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
Anna~Anna
"Flintville Annie"
© 2006-2015
Plain or Peanut. (Memories).
- Oh well.
Sorry.
I looked all over...
There were no other Easter colors anywhere.
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Good Morning All,
And a belated Happy Easter to everyone. Hope yours was joyous!
We are home.
Greg set up my desktop computer as we got back home. (He neglected to tell me the new password to get into it, and I am not going to call there). I am using my laptop once more. Kind of used to it anyway.
Casey made the return trip not without pain, but stoic as she always is. We stopped about 3 times- and I believe Miss Punk was more tuckered out than either one of us.
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And I honestly think she had a bit of pain herself.
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Once upon a time, there was a little family that lived in Flintville, Wisconsin...
The daddy was a dairy farmer, tending his fields and his cattle.- The mama always worked hard tending to her own crops in the garden.
They both tended the two 2~legged female "crops" they had adopted.
When the Autumn weather was right, there were crops to be harvested from the woods too.
Namely, walnuts.
.They would store the walnuts in the attic of the garage, (where the two little females were forbidden to go).
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Lots and lots and lots of walnuts-
By the bushel baskets full!
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. - They would then use those walnuts as needed for snacks -or for baking.
Mmmmmmmmmmmm...
BUT.........
Every now and then, maybe bored, or a bit hungry for a mid~afternoon snack; the youngest female would carefully crawl up the ladder to the attic of the old shed; and bringing a hammer and a screwdriver, would happily sit and eat walnuts until someone missed her.
Sometimes she got a bellyful, and sometimes only one little nut before she heard her name.
She would sneak right back down the ladder, replace the tools, and wipe her mouth on her sleeve.
She had to "borrow" the tools because to remove anything from the mama's kitchen would be spied immediately.
Cracking the nuts was tough for those little hands; but sometimes she could even do it with her teeth, 'specially if the daddy was using all the tools and he might miss the ones she took to use. Sometimes she just put the nuts between the boards and jumped on the boards. (This was sorta dangerous though as it made much noise and she had to make sure that there was no one around to hear).And every now and then she would get caught- Receiving a lecture on the dangers of the ladder, the shed, etc etc etc.
But oh, those walnuts were so delicious! And any reprimand, or spanking, was well worth it to the little girl.
One day in summertime, the mama was tending to her BIG garden.- The little girls also had to be outside with their mama; (perhaps because to leave them indoors, even taking their naps, always resulted in something or 'nother gone wrong).
And so the little girls helped pull weeds. Sometimes they pulled out a "real" plant, and sometimes they were told to leave the garden because of this.
But even then, the little girls were always told to stay within eyesight of their mama; (because if this wasn't done something or 'nother was sorta guaranteed to go wrong).
Not always getting along, sometimes the little girls would not be seen together. (OK, truth be told, this was more often than not).
The little girl went exploring, within Mama's sight too.
Much later, Mama was done working in the garden. She gathered her food, and went to the hose to clean her hands and her food before going in the house to make dinner for the family.
The littlest girl (3 or 4 years old), went to her mama, and was crying a bit. Her face was filthy. (This was normal, along with the rest of herself too), but the little tears made her look even more dirty.
The mama asked 'what the dickens' was wrong?!? Maybe the mama had had a really bad day.
While pulling something out of her mouth to show her mama, the little girl said, "Mama, I can't crack this nut."
Suddenly, in a flash, the mama went absolutely berserk.
The mama swung, clipping the little hand, and the nut went flying far far away from the hungry and sad little girl.
"That's rabbit dirt!" the mama exclaimed.
The little girl got her mouth and her face cleaned out/off real good; and never, ever, ever, forgot about this incident.
..
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.
BUT,
the little girl thought there was some resemblance.
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..
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Somewhere along the line, the little girl lost her taste for walnuts, (and bunny dung).
And back in the day when M & M's only came in brown and light brown colors, she also lost her taste for those.
To this day that little girl will not eat brown M~&~M's.
