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Rectal Prolapse | Cedars-Sinai

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What is rectal prolapse?

Your rectum is the last part of your colon. It’s where stool forms before you have
a
bowel movement. Rectal prolapse is when part of the rectum bulges out of the anus.

At first, a prolapse may happen only after a bowel movement. The
prolapsed part of the rectum may then slip back through the anal canal on its own.
Over time, the prolapse may become more severe and may need surgery.

What causes rectal prolapse?

Rectal prolapse is most often caused by weakening of the muscles
that support the rectum. This can happen from constipation, damage from giving
birth, or defects in the pelvis or lower gastrointestinal tract.

Who is at risk for rectal prolapse?

Rectal prolapse is more common in people age 50 and older. Women
are more likely to have the condition than men. Younger people with the condition
often have chronic health conditions and take several medicines.

A person is more at risk for rectal prolapse if they have any of the below:

  • A long history of constipation
  • Straining to have bowel movements
  • Long-term (chronic) diarrhea
  • Laxative abuse
  • Childbirth
  • Spinal cord problems or previous stroke
  • Cystic fibrosis
  • Dementia

What are the symptoms of rectal prolapse?

Symptoms can occur a bit differently in each person. They can include:

  • Feeling a bulge from the anus after coughing, sneezing, or
    lifting
  • Having mucus in your stool
  • Straining to start or finish a bowel movement
  • Having incomplete bowel movements
  • Having belly (abdominal) discomfort or pain
  • Bleeding from the rectum
  • Trouble controlling bowel movements (fecal
    incontinence)
  • Having to push the prolapse back into the anus by hand
  • Feeling pressure in your rectum
  • Being constipated
  • Having anal pain, bleeding, or itching

The symptoms of rectal prolapse may look like other health conditions. Always see
your healthcare provider for a diagnosis.

How is rectal prolapse diagnosed?

Your healthcare provider will ask about your symptoms and health
history. Your provider will give you a physical exam. You may be asked to squat and
strain as if you are having a bowel movement. You may also have tests such as:

  • Defecogram. This test is a
    type of X-ray taken during a bowel movement.
  • Anorectal manometry. A pressure-measuring tube is placed in the rectum.
    This is done to measure how well the muscles that control bowel movements are
    working.
  • Colonoscopy. A flexible tube with a camera is placed inside the rectum so
    the healthcare provider can do a visual exam.
  • Barium enema. X-ray
    pictures are taken after a type of chalky contrast solution is placed in the
    rectum.
  • MRI. A special MRI can be done during simulated bowel movement.
  • Special urologic or
    gynecologic evaluations.
    Your provider will also assess the rest of your
    pelvic floor. Your provider will look for weakness or signs of other organs
    prolapsing. These might be the bladder or uterus. This test is also done if a
    woman has both rectal prolapse and uterine prolapse.

How is rectal prolapse treated?

Treatment will depend on your symptoms, your age, and your general health. It will
also depend on how severe the condition is. Treatment often begins with steps to
prevent constipation and straining.

If your rectal prolapse is severe and interferes with your quality of life, your
healthcare provider may advise surgery. Types of surgery include:

  • Repair through the abdomen. A cut is made through the lower belly. The
    rectum is attached to the lower part of the backbone to support it and keep it
    in place.
  • Repair through the rectum. Your surgeon removes the part of the rectum
    that has prolapsed and reconnects the remaining parts.
  • Repair with both these methods. These 2 methods may be combined to treat
    your prolapse.

Talk with your healthcare providers about the risks, benefits, and possible side
effects of all treatments.

What are possible complications of rectal prolapse? 

The 2 main possible complications are:

  • The rectal prolapse can’t be pushed back into the rectum. It
    can cause the blood supply to the prolapse to be cut off. This is called
    strangulation. It’s painful and needs emergency treatment.
  • The rectal prolapse happens again. This is common. Following
    your healthcare provider’s advice on lifestyle changes can help prevent it
    happening again. That means preventing constipation. Lifestyle changes may
    include eating a high-fiber diet and drinking enough water.

Can rectal prolapse be prevented?

Not straining during a bowel movement can help prevent the condition. Follow your
healthcare provider’s advice for ways to prevent constipation.

How to manage rectal prolapse

These tips for managing rectal prolapse before or after surgery may help:

  • Don’t do any activities that increase pressure in your rectal area. This
    includes straining to have a bowel movement or heavy lifting.
  • If you have an ongoing cough, have it treated by your
    healthcare provider. They may also urge you to stop smoking.
  • Eat at least 5 servings of fruits and vegetables every day. A high-fiber diet
    can help prevent constipation and straining.
  • Drink 6 to 8 glasses of water every day.
  • If you are constipated, ask your healthcare provider about stool softeners or
    laxatives.
  • Stay active and get regular exercise. If you are overweight, take steps to get
    to a healthy weight.

When should I call my healthcare provider?

Call your healthcare provider if you have any of these symptoms:

  • Fever
  • Chills
  • Swelling
  • Bleeding from the anus
  • Fluid leaking from the anus
  • Constipation
  • Loss of control of bowel movements (fecal incontinence)
  • A rectal prolapse that happens again

Key points about rectal prolapse

  • Rectal prolapse is when part of the rectum bulges out of the anus.
  • It is most often caused by weakening of the muscles that
    support the rectum. It can happen from constipation, damage from giving birth,
    or defects in the pelvis or lower gastrointestinal tract.
  • At first, it may happen only after a bowel movement. But
    over time, the prolapse may become more severe and may need surgery.
  • Symptoms can include feeling a bulge after coughing, sneezing, or lifting.
  • Treatment often begins with steps to prevent constipation and straining. If your
    rectal prolapse is severe and interferes with your quality of life, your
    healthcare provider may advise surgery.
  • Follow your healthcare provider’s advice for ways to prevent constipation.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider
    tells you.
  • At the visit, write down the name of a new diagnosis and any
    new medicines, treatments, or tests. Also write down any new instructions your
    provider gives you.
  • Know why a new medicine or treatment is prescribed and how
    it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could
    mean.
  • Know what to expect if you do not take the medicine or have the test or
    procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for
    that visit.
  • Know how you can contact your provider if you have questions.

Medical Reviewer: Jen Lehrer MD

Medical Reviewer: Rita Sather RN

Medical Reviewer: Raymond Kent Turley BSN MSN RN

© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

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Rectal prolapse traumatizes rectal neuromuscular microstructure explaining persistent rectal dysfunction

Abstract

Purpose

Internal rectal prolapse is common and correlates with age. It causes a plug-like physical obstruction and is a major cause of defecation disorder. The progressive distortion of the prolapsing rectum likely causes secondary defects in the rectal wall, which may exacerbate rectal dysfunction. We undertook a prospective observational study to detect and quantify the neurologic and histopathologic changes in the rectal wall.

Methods

We examined dorsal and ventral rectal wall specimens from consecutive patients with internal rectal prolapse undergoing stapled transanal rectal resection (STARR). We subjected specimens to histopathologic and neuropathologic assessment, including immunohistochemistry. We also recorded patients’ clinical and demographic characteristics and sought correlations between these and the pathologic findings.

Results

We examined 100 specimens. The severity of rectal prolapse and the extent of descent of the perineum correlated significantly with age. Concomitant hemorrhoidal prolapse was noted in all male patients and in 79 % of female patients. Muscular and neuronal defects were detected in 94 and 90 % of the specimens, respectively. Only four specimens (4 %) were free of significant structural defects.

Conclusion

Rectal prolapse traumatizes the rectum causing neuromuscular defects. The tissue trauma is due to shearing forces and ischemia caused by the intussusception. This initiates a self-reinforcing vicious circle of physical and functional obstruction, further impairing rectal evacuation and causing constipation and incontinence. The correlation between extent of prolapse and age suggests that internal rectal prolapse can be considered a degenerative disorder. Neural and motor defects in the wall of the rectum caused by rectal prolapse are likely irreversible.

Keywords: Rectal dysfunction, Megarectum, Rectal hyposensitivity, Rectal inertia, Obstructed defecation, Rectal prolapse

Introduction

The last decade has brought a better understanding of acquired degenerative disorders of the rectum as well as new treatment options. In this context, internal rectal prolapse is recognized as a major cause of defecation disorder. The causal link between internal rectal prolapse and defecation disorder is largely accepted as a pathophysiologic concept known as obstructed defecation syndrome [1–12]. The cause of obstructed defecation is thought to be physical obstruction caused by the plug-like internal prolapse.

Imaging of patients with rectal prolapse—particularly dynamic defecography—often reveals an extremely flaccid and dilated rectum. Resection specimens of prolapsing rectum frequently appear fibrosed and scarred. It would be unlikely that a markedly flaccid, dilated, and intussuscepting rectum still retains the sensorimotor integrity required for evacuation. Conversely, a structurally normal rectum is unlikely to be flaccid enough to undergo intussusception.

