Megacolon

http://emedicine.medscape.com/article/180955-overview

Know that I have posted this only for a point of reference to Caseys latest surgery.

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Megacolon, Chronic

Author: David M Manuel, MD, Fellow, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital and Medical Center
Coauthor(s): Michael H Piper, MD, FACG, FACP, Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates PLC; Roberto M Gamarra, MD, Fellow, Department of Internal Medicine, Section of Gastroenterology and Hepatology, Providence Hospital and Medical Center; Clifford Y Ko, MD, MS, MSHS, Department of Surgery, Assistant Professor, University of California at Los Angeles School of Medicine
Contributor Information and Disclosures

Updated: Aug 3, 2007

Megacolon, as well as megarectum, is a descriptive term. It denotes dilatation of the colon that is not caused by mechanical obstruction.

While the definition of megacolon has varied in the literature, most researchers use the measurement of greater than 12 cm for the cecum as the standard. Because the diameter of the large intestine varies, the following definitions would also be considered: greater than 6.5 cm in the rectosigmoid region and greater than 8 cm for the ascending colon.

Megacolon can be divided into the following 3 categories:

* Acute megacolon (pseudo-obstruction)
* Chronic megacolon, which includes congenital, acquired, and idiopathic causes
* Toxic megacolon

This article is devoted to chronic (noncongenital) megacolon.
Pathophysiology

The pathophysiology of chronic megacolon is incompletely understood.
It likely represents an amalgam of primary disorders involving muscular and nervous systems of the intestine.
Much basic science work has been performed in this area.

For example, with respect to the large bowel reacting to its luminal contents, fatty acids appear to reduce the volume of the proximal large bowel.
Opiate narcotics, on the other hand, reduce the propensity of the colon to constrict.

Control of colonic contractility is through a complex interaction of intrinsic colonic nerves, splanchnic nervous control, and central nervous system input. The final common pathway of intrinsic nervous control of colonic motility is via postganglionic nerves: stimulatory cholinergic nerves and inhibitory nitric oxide-releasing nerves.
Evidence suggests that excessive production of nitric oxide may be the mechanism for toxic megacolon in ulcerative colitis; as yet, there is no evidence for a possible role of nitric oxide in chronic megacolon unrelated to inflammatory bowel disease.

Studies in mouse models and in children with chronic colonic pseudo-obstruction show abnormalities involving the number and function of the interstitial cells of Cajal (intestinal pacemaker cells).
Inherited disorders likely involve abnormal maturation and function of these cells, whereas acquired disorders demonstrate decreased numbers of them.

Animal studies show that the splanchnic nerves can dramatically affect colonic motility, both to contract and relax the colon. Extrinsic adrenergic nerves seem mainly to act by reducing acetylcholine release from intrinsic postganglionic nerves, although a direct action on smooth muscle cells cannot be excluded. At this time, the respective roles of the intrinsic and splanchnic nerves in inducing megacolon have yet to be clarified.

Some experts believe it is common practice to separate the disorders associated with chronic megacolon into the following: (1) colonic inertia (eg, generalized delayed transit), and (2) rectosphincteric dyssynergy (eg, functional outlet obstruction).

Frequency
United States

No large-scale studies have been conducted to determine prevalence/incidence of acquired megacolon.
International

The most common cause of megacolon worldwide is infection with Trypanosoma cruzi (Chagas disease).


Mortality/Morbidity
No large-scale studies have been conducted to determine prevalence/incidence of acquired megacolon. However, once present, the approximate risk of a spontaneous perforation from nontoxic megacolon is 3%.


Race
Race has not been documented to play a role in megacolon.



Sex

* The frequency of acquired megacolon is equally distributed between the sexes.
* The congenital megacolon, Hirschsprung disease, predominantly occurs in males.


Age
Although clinically chronic megacolon can occur in any age group, inherited types usually present in young patients, and acquired types usually present in older patients.


Clinical History

* Historically, chronic megacolon has been categorized into 2 groups, according to when symptoms begin.

o The congenital group experiences onset of constipation before age 1 year.
o The acquired group develops symptoms after age 10 years until adulthood.



Physical

* Physical examination generally reveals a distended abdomen, which may or may not be tense.

* Tympany is invariably present.

* Digital rectal examination may demonstrate a hard mass of stool just above the anorectal ring. Digital rectal examination in a patient with Hirschsprung disease may bring about a large gush of retained fecal material.

