
segment colon adenocarcinoma; compared laparoscopy and laparotomy; excluded many disease types; surgeon’s audit
showed laparoscopy superior in pain management in 3 parameters (oral analgesia, IV or parenteral narcotic analgesia,
and hospital stay); also quicker return to bowel function, shorter hospital stay, and less narcotic usage; supported by other
cohort study data
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| Financial cost: elusive; in literature, “charges” actually refers to costs; varies tremendously; artificial; accurate system
needed
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| Recurrence: rates appear satisfactory but need to look deeper; know length of follow-up; in North America, survival and
recurrence rates acceptable; COST study involved 48 institutions, 872 patients, 5-yr follow-up; since then, equipment,
techniques, surgeon’s skills improved; no difference in recurrence rates and 3 yr-survival
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| Rectal cancer: no prospective trials for laparoscopy in North America; in colon cancer, clearly there is “green light”
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| MANAGING COLORECTAL RADIATION INJURY —Brett T. Gemlo, MD, Adjunct Assistant Professor of Surgery,
University of Minnesota Medical School, Minneapolis
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| Incidence: increasing, probably due to more use; occurs in colon and anus, but rectal injury most common
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| At-risk: patient populations at risk easily identifiable; diabetics; patients with previous pelvic surgery; patients on concomitant
chemotherapy; children and thin patients; fair-skinned patients
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| Signs and symptoms: acute mucosal inflammation and necrosis followed by submucosal hyalinization and radiation fibroblasts;
endarteritis obliterans in walls of arteries and veins that supply affected organ; important to recognize progression
does not cease after irradiation but occurs over years
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| Clinical presentation: 2 phases, acute and chronic; in acute phase of radiation proctitis, patient presents with diarrhea,
nausea, vomiting, and rectal bleeding; chronic phase can include diarrhea, malabsorption (usually from partial obstruction),
ulceration, hemorrhage, fistula formation, and frank infarction
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| Treatment: acute phase—primarily medical; antidiarrheals; antiemetics; bulking agents; hydrocortisone foams or enemas;
for diarrhea, barrier ointments on perianal skin; study of 134 patients undergoing radiation therapy for prostate
cancer randomized to sucralfate, mesalamine, or steroid enemas during therapy; results showed some mitigation of
toxicity in sucralfate and hydrocortisone groups, but much higher incidence of radiation proctitis or acute toxicity in
mesalamine group (arm terminated; agent contraindicated in acute phase); chronic phase—includes antidiarrheals; for
radiation proctitis, use oral 5-ASA compounds, sucralfate enemas, or steroid enemas; formalin instillation; laser or argon
beam plasma coagulation; for stricture, balloon dilation and stents (Food and Drug Administration [FDA] approval
for stents excludes benign disease); for radiation proctitis, little evidence on success of treatments
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 | Surgical treatment: take conservative approach; operate only if necessary; avoid incisions through irradiated skin; locate
original portals; place stoma away from irradiated area; always connect healthy bowel to healthy bowel; use temporary
proximal diversion
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| Rectovaginal fistula: endorectal advancement flap; better to position healthy nonirradiated tissue; Bricker’s procedures bring
down proximal sigmoid colon; often temporary stoma
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| Rectal stricture: dilation, but often resection and colostomy
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| Profuse hemorrhage: usually from fulminant proctitis; can do semielective procedure; consider proctectomy with coloanal
anastomosis, but often not given option (ie, emergency)
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| Anal sphincter dysfunction: from direct irradiation injury to sphincter muscle or concomitant fibrosis and proximal inflammation
in rectum, leading to mucus secretion and diarrhea
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| DESMOID —David A. Rothenberger, MD, Professor and Interim Chair, Department of Surgery, University of Minnesota
Medical School, Minneapolis
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| Desmoid: first described by McFarlane in 1832; single tumor or diffuse and aggressive; incidence uncommon; for colorectal
surgeons, concern is hereditary-type desmoid associated with familial adenomatous polyposis (FAP) where incidence
900 times general population
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| Demographics: three times more common in women than in men; mean age young; slow-growing in general but sometimes
vigorous; symptoms present for long time; often misdiagnosed as low-grade fibrosarcoma
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| Pathology: bland; monoclonal fibroblastic proliferation of cells
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| Risk factors for sporadic desmoid: pregnancy, suggesting hormonal influence; soft-tissue trauma, including previous
surgery; female sex; younger patients
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| Sporadic desmoids: rare, can occur extra-abdominally; if desmoid seen, screen patient for FAP and adenomatous polyposis
coli (APC) gene; amenable to resection; recurrence common; morbidity includes small bowel obstruction, ischemia,
strictures, and ureteral obstruction; mortality in FAP patients most commonly caused by desmoid tumors; die
from sepsis and/or massive hemorrhage
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| Surgery: tumors entangle and may require total-gut enterectomy; prognosis not good; some surgeons suggest delaying
surgery altogether; some argue trauma of surgery precipitates growth of desmoid
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| Nonoperative treatment: nonsteroidal anti-inflammatory drugs (NSAIDs) usually first line of therapy; commonly
sulindac; can add tamoxifen; sarcoma-type chemotherapy if needed; risk for fistulas, abscesses, and bleeding high
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| Desmoids and FAP: try not to operate; make sure obstructions present and surgery really needed; prepare to do bypasses
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| Conclusion: for abdominal wall desmoid, avoid surgery if possible; high recurrence; intra-abdominal desmoids same (especially
FAP patients); try watchful waiting with therapy (eg, sulindac)
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Educational Objectives
| The goal of this program is to educate the listener about colorectal issues in the intensive care unit (ICU), laparoscopy for
colorectal carcinoma, managing colorectal radiation injury, and desmoid tumors. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Identify colorectal problems in the ICU.