The healthy rectum plays central sensory and evacuation roles in defecation. We hypothesized that the mechanics of internal rectal prolapse cause trauma to the rectal wall that in turn leads to sensorimotor impairment of rectal evacuation.

The confirmation of a causal relationship between prolapse, structural damage, and functional deficit would contribute to our understanding of sensorimotor disturbances of the rectum and might explain why dysfunction may persist despite operative removal of the obstructing prolapse.

The objective of this prospective observational study therefore was to detect and quantify histopathologic changes in rectal wall specimens taken from patients with rectal prolapse undergoing stapled transanal rectal resection (STARR). We sought changes that might indicate coexisting deficits of rectal sensory and motor functions and examined whether there was a correlation between structural changes, patients’ demographic characteristics, and clinical findings.

Materials and methods

We undertook a prospective observational study, recording clinical data from patients with internal rectal prolapse undergoing STARR and subjecting resected specimens to detailed neuropathologic examination. We examined the extent to which defects were found in the mucosa-submucosa, muscularis propria, and connective tissue, as well as the neuronal plexus and cells of Cajal. We also sought correlations between defects, the sex, and age of the patients and clinical findings.

Stapled transanal rectal resection

In western Europe, STARR has become a standard procedure for the resection of rectocele and to address internal rectal prolapse [1–12]. In carefully selected patients, the procedure is technically straightforward, safe, and generally has good functional outcomes. During surgery, the anterior and posterior rectal segments of the prolapse are usually resected separately and the remaining wound edges are stapled together. Generally, therefore, two separate full thickness specimens of the affected rectal wall are taken.

Although the STARR technique is widely accepted, it is still considered as controversial in some parts. However, possible pros and cons of the STARR procedure are not the issue of our study.

For the purposes of this study, we undertook investigations, made the diagnosis, selected patients for surgery, performed STARR, and managed patients postoperatively according to our current, routine clinical practice.

Histologic and neuropathologic assessments

Formalin-fixed, paraffin-embedded samples of complete rectal wall were subject to histologic and neuropathologic assessments. All histologic assessment was undertaken at the Institute of Neuropathology of the University Hospital, Münster, Germany, according to previously published techniques [13, 14].

Specimens were stained with hematoxylin and eosin or Elastica van Gieson stains. Immunohistochemical staining was performed for the following antigens: CD117 (Clone c-Kit, Dako, Glostrup, Denmark, concentration 1:400, boiling pretreatment at pH 6.1), S100 (Dako, concentration 1:4000, no boiling pretreatment), calretinin (Dako, clone DAK-calret 1, concentration 1:50, boiling pretreatment at pH 9.0), and muscle actin (clone HHF35, Dako, concentration 1:400, boiling pretreatment at pH 6.1). All samples were independently assessed by two raters (WP and SR).

We examined for mucosa prolapse syndrome (manifested by fibromuscular obliteration, crypt atrophy, erosion, and ulceration) and assessed the integrity of the muscularis propria (for layering, atrophy of the circular or longitudinal layer, scarring of the circular or longitudinal layer, or inflammation), connective tissue (quantity and location), the submucosal plexus (for its structure), the myenteric plexus (for quantity of ganglion cells and scarring), the interstitial cells of Cajal (for density), and the general severity of pathology (see also supplemental Fig. ).

Examples of some of the histologic findings

Statistical analysis

We used the Fisher’s exact test, the chi-squared test, and the Kruskal-Wallis test to compare the clinical and histopathologic features of the patients with rectal prolapse (SPSS software, version 20.0; IBM Corporation, Armonk, NY). P values <0.05 were considered statistically significant. Statistical support was provided by the Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität, Münster, Germany.

Ethics approval

Conduct of the study was approved by the local ethics board (2013–629-f-S, Ethikkommission der Ärztekammer Westfalen-Lippe) and registered as a clinical study with our national database (DRKS00005662, Deutsches Register Klinische Studien).

Results

We collected 100 specimens from 51 consecutive patients diagnosed with obstructed defecation and rectocele/rectal prolapsed, who underwent STARR following our routine preoperative therapeutic and diagnostic protocol (patient demographics; Table ). Of these, 49 were ventral wall specimens and 51 dorsal wall specimens. Two patients in our cohort only required semicircular STARR, which therefore yielded only one specimen. Four patients who had a previous anorectal operation during the previous 12 months were excluded from the study. Staining was performed on all 100 specimens.

Table 1

Patients’ demographic characteristics

Number Age median/average/range (years)
Female 39 57/58/54–80
Male 12 51/52//39–72
Total 51 54/57/39–80

Clinical characteristics

The majority of female patients had a history of vaginal delivery (64 %) and/or hysterectomy (44 %; Table ). The severity of rectal prolapse and extent of the descending perineum corresponded significantly with age (Tables and ). Hemorrhoids were present in all male patients and in 74 % of female patients (Table ). The vast majority of female patients were found to have rectocele (Table ), again correlating with age.

Table 2

Obstetric and gynecologic histories of female patients

(n = 39) Vaginal delivery Hysterectomy
16 (41 %) +
9 (23 %) + +
8 (21 %) +
6 (15 %)

Table 3

Extent of rectal intussusception (RI) versus patient age

Rectal intussusception (RI) Number Median/average age (years)
RI reaches upper part of anal canal 6 49/49
RI reaches lower part of anal canal 22 54/53
RI reaches external anal ring 15 62/62
RI reaches beyond external anal ring 6 68/69
Not stated 2
RI versus age p = 0. 01

Table 4

Extent of descending perineum versus patient age

Descending perineum (DP) Number Median/average age (years)
No significant DP 5 51/50
Descend above level of ischial tuberosities 14 50/49
Reaches level of ischial tuberosities 25 60/61
Descend beyond level of ischial tuberosities 5 66/69
Not stated 2
DP versus age p = 0. 015

Table 5

Extent of hemorrhoid disease versus patient age

Associated hemorrhoidal disease (HD) Number Male Female Median/average age (years)
No significant HD 8 0 8 55/56
Grade I 9 2 7 60/60
Grade II 21 7 14 53/56
Grade III 8 2 6 59/60
Grade IV 3 1 2 60/61
Not stated 2 0 2
HD versus age n. s.

Table 6

Extent of anterior rectocele in female patients versus patient age

Anterior rectocele (AR; females) Number Median/average age (years)
No significant AR 3 49/52
Small (digital examination produces only slight bulging of rectovaginal wall (RVW) seen through the introitus) 1 56
Medium (digital examination produces prominent bulging of RVW seen through the introitus) 30 56/59
Advanced (digital examination produces bulging of RVW protruding externally through the introitus; RVW appears thin and fibrosed) 3 63/62
Not stated 2
AR versus age n. s.

Histologic changes

Muscular and neuronal defects were detected in 94 and 90 % of the specimens, respectively (Table ). Only four specimens from three patients were free of significant histologic or neuropathologic findings (Table ). Notably, two of these three patients had unremarkable ventral specimens but were nevertheless found to have defects on the opposite side. Only 1 of the 51 patients was found to be free of significant muscular or neuronal defects in both STARR specimens.

Table 7

Summary of neuropathologic and histopathologic findings in specimens taken during stapled transanal resection of the rectum

Neuropathologic and histopathological defects Number of specimens affected
Total Ventral Dorsal
Number of specimens 100 49 51
Crypt atrophy 14 8 6
Fibromuscular obliteration of lamina propria 14 10 4
Atrophy of circular layer 68 34 34
Fibrosis of circular layer 81 39 42
Atrophy of longitudinal muscle layer 35 14 21
Fibrosis of longitudinal muscle layer 65 29 36
Rarification of Cajal cells 27 14 13
Fibrosis of myenteric plexus 85 41 44
Neuropathological defects classified as “moderate” or “advanced” 49 25 24
No neuronal defects 10 6 4
No muscular defects 6 3 3
Neither neuronal nor muscular defects 4 3 1

Discussion

Our findings support the hypothesis that internal rectal prolapse formation initiates a vicious circle of progressive structural damage and ensuing loss of function. Internal rectal prolapse is a plug-like intussusception of the rectum. The tissue trauma is most likely caused by shearing forces and ischemia caused by the intussusception.

The healthy rectum assumes an important sensory role in the physiology of defecation. There is consensus that increased intraluminal pressure in the rectum is perceived by receptors, although these have not been conclusively identified [15–19]. Above a certain threshold, rectal intraluminal pressure initiates the urge to defecate. The threshold for urge appears to be variable and may be influenced by acquired changes of the rectal wall (caused for example by inflammatory diseases, radiation, or acquired degenerative changes) [20–23].