* Megarectum with a rectum distended with stool, if chronic, tends to cause the anus to gape open secondary to the dysfunction of the internal sphincter mechanism. These patients may present with factitious diarrhea secondary to overflow incontinence.


Causes

* Causes of acquired megacolon

o Neurologic diseases
+ Chagas disease
+ Parkinson disease
+ Myotonic dystrophy
+ Diabetic neuropathy
+ Spinal cord injury
+ Paraneoplastic neuropathy
+ Amyloidosis

o Systemic diseases
+ Scleroderma
+ Dermatomyositis/polymyositis
+ Systemic lupus erythematosus
+ Mixed connective tissue disease

o Metabolic diseases
+ Hypothyroidism
+ Hypokalemia
+ Porphyria
+ Pheochromocytoma

o Medication-induced conditions

o Idiopathic
+ Nonfamilial visceral neuropathy (sporadic hollow visceral neuropathy or chronic idiopathic intestinal pseudo-obstruction)

+ Results from damage to the myenteric plexus from drugs or viral infections

o The most common nonmechanical cause of acquired megacolon is infection with T cruzi (Chagas disease).
+ This infection results in the destruction of the enteric nervous system.
+ While this disease was originally confined to South America, recent estimates indicate that 350,000 people in the United States are seropositive, a third of whom are thought to have chronic Chagas disease.

* Causes of congenital megacolon

o Enteric neuropathies
+ Hirschsprung disease (congenital aganglionosis)
# It is caused by a single gene mutation of the RET proto-oncogene on band 10q11.2.
# The defect occurs in 1 in 5000 live births.
# Some cases are familial, with an overall incidence of 3.6% among siblings of index cases.

+ Waardenburg-Shah syndrome (piebaldism, neural deafness, megacolon)

+ Multiple endocrine neoplasia type 2A (MEN 2A) or 2B (MEN 2B)


o Visceral myopathies

+ Mitochondrial neurogastrointestinal encephalopathy (MNGIE) - Only type III involves marked dilatation of the colon

+ Oculogastrointestinal neuropathy (OGIN)

+ Idiopathic

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This, from here:
http://www.healthon.com/articles/T/2/Toxic-Dilation-of-the-Colon/Toxic-Megacolon.html


Toxic Dilation of the Colon - Toxic Megacolon

* Overview, Causes, & Risk Factors
* Symptoms & Signs
* Diagnosis & Tests
* Prevention & Expectations
* Treatment & Monitoring
* Attribution

Overview, Causes, & Risk Factors

Toxic megacolon is a serious complication that can follow inflammation or infection of the large bowel, or colon. It causes marked enlargement of the colon.
What is going on in the body?

The colon is the part of the bowel that attaches to the rectum and anus. When the colon becomes inflamed or infected, it may enlarge. Toxic megacolon describes a dangerous enlargement of the colon. This may result in a life-threatening tear, or perforation, of the colon.
What are the causes and risks of the condition?

The two primary causes of this condition are infections and inflammation. Inflammation is usually due to a condition known as inflammatory bowel disease (IBD). IBD can cause inflammation in the lining of the colon for unknown reasons.

Medications used to control diarrhea may also raise the risk of this condition in some cases. Low blood levels of potassium may do the same.
Symptoms & Signs
What are the signs and symptoms of the condition?

Symptoms of toxic megacolon may include:
# fever
# abdominal distress
# diarrhea, with blood in the stools
# rapid heartbeat

On physical exam, the person looks quite ill. If a tear in the colon has occurred, the person is likely to show signs of peritonitis. These signs may include a hard, rigid abdomen, and severe abdominal tenderness.
Diagnosis & Tests
How is the condition diagnosed?

The person's medical history and a physical exam are important in making the diagnosis. Abdominal x-rays can help confirm the diagnosis by showing a severely enlarged colon.
Prevention & Expectations
What can be done to prevent the condition?

Early treatment of inflammatory bowel disease flare-ups may help prevent toxic megacolon. Medications to control diarrhea should be used with caution when the colon is inflamed or infected.
What are the long-term effects of the condition?

Toxic megacolon is life-threatening and may result in death. A person who develops a tear in the colon will require surgery. A colectomy, the removal of part or all of the colon, may be needed.
What are the risks to others?