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| 2. Make a diagnosis of Clostridium difficile colitis.
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| 3. Cite known benefits of laparoscopy over laporotomy in management of colorectal cancer.
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| 4. Discuss colorectal radiation injury
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| 5. Discuss the incidence and management of desmoid tumors.
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Discussed on This Program
Mesalamine [5-aminosalicylic acid; 5-ASA) [Asacol, Pentasa, Rowasa]
Neostigmine methylsulfate [Prostigmin]
Sucralfate [Carafate]
Sulfasalazine [Azulfidine, Azulfidine EN-tabs]
Tamoxifen citrate [Nolvadex]
Suggested Reading
Acosta-Merida MA et al: Identification of Risk Factors for Perioperative Mortality in Acute Mesenteric Ischemia.
World J Surg [Epub] July 24 2006; Antropoli M et al: Laparoscopic procedures for colorectal cancer: analysis of 134
cases. Chir Ital 58:77, 2006; Bjoholt I et al: Principles for the design of the economic evaluation of COLOR II: an international
clinical trial in surgery comparing laparoscopic and open surgery in rectal cancer. Int J Technol Assess Health Care
22:130, 2006; Bockler D et al: Undiagnosed fatal mesenteric ischemia in acute type B aortic dissection. Vasc Med
11:133, 2006; Cholongitas E et al: Desmoid tumor presenting as intra-abdominal abscess. Dig Dis Sci 51:68, 2006;
Dietz et al: Strictureplasty for obstructing small-bowel lesions in diffuse radiation enteritis--successful outcome in five
patients. Dis Colon Rectum 44:1772, 2001; Foulke GE et al: Clostridium difficile in the intensive care unit: management
problems and prevention issues. Crit Care Med 17:822, 1989; Green BT et al: Urgent colonoscopy for evaluation
and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 100:2395,
2005; Jaramillo EJ et al: Bedside diagnostic laparoscopy in the intensive care unit: a 13-year experience. JSLS 10:155,
2006; Larson DW et al: Safety et al: Cancer screening with CT: dose controversy. Eur Radiol 15 Suppl 4:D55, 2005;
Mazeh H et al: Desmoid tumor causing duodenal obstruction. Isr Med Assoc J 8:288, 2006; Mofredj A et al: Laparoscopic
sentinel node mapping for colorectal cancer using infrared ray laparoscopy. Anticancer Res 26:2307, 2006;
Molelekwa V et al: Conservative management of a desmoid tumour in pregnancy. J Obstet Gynaecol 24:700, 2004;
Nakada I et al: Prednisolone therapy for intra-abdominal desmoid tumors in a patient with familial adenomatous polyposis.
J Gastroenterol 32:255, 1997; Rotimi VO et al: Hospital-acquired Clostridium difficile infection amongst ICU
and burn patients in Kuwait. Med Princ Pract 11:23, 2002; Saunders MD et al: Colonic pseudo-obstruction: the dilated
colon in the ICU. Semin Gastrointest Dis 14:20, 2003; Tsujinaka S et al: Formalin instillation for hemorrhagic radiation
proctitis. Surg Innov 12:123 June, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, Dr. Wexner
reported relationships with Incontinence Devices Inc., Boston Scientific, Curon Medical, Baxter Healthcare, and Power
Medical Interventions and research support from Curon Medical, Ethicon Endo-Surgery Inc., Ethicon Inc., Incontinence
Devices Inc., Karl Storz Endoscopy America Inc., Medtronic Inc., NIH Grant #K07-CA92445, SurgRx, Synovis, and Genzyme
Biosurgery Inc. He is a shareholder in Intuitive Surgical, Medsurge Medical, and Power Medical Interventions.
Dr. Ramamoorthy spoke at the Critical Care Summer Session 2005, held July 21-23, 2005, in San Diego, CA, sponsored
by the University of California, San Diego, School of Medicine. Dr. Wexner spoke at the 17th Annual Colorectal Disease
Symposium held February 16-19, 2006, in Fort Lauderdale, FL, and sponsored by the Cleveland Clinic Florida. Drs. Gemlo
and Rothenberger spoke at the 68th Annual Colon & Rectal Surgery: Conundrums and Controversies, held September 8-
10, 2005, in Minneapolis, MN, and sponsored by the University of Minnesota Medical School. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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