Contrary to widely held beliefs, a physiologically intact rectum has no role as reservoir. However, with advancing age, acquired degenerative changes, and ensuing loss of evacuation strength, the rectum commonly mimics a stool-filled reservoir. The rectum acts as barrier to colonic peristalsis, which usually ends at the recto-sigmoid junction and is not propagated into the rectum [18]. During the resting phase, there appear to be retrograde propulsion motor complexes that transport smaller amounts of fecal matter back into the sigmoid colon until mass peristalsis from above is initiated [24]. Retrograde propulsive activity is also stimulated by the conscious suppression of defecation urge. A chronically stool-impacted rectum, which is a common finding, particularly in the elderly, can therefore be taken as evidence for a rectal evacuation deficit.

Evacuation of stool is also supported by active rectal motor activity. Defecation can be consciously initiated by the parasympathetic nervous system. To evacuate stool, the levator and anal sphincters relax, opening the anal canal. The rectum contracts mainly axially. To achieve axial contraction, colonic tenia spread anatomically over the rectum to form the external layer of the muscularis propria, which covers the entire organ. There is, however, also transverse peristalsis in the rectum brought about by contraction of the inner and more circular layer of the rectal muscularis propria [15–18].

The healthy rectum therefore has important and complex sensory and evacuation functions for defecation; proper sensory and motor functions require intact nerve and muscular structures in the wall of the rectum. Our findings confirm that rectal prolapse causes sufficient trauma to compromise these functions. This is perhaps not surprising if one considers the marked morphologic changes in an intussuscepting rectum. Dynamic defecography often reveals an extremely flaccid and dilated rectum in patients with rectal prolapse (Fig. ).

Defecographic sequence showing distortion of the rectal wall associated with internal rectal prolapse formation

Our finding that there is a positive correlation between age and the extent of internal rectal prolapse and rectocele strongly supports our opinion that the disorder is acquired and foremost a degenerative one. It may possibly be regarded as yet one more specific aspect of aging and be likened to other age-associated degenerative disorders.

It is likely that prolapse formation starts as mucosal prolapse and that in many cases, a reduction of connective tissue tautness may contribute to it. The shearing forces exerted by the passage of flatus or fecal matter push and pull the obstructing mucosal folds, thereby gradually involving and progressively traumatizing the deeper layers of the rectal wall and initiating a vicious circle of obstruction and prolapse formation.

Mucosal prolapse is in turn linked to many proctologic disorders, in particular hemorrhoidal disease. This is the rationale for undertaking stapled hemorrhoidopexy, as well as for ligation and injection sclerotherapy. Internal mucosal and ensuing rectal prolapse are therefore very common.

The formation of internal rectal prolapse invariably promotes physical and functional defecation obstruction. Obstruction may cause few symptoms, or even be asymptomatic, for many years. Obstruction usually evolves gradually, and the severity of its effects may ebb and flow, being influenced by factors such as diet, food allergies, laxative intake, and exercise. This explains why the obstructive effects of prolapse formation remain undetected in many patients and why the functional significance of these common degenerative changes is still a matter of much controversy.

That even near-to-complete obstruction of passage of fecal matter may cause few or no symptoms for a long time is not exclusive to patients with internal rectal prolapse. Patients with long-standing stenosing diverticular disease, Crohn’s disease, or malignancies often report “normal” bowel function.

The degenerative process is usually not limited to the infolding rectal wall; it appears to gradually involve the entire rectum and may affect the pelvic floor and adjoining organs, particularly in women. This typically presents with associated phenomena such as a descending perineum. As the diameter of the pelvic outlet is smaller in men, a smaller amount of mucosal prolapse—as seen in hemorrhoidal disease—may result in significant obstruction.

There may be factors contributing to the development of internal rectal prolapse or rectocele, such as defecation disorders or a history of vaginal delivery and/or hysterectomy in women; however, numerous patients are affected without any obvious risk factors.

The acquired structural damage leads to impairment of rectal function, which may persist despite operative repair of the obstructing prolapse. The persistence of rectal dysfunction after surgery contributes to the ongoing debate about the optimal intervention for rectal prolapse. For many decades, this has been a matter of lively debate. It appears likely that the mode of operative repair, in particular whether the rectum is mobilized anteriorly, posteriorly, or circumferentially, may have little or no effect on functional outcome. Within the context of circular mobilization, the significance of the so-called lateral ligaments of the rectum has in particular been a matter of some controversy [25]. Whatever nerves these ligaments may contain, however, they may be of negligible significance in a prolapsing and therefore dysfunctional rectum.

The self-reinforcing sequence of physical and functional obstruction of the rectum may also explain why there have been consistent reports of marked motor and sensory disturbances of the rectum detected in patients with constipation, defecation obstruction, fecal incontinence, and irritable bowel syndrome (Fig. ) [26–36].

Internal rectal prolapse is common, and therefore, rectal dysfunction is common. It is an often unrecognized and possibly to a certain extent unavoidable consequence of aging that affects men and women alike. It initiates a vicious circle of physical obstruction and functional impairment. Progressive impairment of rectal evacuation and the ensuing fecal congestion cause the typical symptom overlap of constipation and incontinence. The current strategy of evaluating and treating constipation and fecal incontinence as two distinct disorders needs to be reviewed in the light of this.

An understanding that rectal evacuation depends on an intact rectum, and that over time, the rectum is as prone as any other organ to age-related progressive degeneration in structure and function, increases our understanding of constipation and incontinence—particularly in the elderly. Both disorders significantly impair quality of life and are also of considerable socioeconomic relevance.

Rectal perforation due to a lost toothbrush

Inserted rectal foreign bodies are generally seen in mentally challenged or sexually deviated persons and often pose a challenging diagnostic and therapeutic dilemma.1 Retained rectal foreign bodies may present with perforation, obstruction, or bleeding.1

A 54-year mentally challenged female presented to the surgical emergency with the features of subacute intestinal obstruction with a lump palpable in the left iliac fossa and normal rectal examination. All attempts to manage the patient conservatively ultimately ended in futility. A contrast-enhanced computed tomography abdomen was ordered, and, to our surprise, it revealed the presence of a tooth brush within the rectum with free air pockets and distended gut loops around it (). The patient underwent an emergent exploratory laparotomy. Exploration revealed matted gut loops and omentum in the left iliac fossa with minimal fecal contamination of the peritoneal cavity. After the adherent gut loops were separated, the tooth brush came into view. The tooth brush had perforated the rectal wall, and a part of it was lying outside the rectum (). The tooth brush was retrieved, and as the surrounding rectal wall was not healthy, a Hartmann procedure was done.

Reconstructed contrast-enhanced computed tomography image showing the presence of toothbrush with pneumoperitoneum within the abdomen.

Toothbrush seen coming out of a mass of matted gut loops.

Although rectal foreign bodies have been reported in all ages and ethnicities, they are most commonly seen in men in the age group of 30 to 50 years. A variety of objects have been described in the published reports, and the list includes vibrators, dildos, cucumbers, apples, light bulbs, knives, nails, bottles, utensils, drug packets, and so on.1 Although a toothbrush present as a foreign body in the rectum has been previously reported,2 but such a presentation as has been reported in this study is the first of its kind.

An important problem encountered in the management of rectal foreign bodies is the delay in presentation, as many patients may be embarrassed and conceal the history. As our patient was mentally challenged, we were not able to extract the proper history from her, but she vaguely remembered inserting the toothbrush rectally.

Retained rectal foreign bodies can be managed by colonoscopic extraction, but in the setting of perforation, surgical intervention is mandatory.1

SUCCESSFUL DIAGNOSIS AND TREATMENT OF BILATERAL PERINEAL HERNIAS IN A SKUNK (MEPHITIS MEPHITIS) on JSTOR

Abstract

This brief communication describes the diagnosis and surgical treatment of bilateral perineal hernias in a 1-yr-old, intact female, striped skunk (Mephitis mephitis) that was evaluated for chronic intermittent constipation, following early age, bilateral anal sacculectomy for descenting. Complete blood count and biochemistry results were within the reference ranges. Diagnosis was based on history, physical exam, clinical signs, and diagnostic imaging. A two-stage surgical approach for treatment was performed. First, colopexy and cystopexy were performed via celiotomy, which was followed by unilateral perineal herniorrhaphy by using an internal obturator muscle flap augmented with porcine small intestinal submucosa biomaterial. Long-term resolution of clinical signs was achieved without evidence of recurrence. This is the first description of bilateral perineal hernia in a skunk following routine anal sacculectomy for descenting.

Journal Information

The Journal of Zoo and Wildlife Medicine publishes original research findings, clinical observations, and case reports in the field of veterinary medicine dealing with captive and free-ranging wild animals. It also publishes editorials, review articles, and special reports relevant in this field.

Publisher Information

AAZV is an international organization that applies the principles of comparative
veterinary medicine to zoo and wildlife species. We work in clinical zoo medical
practice, diagnostic laboratories, reproductive and pathological laboratories,
pharmaceutical companies, and a wide range of governmental health and wildlife
management agencies. Our mission, as an advocate for the profession, is to improve
the health care and promote the conservation of captive and free-ranging wildlife.
Our website is www.aazv.org.