Toxic megacolon is not contagious and poses no risks to others.
Treatment & Monitoring
What are the treatments for the condition?

Once toxic megacolon is diagnosed, the person is asked not to eat or drink anything. Fluids and salt are given intravenously (IV), which means through a vein. If the person's blood count is low, blood transfusions may be given. Gastric suctioning, a procedure in which a thin tube is used to remove stomach contents, can help reduce abdominal bloating. Antibiotics are usually given to kill bacteria. IV steroids, which are medications that reduce inflammation, may also be given.

In some cases, food is given intravenously. Someone with a suspected or known tear of the colon will need surgery to remove part or all of the colon.
What are the side effects of the treatments?

Antibiotics can cause stomach upset and allergic reactions. Other side effects vary depending on the medication that is used. Surgery carries the risk of bleeding, infection, and allergic reactions to anesthesia.
What happens after treatment for the condition?

If the person recovers completely from toxic megacolon, no further treatment may be needed. Some people have no long-standing problems from this condition, especially if surgery is not needed. However, a person with inflammatory bowel disease will need lifelong treatment.

Those who had surgery for this condition need follow-up visits with the surgeon to ensure proper healing. Sometimes a second operation is needed in the future.
How is the condition monitored?

After recovery from toxic megacolon, the person will need no further monitoring if the cause was an infection. A person with inflammatory bowel disease will need lifelong monitoring. Any new or worsening symptoms should be reported to the healthcare provider.
Attribution

Author:Minot Cleveland, MD
Date Written:
Editor:Coltrera, Francesca, BA
Edit Date:07/19/00
Reviewer:Adam Brochert, MD
Date Reviewed:08/09/01
Sources

Harrison's Principles of Internal Medicine, Fourteenth edition. 1998. McGraw-Hill, pp. 1633-1643

Current Medical Diagnosis & Treatment 2000, Lange Medical Books. McGraw-Hill, pp. 639-640

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Click here for more about Caseys latest surgery:
http://flintville.multiply.com/journal/item/775

Young Lady Casey; and Old Man River

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Caseys New Unit
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Good Late Afternoon Everyone;
I am sorry to not have blogged earlier- Just was so worn out.

As was Casey.
So much pain, and so little relief; no matter how much they turned up her painkiller, she could only sleep for 10 or 15 minutes at a time. This is not conducive to healing.

I called the hospital about 3 times Monday night, overnight.
Yes, she was still in pain, and little/no sleep.

This was Casey waking up Tuesday morning- I had gotten there before she'd woke, and gone in search of her nurse. We chatted a bit, and I would go wait til Casey woke...

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This was just after another of her 15 minute naps.
She had just been resting when I had gone in there.
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10 minutes later, she was up and sitting in a chair...
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Not sure what the heck happened to her back during the surgery,
but when she came to, it was hurting her awful.
Relieved when she walked,
though that made everything else hurt more.
That, and she is so very weak.
One of the nurses came in and helped her get up and about too.

I took over after taking this picture...
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They sure have fancy clothes in this hospital, no?
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As we walked around the place, there were different things to be seen. Especially the views from the 7th floor. But sad to say, my pictures were taken through some mighty dirty windows and didn't turn out for the most part.

We came upon this room, and I had to open the door and peek in...

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Very very cool!

Although I find it very odd that they have NO hypnotists available,
especially thinking how much pain relief may be gained through hypnosis
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Speaking of the view,
this is taken from her room...

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That is The Mississippi River.
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Each time I visited yesterday, there was no great improvement. And oh how it hurts me to see her in such non~retractable pain.
Last night she was still awake so we hiked some more. She IS a trooper!

But her back is just awful. (I still want to know why)?!


As we walked, another nurse at the desk was trying to contact a doctor who maybe would prescribe something for her to sleep.

Her saline had gone dry-
Her nurse, (Mary)? changed the bag.

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We talked a bit, and I even gave her my blog address!
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Casey.

As I left her last night...
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So tiny- So frail
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I came back here, and had problems falling asleep myself... Nice to have the computer for those times.

Later to turn the TV on too. Nothing was on- Bunch of noise and distraction.
That seemed to help.

I didn't wake until it was light out! Not like me at all!
But it was good to sleep too...

I wondered if Casey would call; I did not want to wake her up if she was sleeping.

She did call around 9, and sounded good!
Would I bring her this and that? Of course!