Not for love or money.
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.......
Plain... or ....peanut
Doesn't matter.
No brown M & M's for this little girl.
'specially when they are brought by The Easter "Bunny"!.
Additionally, this little girl found NO humor
when she received this in her inbox..
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Love to all.
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Ph-tooey. ~I gotta go brush my teeth.
Casey, Sneakin' Around
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- Casey, yesterday morning-
- Looking SO innocent...
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Good Morning All;
I tried to post last night and messed up my entry- So here I am, trying again.
The top picture is Casey Thursday morning, as I'd walked in- (After yet another good night sleep)! - And the reason she'd felt so good?
We snuck out of the hospital Wednesday afternoon. hehehe
A few breaths of fresh air is good for the spirit- right along with the sunshine.
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Nobody said a word to either of us.
-Save for one man who told her "No running in the halls."
hehehe
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- And so, she just didn't run...
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Wednesday evening was boring for Punk.
First she tried to rest. (On my bed no less). - .
Then I caught her dreaming about chasing squirrels.
One of the toys she got for her birthday was a tennis ball with fur attached.
When it is thrown it really looks alive!
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- So she stares at it... thinking...
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Down to the desk to find out if any floors were empty.
Yes. Half of the 6th. (Thank you Amy)!
There are no places to play outside unless one wishes to run the risk of being hit by a car. Nothing doing. And some days, walking just doesn't do it.
So we were off to the 6th floor... - .
First you HAVE to make sure it's yours!
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- Sniff. Sniff.
- And she brings it to me.
- I throw it...
- ~but~
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"WAIT Punkie, WAIT" ...
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- "GO!"
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.
- Over
- and over
- and over
- and over again...
- (Did I mention that it was over and over and over and over again)?!
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Back to the room after she returned he fake squirrel to me and just laid down.
That's her signal for "enough". - Finally!.
There was lots of noise and commotion out my window- Too much-
And I saw it was time to grab the camera once more.
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- This little guy was just saying Grace before dinner
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- He spied the one he wanted and was gone.
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After he left, it was time to rest, (which brings me back to the topmost picture).
Yesterday (Thursday), brought a very pleasant surprise. Even though when he had called, I had told him to go to the wrong side of campus, my brother John made it up to see Casey!
Nice that.
And even though he complained after seeing the picture that the camera added at least 40 pounds, he was still laughing.
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- Camera weight or not we were just happy to see him again!
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As my Xanax was wearing off, it was time for me to go- - I had still to pick up a few things for Casey and to get them to her.
- .They walked me to the elevator-/
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Uncle John and Casey
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I came back here to fetch her things, - grabbed The Punk,
- and we were off to WalMart.
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Then back to the hospital where she met us down at the door.
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- Sneaky little thing that she is!
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She called here later, after she had asked the nurse if there was any way she could go outside?
The nurse said "absolutely!"
I hear that Fairview is one of the few hospitals that actually believes in sunshine and fresh air.
No wonder no one had stopped us earlier... - Jokes on us.
And we thought we were being so sneaky!
Sheesh, at St Marys in Green Bay you cannot even leave whatever stuffy floor you are on!
(Too many doctors have a LOT to learn about healing, and attitude, and back to nature, and just the plain old basics)...
I'd better close for now- I still have to take Punk out, and get in the shower.
Casey called about an hour ago- Said she was up on and off last night too. But she still sounds real good.
The hospital has a mass at 2:30 this afternoon. If I time my little pill just right, we can make that service.
And so begins this holy and joyous weekend.
Love to all.
XOXO
Me
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
Just a short note
Good Afternoon Everyone
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Casey is doing alright.
But I am almost ready to go back up to the hospital, and cannot write a whole blog yet.
I will fill you all in later this afternoon.
Love to all
XOXO
Me
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Casey is doing alright.
But I am almost ready to go back up to the hospital, and cannot write a whole blog yet.
I will fill you all in later this afternoon.
Love to all
XOXO
Me
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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