Deviated Rectum meaning and definition

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Deviated Rectum meaning

What happens to your ass after a hot, rough night of anal lovin’

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Disorder of the nose involving displacement of the nasal septum. A condition in which the cartilage that divide the nasal cavity in half is off center or crooked!

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A pad that conveniently fits between your cheeks and stops the noise of farts by keeping your cheeks from vibrating. Useful when being around important people or just a hot babe. Can be found at your local sport n goods store

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If you charge a device with another device, like charging your smartphone with your laptop, without connecting the laptop to the power supply.

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a person that cant be away from any eletric device for longer than a hour at most

A novel model to correlate hydrogel spacer placement, perirectal space creation, and rectum dosimetry in prostate stereotactic body radiotherapy | Radiation Oncology

Clinical relevance

Our institutional experience describes the early stages of SpaceOAR hydrogel implementation in high-dose per fraction SBRT setting, where the benefits of a well-placed spacer on rectum dosimetry quickly become clinically evident upon examination. Our objective was to develop a systematic method to quantify the perirectal space after hydrogel placement and identify a hydrogel placement metric to correlate perirectal space creation with rectum dosimetry. The findings showed increased perirectal space and optimal hydrogel placement have a positive impact on rectal dosimetry when we considered the θ*hydrogel volume metric. This metric was at least, if not more, predictive of rectum dosimetry than any perirectal space measurement. With longer follow up and greater sample size, this metric should have added utility of eventually tracking placement quality and operator experience.

Evidence of a learning curve in developing operative skillsets is well-established as seen in prostate brachytherapy implant quality that improves with experience up to a point [16, 17], after which proficiency is maintained with a minimum annual caseload [18]. The learning curve phenomenon for hydrogel placement was first reported by Pinkawa et al. in a study of 64 patients that showed improved lateral hydrogel symmetry, increased perirectal space, and better rectum dosimetry in the latter 32 patients compared with the first 32 patients [19]. Such a learning-curve effect is minimized in a well-established training environment with appropriate mentorship and operator feedback [20]. We expect that a well-designed hydrogel placement metric, such as we have described in this manuscript, would provide one such measure of feedback.

Quantifying perirectal space

While results from this study are in agreement with the general expectation that a well-placed hydrogel is important for rectum dosimetry, to our knowledge this is the first time the post-hydrogel perirectal space has been rigorously mapped. We showed that precise perirectal space measurements can be obtained independently from either the post-hydrogel T2 weighted MRI or CT simulation scans (Tables 2 and 3). Prior to hydrogel placement, the prostate apex and midgland lie close to the rectum on the pre hydrogel placement MRI (Table 3A). Following hydrogel placement, almost all regions of the prostate have increased separation from the rectum, with the greatest mean increase seen at the prostate apex and midgland (Table 3C). Several publications have described a wide range of post-hydrogel perirectal separation ranging from 0.6 to over 2 cm, but to-date few have described in detail the optimal location to obtain this perirectal measurement, or Δ measurement, resulting from hydrogel placement [11, 14, 21,22,23].

From our perirectal space maps, we identified the perirectal distance measurement obtained posterior to the prostate at midgland, midline, or CTV center, as that which is most strongly correlated with rectum dosimetry (Table 4A). This is followed by the perirectal distance measurements 1 and 2 cm that are immediately inferior to it i.e. toward the prostate apex. As enlargement of the perirectal space at, or slightly inferior to, the prostate CTV center led to the greatest improvement in rectum dosimetry, this position represented the optimal location for hydrogel placement.

SpaceOAR characteristics and rectum dosimetry

Distribution of lateral hydrogel deviation in our patient cohort was nearly identical to that of earlier work by Fischer-Valuck et al. [14] Half (n = 10) of patients had symmetric gel placement (SYM1, lateral deviation < 1 cm) in all three axial slices, and 15% (n = 3) had hydrogel in all three axial slices but with lateral deviation < 2 cm in only one axial slice (SYM2). Consistent with their conclusions, the rV95% and rDmax 1 cc were not significantly different between SYM1 and SYM2 hydrogels in our study (Fig. 2).

While the effect of lateral hydrogel deviation on rectum dosimetry is thus well-characterized, hydrogel distribution along the craniocaudal dimension has not been commented upon in existing literature. In our study minor hydrogel deviation along the craniocaudal axis had a more pronounced effect on rectum dosimetry than lateral deviation of a similar scale (~ 1 cm). The absence of hydrogel in the axial slice 1 cm inferior to midgland (n = 4) correlated to an increase in rDmax 1 cc of 171 cGy (p = 0.005, Fig. 2).

This is unsurprising as the native perirectal space is most limited inferomedially, averaging 1–2 mm in our analysis. In the vast majority of patients, such close proximity between the prostate and rectum begins inferiorly at the prostate apex and extends superiorly at least as far as the prostate midgland. Whereas previous analysis emphasized the importance of lateral hydrogel symmetry, we conclude that hydrogel deviation must be accounted for in both the lateral and cranio-caudal dimensions to accurately predict rectum dosimetry.

As a result, we defined θ to quantify hydrogel deviation from the optimal CTV center location in three-dimensional space rather than along a single axis. θ alone correlated moderately with rDmax 1 cc and rV95% and predicted only a minority of variance in these statistics (R2 = 0.36 and 0.43, respectively; Table 4B) as it does not take into account the volume of hydrogel centered around the θ vertex.

Similarly, hydrogel volume alone was modestly correlated with rectum dosimetry (R2 rDmax 1 cc = 0.23; rV95%, 0.2). This is due to minimal enlargement of the perirectal space in the instance of suboptimal injection site (i.e. small θ). Indeed, hydrogel volume was not significant in two-variable regression of hydrogel volume and θ against rDmax 1 cc (pVOLUME = 0. 06, pθ < 0.01, n = 20), but became significant only in the subset of patients with θ > 35° (pVOLUME = 0.04, pθ < 0.01, n = 16).

We thus inferred that an interaction exists between hydrogel volume and θ such that the correlation of each θ and hydrogel volume influenced rectum dosimetry. Based on this examination of data, we tested the product θ*hydrogel volume which showed strong ability to explain rectum dosimetry (R2 rDmax 1 cc =0.64; rV95%, 0.6; Table 4B). A three-variable regression analysis of θ, hydrogel volume, and θ*hydrogel confirmed that θ*hydrogel was the only significant predictor of rV95 (R2 = 0.694; Fvalue 12.08; p = 0.008). We thus conclude that the parameter θ*hydrogel volume quantifies perirectal space enlargement effect following hydrogel placement, and should be considered in evaluating hydrogel placement success.

Previous work has shown no statistically significant variation in rectum dose with CTV volume ranging up to 100 cc, and is consistent with our findings [21].

Acute rectal toxicity and θ*hydrogel volume

Hydrogel spacer use in prostate SBRT was documented as early as 2013 by Alongi et al. and continues to represent a growing proportion of SpaceOAR utilization [11, 24, 25]. Yet as of this study, the only published phase III randomized prostate hydrogel data were obtained in the conventionally fractionated setting [22]. In their control arm without hydrogel, acute rectal toxicity ≥grade 2 benefit was not statistically significant, but any late toxicity was improved 4.5-fold at 3 years.

We expected that relative toxicity benefits attributed to hydrogel use would be at least as prominent in the high-dose per fraction SBRT setting as it is in conventionally-fractionated treatment. In addition, projected cost-benefit decision analysis suggests that the use of hydrogel spacer will be cost-effective for toxicity management in the long term for all forms of prostate radiotherapy, but particularly so for prostate SBRT [26].

With the hydrogel spacer and prostate SBRT to a dose of 3625 cGy in five twice-weekly treatments, less than one third of patients developed grades 1–2 acute rectal toxicity either during or immediately after treatment, which resolved at the latest by the one-month post-treatment visit. It is noteworthy that these men had characteristics of rectum dosimetry, perirectal spacing, and θ*volume that we quantified as being in the less favorable half of our cohort (Fig. 4).

Likely as a result of small sample size, no statistically significant difference was observed in rDmax 1 cc, rV95%, perirectal distance at CTV center, and the metric θ*hydrogel volume, between men who developed acute rectal toxicity and men who did not. We suspect that the likelihood of statistically significant relationships between these parameters and symptomatic toxicity would emerge at the higher SBRT doses currently being evaluated in phase II clinical trials, with larger sample size, and longer follow-up.

We have nonetheless shown from our early hydrogel SBRT patient cohort a correlation between the metric θ*hydrogel volume and rectum dosimetry. We expect that the learning curve necessary to attain high-quality hydrogel placements will also become evident as measured by the θ*hydrogel volume metric as our experience with hydrogel placement increases.