She said they had given her toradol (sp), and that she had also gotten some good sleep.

So I hustled up there fast as I could...

This is what I walked in on...

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Less than 48 hours post surgery!
(Ain't she cute)?!?
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After she had washed up and changed, we were off walking again.
She has gotten rid of her foley catheter, (and her "fall" bracelet)
and can now go for walks on her own.

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She stopped at a wall chart
to point out all the 'innards' she is missing...
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And then sat in the sunroom for a bit
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Oops I think this was a Tuesday picture...
Oh well.
We sat there today too.

She eats her ice.
(How very yummy and nutritious)!


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She has been told that she can have clear liquids tomorrow...
Baby steps for my baby girl.
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And now what you have been waiting for...

Drum roll please?
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TADA!!!!!!

"Look Mom, no zipper!"
hehehe

They taped her together!
Using the same scar, and just extending it lower a bit.

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And that is the last two days for us.
Punk needed to see Casey too, so I brought her up to visit this afternoon.

Casey had wanted me to bring her computer.
Maybe she will even feel good enough to blog in the next day or two. Hopefully.

Hope all is well with everyone- My apologies for not getting to your own blogs, or even answering all of your notes.
Please bear with me.

(I can't even get to them right now either- Punk has been patient enough).

Hope all is well with everyone

My love to all

XOXO
Anne

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Posted to my Y! 360, Wednesday April 8, 2009 - 05:39pm (CDT)

Casey, Morning 'Til Night, megacolon pic

Morning 'Til Night.

You asked about the weather?
Suffice to say Minneapolis still needs this dang chart.

Hello Old Man Winter?
"JUST LET IT GO ALREADY!"

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And what a long day-
I left Casey at the hospital where she says she is in the worst pain of her life. (These statements inbetween dozing and waking to pain in her front and more pain in her back).
They have upped her dilauded drip- But then it knocks her out and it is worse then when she wakens, or even tries to adjust herself or move.

Tonight will be tough on her- Tomorrow will be worse.
But by Wednesday we will see more and more spunk~n~sass coming back.

For now I must find some sleep. (It's here somewhere)...

And yet I am so afraid of falling asleep and not hearing the phones.

My head is back- almost full force, but no barfing anyway.
I won't take anything because then for sure i won't hear the effing phone.

Wanted to share a few pics before I lie down.

Know that the two photos at the bottom (under my XO's) are from her surgery.

You have been warned.

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Greg at home-
Waiting for me to bring his Casey back.
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Just hung up from talking to Kelli once more too...

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Morning 'til night now...
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Showing off her healed scar from her TP/AIT .
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Joking with one of the anesthesiologists
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Showing off her new STYLE!
hehehe
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A bit of a break while she was in surgery-
I came back here and and found Punk loving her little Henrietta
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She has taken to crying as the little chicken makes its own noise...
(Mama Milly used to do that with her own toys).
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And back up to the hospital.
I waited in the waiting room after talking to one of her nurses.
That wait got longer and longer- And finally I went back up to the front.
No one there!
So I found a computer that had some info on it about the patients- It told me that Casey was up in a room already!
Yikes!
So I hightailed it straight up there.

She was resting; just not comfortably... .

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This is how I left her...
In and out of sleep.
Probably more drug induced than comforting.
But she was still, quieted, anyway.

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I will call up there before I rest, just to make sure all is well enough.

Love to all, and for all of your kind words and prayers and reassurances too.
This is plain old tough, and you have helped by being there for us.

XOXO
Anne


**** Now here are the pictures I warned you about.

WARNING!
If you cannot bear to see insides, it is time for you to scroll right on past
(And to my comments of course). ;-)

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This is Caseys colon before it was removed,

It is longer, and as wide as my arm!

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The same colon.
OUT...
In the harvest pan.

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Is it not miraculous what the human body can do to itself

and live through?
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God bless you my Baby Girl
Forevermorelonger
XOXO,
Mama D.

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Posted to my Y! 360, Monday April 6, 2009 - 08:43pm (CDT)

Update on Casey

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Casey pre-surgery this morning...

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What a morning!
Early came too early for us today- (She was one minute late getting to the darn hospital).

Casey is still in recovery, and will be 'out of it' for quite some time.