The relatively wide range of hydrogel volumes as measured on post-hydrogel T2 weighted MRI bears further evaluation. Each SpaceOAR hydrogel is injected transperineally as a 10 cc suspension following dissection of Denonvillier’s fascia with saline solution. Potential explanations for small hydrogel volumes include suboptimal placement, hydrogel dispersion prior to polymerization and incidental withdrawal of hydrogel along with the needle following the procedure. Explanations for large hydrogel volumes include contouring software volume overinterpolation and overcontouring of hydrogel. The latter may occur as saline solution used in the fascial dissection and SpaceOAR hydrogel is indistinguishable on the MRI T2 image obtained after hydrogel placement. In our cohort, the earliest post-hydrogel MRI was obtained two days after hydrogel placement.

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MEDISON.RU – Doppler ultrasonography of the rectal wall in children with chronic constipation

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Introduction

Chronic constipation remains one of the urgent problems in pediatrics, and it does not have age restrictions.The main research methods for such patients are considered to be radiopaque and echographic. Both methods are highly informative and complementary. The value of the latter lies in the possibility of studying the size and structure of the wall of the distal colon, in particular the rectum, which is most susceptible to changes in chronic constipation, as a result of which its condition is decisive in the tactics of treatment and its prognosis.

In this regard, the purpose of the work is to assess the condition of the rectum in children with varying duration of chronic constipation.

Materials and methods

Ultrasound examination of the distal colon was performed in 300 children aged from 5 days to 16 years. The research technique has been repeatedly described in previous works [1-3]. In addition, Doppler ultrasonography of the bowel wall vessels was performed in color and pulsed modes.

Assessment of the functional state of the rectum was carried out according to the following parameters: reaction to fluid administration, width of the intestinal lumen, thickness and structure of its wall.Doppler examination in color mode determined the presence or absence of blood vessels in the muscle and submucosal layers, the direction of blood flow through them. Pulse examination made it possible to differentiate veins and arteries and determine the standard characteristics of blood flow: direction, velocity, resistance index.

It should be emphasized that, technically, the visualization of the vessels was very difficult due to the small caliber of the vessel and peristaltic contractions in the intestine.

All children were divided into groups; the main criterion for division was the state of the rectum.

Group I included children with normal thickness and structure of the wall, but without expansion or with slight expansion of the rectum. In II – children with a thickened but uniform muscle layer, an enlarged rectum, but a functioning rectosigmoid sphincter. In group III, there were children with a thickened muscular layer of the intestinal wall, from which hyperechoic echo signals of a linear configuration were recorded.In all patients of group III, the rectum was sharply dilated. Group IV included patients with an enlarged rectum and sigmoid colon and with a thinned rectal wall. Group V consisted of 11 patients with local thickening of the mucous membrane in the distal rectum. In patients of all groups, according to echography, the sphincter apparatus was formed normally.

Research results

The age of children of the 1st group is from 5 days to 6 years.In 70% of children (usually up to 5-6 years old), the rectum and especially the sigmoid colon expanded very slightly or did not expand at all when fluid was injected. there was a hypertonicity. Characteristically, in most of these patients, spasm in the sigmoid colon was localized in its middle and lower third. Above this spasm, there was some expansion of the intestine, but the absence of the hypertrophied muscle layer, characteristic of suprasthenotic expansion, excluded Hirschsprung’s disease. In the remaining 30% of children, usually between the ages of 6 and 10, the lumen of the rectum and sigmoid colon, both before and after the introduction of fluid, was expanded, reaching 50 and 45 mm, respectively (norm 2.1 + 0.4 and 1.5 + 0.1 mm).This state of the intestine made it possible to speak of its hypotonia, but without changing the structure of the wall.

In none of the children from this group, the vessels were not visualized by Doppler examination.

The age of children of group II (thickened muscular layer of the rectum) is from 6 to 12 years. The number of children with hypo- and hypertonicity was practically equal: 48 and 52%, respectively. The muscular layer of the intestine in these patients appeared to be a heterogeneous, hypoechoic structure with an asymmetric thickness that reached 9 mm (norm 1.8 + 0.3 mm).In 31% of the total number of children in the muscle layer, color Doppler mapping revealed vessels in the form of short linear signals located mainly in the area of ​​the rectosigmoid sphincter. By color, the blood flow in these vessels was multidirectional. Pulse evaluation demonstrated that all visible vessels were veins (Fig. 1), the Doppler curve was clearly linear, and the mean blood flow velocity was 0.03–0.08 m / s. The presence of visible veins in the intestinal wall did not depend on the patient’s age, but was associated with the duration of stool retention.

Fig. 1. Doppler images of multidirectional venous blood flow in children of group II.

Group III (heterogeneous muscle layer) included children from 7 to 16 years old. The vast majority of children (93%) had rectal hypotonia when the width of its lumen reached 80 mm.The thickness of the muscular layer of the intestine was identical to that in group II. The obvious difference was the visualization of strong echo signals of a linear configuration, which in some cases were combined into a ring. In addition, in the majority of children (64%), thickening of the mucous membrane was observed throughout the rectum and rectosigmoid region. In 41% of children, color Doppler mapping revealed vessels in multidirectional blood flow, localized both in the area of ​​the rectosigmoid sphincter and visible over a fairly long period in the rest of the intestine (Fig.2 a). Pulse study showed that the latter were arteries. Assessment of blood flow through them in patients with a disease duration of at least 4 years showed a high resistance index IR = 1.0 (Fig.2b), while in children suffering from constipation for more than 5 years, the resistance index was 0.76 + 0.03 (Fig. 2 c). It was in these children that the venous blood flow had a shunting character (Fig. 2d). This was expressed in the registration of a sharply increased blood flow velocity at the site of veins junction with multidirectional blood flow.This pseudoacceleration is usually associated with turbulent blood flow.

Fig. 2. Study of blood flow through the vessels in the wall of the rectum in children of the III group.

a) Multidirectional arterial blood flow in the color Doppler mapping mode.

b) In pulsed mode at IR = 1.0.

g) Venous shunting blood flow.

Group IV included 15 children from 10 to 16 years old with a thinned wall (less than 3.0 mm), the layers of which did not have a clear delineation.The lumen of the rectum and sigmoid colon was sharply expanded. Vessels in the intestinal wall were not identified.

Discussion

Analysis of the data obtained shows that functional disorders of bowel emptying can already develop in newborns and infants. The risk of such disorders increases if the child has had birth asphyxia. In the first months of life, they have stool retention, and the consistency of feces is dense, sometimes of the “sheep” type.This is due to severe spasm in the colon, which is confirmed by X-ray and ultrasound studies, when hypertonicity can be detected in the distal colon, especially in the rectum and sigmoid colon. As a rule, a spastic state in the intestines can be traced in children up to 4-5 years old, much less often at an older age. During ultrasound examination during this period of the disease, there are no pronounced changes in the wall of the rectum and sigmoid colon, the vessels are not visualized.

Only the expansion of the rectum is characteristic, which is most clearly seen in children from 3 to 5 years old.

As the disease progresses, when bowel emptying occurs not regularly and not completely, in parallel with the expansion of the distal colon, vicarious (working) hypertrophy of the muscle layer develops, when its thickness, according to ultrasound studies, reaches 9 mm. The development of hypertrophy leads, obviously, to the development of additional vessels and an increase in the diameter of the existing ones.Initially, veins with a different direction are detected; in this case, the main site of the primary localization of the vessels is the area of ​​the rectosigmoid sphincter. The spasm in the intestine gradually decreases and is replaced by hypotonia, which initially spreads to the rectum, and then captures the proximal colon.

A further increase in the duration of the disease leads to the development of heterogeneity in the muscular layer of the intestine, expressed in the appearance of linear hyperechoic signals, which in some cases represent a ring that repeats the shape of the intestine in a cross section.An earlier histological study of preparations of such a bowel showed that the mucous membrane had an accentuated and somewhat hypertrophied basement membrane, the submucosa was moderately sclerotic, infiltrated with lymphohistiocytic elements with a small number of neutrophils. In the muscular membrane, which has an insignificant thickness, there was an intensely developed interstitial edema and swelling of myocytes. In some of the swollen muscle cells, there was a mixing of vacuoles in the nuclei and even lysis of the latter, which indicates sclerotic processes in the muscle layer.Given the high density of sclerosis areas, it can be assumed that they were the cause of additional echo signals.

Structural changes in the intestinal wall, according to the Doppler study, lead to its additional vascularization, which was expressed by the presence of both venous and arterial blood flows.

Evaluation of the resistance index (IR) showed that in children with a shorter duration of the disease, its indicator was quite high (1.0), which is determined by a low diastolic blood flow velocity, possibly due to hypertonicity of the vascular wall.At the same time, such an indicator of the resistance index is typical for vessels remote from the heart, for example, the arteries of the lower extremities.

In children with a disease duration of more than 5 years, the characteristics of blood flow significantly differed from the previous ones due to the presence of a sufficiently high diastolic velocity and, as a consequence, a significantly lower index of resistance (0.76 + 0.03). The reason for this could only be a decrease in the tone of the vessel wall and ruled out the second assumption about the cause of the high resistance index in previous patients.The difference in diastolic blood flow velocity between these patients suggested the presence of relative stagnation of blood in the intestinal wall, which was indirectly confirmed by the detected multidirectional venous blood flow with shunting. It was in these children, despite the complex treatment, that there was no obvious clinical improvement.

A further change in the wall in patients with a disease duration of more than 10 years was characterized by its structural rearrangement: a decrease in thickness and the absence of clear differentiation of layers.None of these patients had visualized vessels, which could be due to their significant thinning and slowing of blood flow.

Conclusion

Functional disorders of colon motility, manifested in the form of chronic constipation with irregular and incomplete bowel movements, pose a serious potential danger to the lower parts of the colon and can cause a deep restructuring of the structure of its wall.Ultrasound assessment of the dynamics of changes in the intestinal wall suggests the following stages of changes. Initially, against the background of episodic constipation, when the leading spasm is in the distal colon, there are no changes in the rectal wall. As constipation intensifies, there is a gradual expansion of the rectum and sigmoid colon with hypertrophy of the muscle layer and the development of additional venous blood flow. In the future, sclerotic changes develop in the muscle layer, and the state of hypertonicity is replaced by hypotonia.Compensatory, apparently, there is an increase in arterial blood flow, and then a decrease in the tone of the arterial walls and the development of shunting venous blood flow. The final stage of long-term functional disorders of the motility of the colon (chronic constipation) is atony of the distal sections with thinning of the intestinal wall and impaired blood flow in it.

Thus, the registration of additional venous and arterial vessels in the wall of the rectum and sigmoid colon during their hypotonia is a poor prognostic sign for a child with chronic constipation.

Literature

  1. Possibilities of echography in assessing the condition of the distal colon in children / I.V. Dvoryakovsky, L.V. Kedik, A.I. Lenyushkin, V.V. Lukin // Ultrasound in obstetrician, gynecological. and Pediatrics 1993. No. 3.S. 88-92.
  2. Dvoryakovsky I.V. Ultrasound diagnostics in the practice of planned surgery // Ultrasound diagnostics in pediatric surgery. I.V. Dvoryakovsky, O.A. Belyaeva. M .: Profit, 1997.S. 48-64.
  3. Kedik L.V. Clinical evaluation of ultrasound changes in violation of the function of the colon in children: Dis. … Cand. honey. sciences. M., 1993.S. 160.
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Inert colon | Parfenov A.I., Karlov A.V., Orlova N.V.

Inert colon (synonyms: chronic idiopathic constipation, slow-transit constipation) is a violation of the motor function of the colon, associated with a decrease in the rate of movement of intestinal contents in the absence of anatomical abnormalities.

The main clinical manifestation of an inert colon (ITC) is chronic constipation (CZ). The prevalence of ITK among the population is, according to different authors, in the range from 4% to 20% [1, 2].The slow transit is caused by structural, mechanical, metabolic and cortical-visceral influences on the colon. Particularly severe transit disorders develop in Parkinson’s disease, a pseudo-obstruction due to systemic neuropathy and selective neuropathy of the colon.

With ITK, there is a decrease in both background and stimulated motility after food load and other stimuli. Depending on the type of response of the colon to stimulating influences, we distinguish three degrees of impairment of motility in this disease.

The degree of impairment of motor function in ITK [3]

Type 1 is observed in the compensated stage of chronic colostasis. It is manifested by the absence of a gastrocolic reflex and a decrease in the amplitude and duration of responses to all types of influences.

Type 2 is characterized by the absence of reactions to food (no gastrocolic reflex) and mechanical stimulation.

3rd type (refractory) – lack of response to food, mechanical and electrical stimulation.Such violations indicate severe organic changes in the neuromuscular apparatus of the colon and may be an indication for surgical treatment in the amount of colectomy with the imposition of ileorectoanastomosis.

Long history, lack of effect from the use of dietary supplements in adequate quantities, laxatives and the need for systematic bowel cleansing with enemas give every reason to assume TKI. It is necessary to find out the amount of dietary fiber and fluid consumed by patients, as well as the diet.Clinical diagnostic criteria for ITK were formulated by the Rome Consensus in 2006 [4].

Diagnostic criteria for ITC according to the 2006 Rome Consensus [4]

The patient must meet the diagnostic criteria for functional constipation (Rome III, 2006). Any 2 of 6 items:

1. Straining during bowel movements.
2. “Sheep” or hard stools.
3. Feeling of inferiority in defecation.
4.Feeling of anorectal obstruction (blockage).
5. Help with bowel movements by hand.
6. Less than 3 bowel movements per week.

Criteria 1, 2, 3, 4, 5 are present in at least 25% of bowel movements, appeared no earlier than 6 months. back and appear for the last 3 months.

The examination algorithm should include functional studies of the intestine: anorectal manometry (APM), a balloon squeeze test and determination of the intestinal transit time using a radiopaque test system.Figure 1 shows an algorithm for diagnosing ITC.

If the result of the AWP is doubtful, it is proposed to conduct a defecography.

The main functional method for confirming the ITC is the determination of the transit time. The study of intestinal transit is carried out using a radio-opaque test system. The patient is offered to take 20 radiopaque markers orally. After 120 hours, a general X-ray of the abdominal cavity is performed. The criterion for impaired motor-evacuation function is the presence of 5 or more markers in the lumen of the colon; also, by assessing the location of markers, one can judge about the cologenic (ITC) and proctogenic (dyssynergic defecation – DD) causes of constipation.With DD, markers are located mainly in the ampulla of the rectum and distal parts of the sigmoid, while with ITK they are distributed throughout all parts of the colon, including its right parts.

The traditional view of the association of constipation with a lack of fiber [4] is a sine qua non for increasing fiber intake as an initial therapy for chronic constipation of any etiology. Insoluble fiber such as wheat bran is thought to decrease intestinal transit time, thereby increasing stool frequency [5].Soluble fiber, such as psyllium seeds, dissolves in water and increases stool volume and frequency [6]. Numerous studies carried out in the following decades, including randomized ones, have shown that dietary measures and lifestyle changes alone cannot solve the problem of treatment and prevention of TKI. For the pathogenetic effect on the reduced motor activity of the colon, peristalsis stimulants, hyperosmolar agents are used, and in the case of a protracted or refractory course – enterokinetics (Table 1).1).

The purpose of this work is to establish the frequency of TKI and the effectiveness of sodium picosulfate (Guttasil) in patients with primary chronic disease.

Material and Methods

A survey of 132 patients with primary chronic disease aged from 18 to 89 years, who were admitted for treatment at the MSCC, was carried out. The exclusion criteria were secondary chronic diseases and mental illness. Among the patients, women predominated – 121 (91.6%). Patients met the criteria for functional constipation (FZ) (Rome III criteria).Stool frequency was less than 3 times a week in all. 119 (90%) people had hard stools (type 1–2 on the Bristol scale). More than half – 76 (57%) – complained about the feeling of incomplete emptying of the rectum, 60 (45%) – about the lack of urge to defecate, 92 (69%) – about the difficulty of defecation. In 7 (5.3%) patients, manual assistance was required for defecation.

All patients underwent proctological examination, colonofibroscopy, esophagogastroduodenoscopy (EGDS) and ultrasound examination of the abdominal organs.A balloon extrusion test was also performed. A balloon was introduced into the rectum, which was filled with water to a volume of 50 ml, after which the patient was asked to push it out for 5 minutes. Workstation was also performed using an 8-channel water-perfusion apparatus Solar GI, MMS. Patients in whom DD was not confirmed were examined for intestinal transit using 20 radiopaque markers.

Results and discussion

The research results are shown in Figure 2.In 51 out of 132 (39%) patients, the transit time through the large intestine and the APM indicators did not go beyond the normal range.

Therefore, in accordance with Rome III criteria (2006), they have the first type of chronic disease – functional constipation associated with intestinal dyskinesia. In 59 (45%) patients with chronic disease, DD was identified, i.e., the third type of chronic disease. In 25 (39%) patients with diagnosed DD, the time of balloon extrusion exceeded 5 min, which confirmed a pronounced violation of the defecation mechanism. In 21 (16%) patients, TKI was confirmed, i.e.That is, the second type of chitosan (more than 5 markers remained in the intestinal lumen with a predominant location in the descending, sigmoid and rectum, in 5 of them the markers were also in the ascending and transverse colon).

All patients with type 1 chronic disease were prescribed drug therapy using dietary fiber, motor regulators, and in the mixed form – the minimum dose of antipsychotics.

Patients with diagnosed DD, in addition to general recommendations for the treatment and prevention of constipation, were offered a course of biofeedback therapy.It consisted in teaching the patient to relax the anorectal muscles under his own visual control using the Solar GI, MMS apparatus.