Dr Sutherland came out from surgery about an hour and a half ago.
He said Casey's surgery went very well, they said he had to extend her scar just a little bit.
He also emailed me pictures! I have not asked Casey yet if I can post them; I am sure she won't have a problem with that, but I still want to ask her first.

He spoke of removing her ng tube already, and that if all goes well she may even be out of the hospital by the end of the week!
(Keep those prayers coming, they are working)!

I have already spoken to Greg, my sister Barbara, and have just hung up from talking to Kelli.
Now who did I miss???
My apologies!

Time to walk Punk again and to get back up to the hospital and watch her wake up.

Love to all

XOXO
Anne

Signs of Spring!

hehehe
So it's fake. Sue me.
(I didn't want to be the only one not posting pics of blooms).

Good Evening Everyone!
As I write, it occurs to me that I don't remember how to write a blog anymore. It seems like so long ago. But it really wasn't. Just so much has happened, and many miles removed from the scene of the crime, as it were.

Hope everyone is having a great weekend...
Yesterday for us was the trip here. Uneventful for once. But we did wake to snow this morning.
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Maybe not so 'uneventful' for these folks though...
The smoke was lots thicker and darker a few miles back.

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For most of us, 300 miles is no big deal. (And it really isn't for me either)- But things got tough as I began to see the aura that precedes my migraines about 75 miles out from arrival.

Getting sick in a car is no fun. But I was better by the time we got here.

For Casey's last big meal, we ordered Applebee's.

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Our steaks, by the way, were ordered rare.
Ummm... "Yeah, right"
(But they were eaten none the less).
Just no "Mmmmm's" to be heard in this room.

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Methinks Casey was digesting.
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For breakfast, part of a waffle for her, and then this GIANT muffin
Both from Perkins

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Chocolate...
With chocolate chips too.
It wasn't finished, (but it did get completely scalped)!!!

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I didn't eat, my tummy and head still "off" enough for me not to...

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I did get a few pictures in and posted to Flickr.
And Deb, I cannot find the ones of Punk with her new birthday toys from you!? I must have already downloaded them to the other computer. Know that Greg saved all those pictures.

As you all know, it was Punks birthday on the 27th.
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My Little Miss Punkin
3 whole years old.
My favorite picture, ever, of her.
As she waited by the refrigerator door.

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We had to run to town on her birthday to pick up a prescription.

She wasn't particularly happy with me for not giving her a present.

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Unbeknown to herself, I did pick her up a few things at the Rx store.
And then we headed home.


She had to wait outside while I went in...
Still mad at me too.
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That wild whisker has since been trimmed!
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After a few moments she gained entry to the house...

Funny she knew just where to go???

And she even SMILED!!!!
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She peeks!

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But needs a closer look...
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I do believe she liked what she saw!
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A squeaky squirrel, among other things...

(Like a new frisbee that fell apart after 3 throws).

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Spring is slowly but surely beginning to be sprung around Flintville.

The first sign this year is being able to actually see the picnic table back by the woods.

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Then there is some kind of life that has remodeled my barngrade.
Not sure I want to know what kind either...
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There is spunky & sassy life too!
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And Mr. Miller even gets to come over!

He steals Punk's Sponge Bob toy.
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But gets that one taken away fast.
It has now become a 'game' for them both.


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There is "life" of the six legged variety out and about...
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And of the two legged, double winged variety too!
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Sure are noisy!
And most welcomed!
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Unlike this "thing"
Whatever it is... ?
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maybe I don't want to know.
Thankfully it was outside...
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Spring is when all your friends come out of their own little holes and come visit.
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And they love you just enough to tease you...
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Spring brings neighbors over too!

This is Julie with her new friend,
"Lady"
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Lady is a mere 9 months old.
Basically unwanted by the people that were selling her
because she didn't have a patch over her other eye too.
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Patch or not, methinks Lady is just a doll!
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I'd better close. I have Punk waiting patiently to go outside once more before she sleeps.
I shall post this now and get out there to walk a bit.

We will leave early tomorrow; needing to be at the hospital for 5:30.
Casey is on clear liquids 'til midnight and then nothing for who knows how long. (Hopefully she enjoyed that steak)!

Please keep her in your thoughts...

My love to all

XOXO
Me

PS

Casey posted a new blog last night.

Please CLICK HERE to visit and to answer her questions

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posted to Y! 360, Sunday April 5, 2009 - 07:40pm (CDT)