For the treatment of 21 patients with TKI, in addition to general recommendations on diet, water load and fiber intake, sodium picosulfate (Guttasil) was prescribed for therapy in order to stimulate peristalsis at an initial dose of 15 caps / day. In the future, the patient could change the dose of the drug by 2–5 drops / day, achieving a normal stool. The maximum dose was 27 drops.

Sodium picosulfate (Guttasil) stimulates receptors in the intestinal mucosa, enhances peristalsis. The active form of the drug, formed by hydrolysis under the influence of intestinal microorganisms, directly excites the nervous structures of the intestinal wall, as a result, the advancement of intestinal contents is accelerated, the absorption of electrolytes and water decreases. The laxative effect occurs within 6-12 hours after ingestion. When taken orally, it is not absorbed from the gastrointestinal tract and does not undergo hepatic-intestinal circulation.

To achieve daily stool, 5 patients required 20 drops (9–25 drops), in 5 patients at a maximum dose of 27 drops. per day, independent stool was noted every 2-3 days. In 2 patients, while taking a maximum dose of 27 cap. stool frequency persisted less than 3 times a week, which was the basis for the appointment of prucaloprid at a dose of 2 mg / day.

All patients required a systematic intake of Guttasil to maintain normal stool.Subsequently, 4 patients managed to reduce the dose to 15 caps. per day.

Thus, the use of Guttasil in 14 patients with TKI and lack of independent stool made it possible to achieve daily defecation, and in 5 patients – once every 2-3 days. Here is one of the clinical observations.

Patient M., 67 years old, was admitted to the Department of Intestinal Diseases of the MSCC on September 14, 2014 with complaints of constipation, forcing the regular use of laxatives and cleansing enemas, hard stools (type 1–2 on the Bristol scale), and difficult defecation.

Suffering from constipation since 20 years, last 6 years stool only with the help of laxatives and cleansing enemas. In January 2014, she was admitted to the district hospital due to abdominal pain and lack of independent stool. Irrigoscopy revealed no pathology, with EGDS – superficial gastritis. The therapy was carried out with laxatives, against the background of which constipation persisted. Further examination at the ICSC is recommended.

Examination data: general condition is satisfactory.The physique is normal. Height 158 ​​cm.Weight 78 kg. BMI – 31.2 kg / m2, obesity of the 1st degree.

Clinical and biochemical blood tests without pathological values. Ultrasound of the abdominal organs: deformation of the gallbladder. Sigmoidoscopy and colonoscopy with an examination of 15 cm of the distal ileum – no pathology.

Based on the results of the automated workplace, data indicating DD and other defecation disorders were not received. To assess the motility of the colon, a study of intestinal transit was carried out using a radiopaque test system.The patient was asked to ingest 20 radiopaque markers. After 120 hours, an overview roentgenogram of the abdominal cavity was performed: 16 out of 20 markers remained in the lumen of the colon, which confirms the violation of the motor-evacuation function of the colon, and the distribution of markers in different parts of the colon corresponds to ITC (Fig. 3).

The patient was prescribed sodium picosulfate (Guttasil) at a dose of 15 drops / day. In the course of treatment, she gradually increased the dose to 25 drops / day.Against the background of supportive therapy, she retains independent stool 2-3 times a week, without the additional use of cleansing enemas.

Thus, for the treatment of patient M. with pathogenetically grounded TKI therapy with sodium picosulfate (Guttasil) turned out to be quite effective.

Conclusion

The diagnosis of ITC should be established in the sequence of the proposed algorithm in compliance with the Rome criteria. The leading role in the diagnosis of ITCs is played by functional research methods – AWP, balloon extrusion test and determination of the transit time through the colon using radiopaque markers.In the treatment of TKI, enterokinetics are of primary importance, but laxatives that stimulate peristalsis (Guttasil), as well as hyperosmolar agents and dietary fiber, can also play a role.

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Preparation for endoscopic examinations – BU “Surgut City Clinical Polyclinic No. 2”

Preparation for endoscopic examinations

Details
Updated 07.10.2016

Esophagogastroduodenoscopy

If the study is scheduled for the first half of the day, then the day before the last meal is until 19:00.In the morning, the study is carried out strictly on an empty stomach.

If the study is scheduled for the afternoon (after 13:00), then a light breakfast (tea, porridge or yogurt) is allowed. The last meal should be 6 hours before the study!

Intestinal rectoscopy

Examination with rectoscopy is carried out both for the purpose of a preventive study, in order, if possible, to prevent the development of various diseases, and in the presence of certain disturbing symptoms.The rectoscopy procedure allows you to detect various types of neoplasms of the rectum and some parts of the sigmoid colon, even at precancerous stages, when the state of the tumor is reversible. In addition to visual examination, it is possible to take a biopsy (that is, part of the tissue) of the area of ​​the rectal wall that is suspicious. In the future, the pathological piece of the intestine is subjected to histological examination for the presence of altered cells in it. The reliability of rectoscopy is high due to the fact that a specialist can not only notice neoplasms on the rectal mucosa, but also examine it in detail.With the help of rectoscopy, you can not only examine the patient’s intestines, but also remove small tumors. This procedure is quick and non-traumatic. For the purpose of prophylaxis, rectoscopy of the intestine is prescribed to patients over forty years of age and is performed once a year.

Indications for rectoscopy:

  • the presence of pain in the anus
  • the appearance of stool disorders – constipation or diarrhea.
  • the occurrence of intestinal bleeding.
  • appearance of mucous or purulent discharge from the anus.
  • the appearance of a feeling of incomplete bowel movement.

It can be said that any pathological changes in the rectum and the lower part of the sigmoid colon, or the suspicions of these changes are indications for rectoscopy.

Contraindications to rectoscopy

  • The appearance of profuse bleeding from the intestine.
  • The presence of acute inflammation in the anal area – hemorrhoids, paraproctitis, and so on.
  • There are acute inflammatory processes in the abdominal cavity.
  • The patient has an acute anal fissure.
  • Occurrence of narrowing of the lumen of the anal canal due to various reasons – congenital or acquired. Usually, this symptomatology is one of the signs of a rectal tumor.
  • The appearance of traumatic lesions in the anus.For example, as a result of chemical or thermal burns.
  • A history of heart disease that is at the stage of decompensation.
  • The emerging severe condition of a general patient or the manifestation of acute forms of diseases.
  • Existing menstrual bleeding in women.

A prerequisite for high-quality preparation for rectoscopy is a thorough bowel cleansing . Until recently, enemas were the only way to do this.In order to properly cleanse the intestines, an enema should be given in the evening on the eve of the examination and in the morning on the day of the rectoscopy. In the evening, the intestines are cleaned twice: at 19-00 and 20-00, or a little later – at 20-00 and 21-00. A single volume of an enema should be at least one and a half liters, and you need to “wash” the intestines to clean water. On the morning of the examination, the enema is repeated twice more – at 7-00 and 8-00. The advantages of the method are its simplicity, availability and low cost, because it costs absolutely nothing. The disadvantages of the method are the inconvenience of independent conduct and the need for an assistant.Indeed, a person who is trying to make himself an enema with 1.5 liters of water on his own must simultaneously control the flow of fluid and try to keep this fluid in the intestines. Therefore, the procedure is often performed poorly.

Microlax preparation before rectoscopy . Mikrolax can be used before rectoscopy instead of a cleansing enema. It is a topical solution already prepared for use, which is packaged in tubes of five ml each.In the package of the medication, four pieces of tubes are produced and each is intended for use once. To use Microlax, it is enough to carefully read the instructions and follow them. At the same time, the drug is designed in such a way that it can be used in almost any conditions where there is a bathroom, including at work, and so on.

Preparation for the procedure with Fortrans. The drug is not absorbed in the gastrointestinal tract, acts exclusively in the intestine and is excreted unchanged.Preparing Fortrans is simple enough. A whole package of the drug is diluted in 1 liter of water. The amount of solution for one patient is taken at the rate of 1 liter per 15 – 20 kg of body weight. On average, for an adult, this volume is 3-4 liters. Take a ready-made solution – the use of the entire volume on the eve of the examination, starting at 15-00, at a rate of about 1 glass per hour. The last Fortrans dose should be no later than 3 – 4 hours before the examination.

Preparation with Duphalac. Duphalac is another laxative that gently and effectively prepares the intestines for endoscopic examination. The drug should be taken the day before, 2 hours after a light lunch. The entire bottle of Duphalac (200 ml) is diluted in 2 liters of plain water. They drink the ready-made solution by sips, and the entire volume must be consumed in 2 – 3 hours. Bowel emptying begins in 1 – 3 hours from the beginning of taking Duphalac and ends 2 – 3 hours after the final dose is consumed. With the help of the drug Duphalac, preparation for the procedure is carried out gently and very comfortable for the patient.

Prepare with Fleet . Fleet is a relatively new tool that has been successfully used alongside Fortrans and Duphalac. It is also taken on the eve of the examination, only twice a day. The first dose (45 ml) is diluted in half a glass of chilled water and the entire volume is drunk immediately after breakfast. The second dose (45 ml) is prepared in the same way and is taken once in the evening after dinner. If the examination is not scheduled too early, it is allowed to take another dose of Fleet in the morning after breakfast.In this case, the liquid is allowed to drink until 8-00.

Preparing a patient for a colonoscopy with Fleet requires certain conditions to be met:

  1. For breakfast and dinner on the day of taking Fleet, there should be only water in an amount of at least 1 glass.
  2. Lunch should be light and consist of 750 ml of water or any other liquid: meat broth, tea or juice.
  3. Each dose of Fleet must be washed down with 1 to 3 glasses of cold water. The amount of liquid drunk after taking the drug may not be limited.The laxative effect against the background of Fleet develops in at least 30 minutes and a maximum – 6 hours after taking the first dose.

Modern preparations for preparation for colonoscopy or other methods of examining the large intestine, no doubt, are in no way inferior in efficiency, and even surpass the traditional bowel cleansing with enemas.

But no matter what method you choose, remember that it depends on the person himself whether there will be a high-quality colonoscopy of the intestine – preparing the patient according to all the rules is the key to an effective and informative examination.

Fibrobronchoscopy

This is a method of direct examination and assessment of the state of the mucous membranes of the tracheobronchial tree: trachea and bronchi using special devices: a broncho-fibroscope. A modern video bronchoscope is a complex device consisting of a flexible rod with a controlled bend of the far end, a control handle and a lighting cable connecting the endoscope with a light source equipped with a video camera, as well as manipulators for biopsy and removal of foreign bodies.

Fibrobronchoscopy is the only method that allows you to examine the inner surface of the bronchi, examine the relief of the mucous membrane and its folds, the vascular pattern, the configuration of the mouths and spurs of the bronchi, and also perform a biopsy – pinching off tiny pieces of tissue to establish an accurate diagnosis.

Indications for fiberoptic bronchoscopy:

Fibrobronchoscopy is used for diagnostic and therapeutic purposes. The indication for bronchoscopy is the suspicion of a tumor or inflammation in the bronchi.Bronchoscopy is used to diagnose the causes of hemoptysis and when detecting radiological signs of disseminated processes in the lungs. With the help of bronchoscopy, it is possible to extract foreign bodies from the bronchi, examine curved and narrowed bronchi, conduct a biopsy and administer drugs.

Contraindications for bronchoscopy:

  • bronchial asthma and pneumonia in the acute period;
  • acute disorders of cerebral circulation;
  • acute myocardial infarction;
  • severe cardiovascular insufficiency and cardiopulmonary insufficiency (III degree).

Preparation for bronchoscopy:

The study is usually carried out in the morning on an empty stomach. On the eve, you can afford a light dinner, preferably no later than 19.00. If an endoscopic examination is carried out in the afternoon or in the evening, it is necessary that after the last small meal it is about 8 hours.

  • Before the morning endoscopic examination, you can brush your teeth, rinse your mouth with water (you can take 1-2 sips of water).
  • Take a clean medium to large sized towel (or diaper) with you to the endoscopy unit.
  • Enter the endoscopy department with the second shoe. You can wear clean overshoes over your outdoor shoes.
  • It is advisable to have an identity document, medical documentation (policy, outpatient card, referral for endoscopic examination, data from previous examinations, etc.)

Bronchoscopy technique:

During the examination, the patient is sitting or lying down. The duration of a bronchoscopy is several minutes.

Examination of the bronchi using a fibroendoscope consists of three stages: local anesthesia, insertion of a broncho-fibroscope and examination of the tracheobronchial tree.

The study begins with anesthesia of the mucous membrane of the upper respiratory tract by spraying 10% lidocaine spray into the cavity of the oropharynx and lower nasal passage.

After anesthesia of the nasal cavity and pharynx, the fibroscope tube is passed along the lower nasal passage into the nasopharynx, then into the larynx and after anesthesia of the vocal cords, 2% lidocaine solution is injected into the trachea and then into the bronchi.Then the doctor assesses the condition of the mucous membrane of the trachea, bronchi. For anesthesia of the mucous membrane of the trachea and bronchi, a 2% solution of lidocaine is used.

The diameter of the flexible endoscope to be inserted is a few millimeters. This does not interfere with the patient’s breathing. During the procedure, the patient may experience discomfort (feeling of a foreign body in the larynx, desire to cough). After the completion of the procedure, the discomfort disappears.

Complications:

According to the medical literature, bronchoscopy poses minimal risk to the patient.The probability of complications is 0.3%, and of serious complications (such as bleeding, pneumothorax, perforation of the bronchial wall) – 0.08%

90,000 Foot deformities and their treatment – (Di Center clinics)

The human foot carries a tremendous load on itself, allowing a person to move freely in space. Fluctuations in body weight always end with changes in the fornix area.

Any deformations are characterized by a persistent change in natural appearance.Similar changes can affect the length of individual bones, as well as the strength of the tendons and ligaments. When a person experiences deforming changes in the limbs, his gait is disturbed, discomfort and soreness appear during physical exertion.

The reason for such changes is the incorrect distribution of human weight over the entire area of ​​the feet. Deforming changes occur with the same frequency in males and females, regardless of age.The risk group includes people suffering from chronic diseases of the osteoarticular apparatus, athletes, as well as persons whose work activity is associated with excessive load on the legs.


Causes of foot deformity

The most common causes of deformity are:

  • trauma;

  • connective tissue diseases;

  • hereditary predisposition;

  • prolonged stay in low temperature conditions;

  • congenital malformations of the osteoarticular apparatus.

Even a slight deformation of the foot area can cause the development of diseases such as arthrosis and osteochondrosis. In addition, in people with deformities, there is a change in posture, up to scoliosis.


Types of foot deformities

Depending on the place of localization of pathological changes, it is customary to distinguish the following types of foot deformities:

  1. Hammer-shaped curvature of the phalanges.This pathology most often affects the II and III fingers, which take the form of hammers. Against the background of curvature, complications such as calluses in certain areas of the foot, as well as osteoarthritis, arise.

  1. Clubfoot. This type of deforming changes is most common in everyday practice. Most often, the disease is diagnosed in children in preschool and primary school age. Clubfoot is characterized by a decrease in the length of the foot, and its supination.Clubfoot is caused by subluxation of the ankle joint. This disease can be either acquired or congenital. The acquired form of the disease is formed as a result of injuries, paresis and paralysis. As a result of improper distribution of the load, a person forms calluses on those parts of the foot that act as a support when walking.

  2. Arched foot. This condition is expressed in the form of increased curvature of the longitudinal part of the foot. With a severe course of pathology, a person does not touch the middle of the foot and the surface on which he stands.

  3. Flat feet. The incorrect distribution of the weight of the human body very often provokes a flattening of the transverse or longitudinal region of the arch. If a person has longitudinal flat feet, then the load applies to the entire foot, and not along its outer edge (normal). Transverse flat feet are characterized by an increase in the spaces between the heads of the metatarsal bones, and an expansion of the forefoot.

  4. Calcaneal foot.This disease is characterized by constant flexion of the dorsum of the foot. With a severe course of pathology, a person may experience contact between the back of the foot and the front surface of the lower leg.

  1. Valgus and varus feet. Such a pathology occurs most often in children, with a valgus foot, the legs take an x-shape, and a varus feast – an o-shaped one.

  2. Hallux valgus is accompanied by the formation of a bone at the base of the big toe.The pathology occurs most often in women who constantly wear high-heeled shoes.

There is also a congenital deformity. This type of deformation is not so common, but it cannot be completely ruled out. A striking representative of congenital pathologies is equinus deformity of the foot and vertical deformity of the talus region. This disease is caused by congenital malformations of fibrous (connective) tissue. During the period of age-related growth of the musculoskeletal system, the muscles do not keep up with the growth rates of individual bones, as a result of which they are displaced beyond the anatomical norm.


Features

Each type of deformity has its own clinical picture. As general signs of violations of the shape of the foot, one can single out:

  • discomfort and pain when walking;

  • violation of gait;

  • impossibility of flexion or extension of the foot at a certain angle;

  • change in posture.

Clubfoot is characterized by the impossibility of turning the leg inward and turning the toe. With different types of flat feet, a person has a heavy gait. In order to reduce pain, a person tries to lean on the edge of the leg while walking. Changes in the shape of the feet with hammer curvature and hallux valgus become the reason for the impossibility of wearing tight shoes, as well as shoes with heels.


Diagnostics

When making a diagnosis, the medical specialist takes into account the patient’s complaints, as well as the data of the clinical examination.Mandatory criteria are foot position, range of motion in the ankle and metatarsal joints, as well as the appearance of the legs. To obtain a reliable diagnosis, the following methods are used:

  • X-ray examination of the foot and ankle. This type of study allows you to find the place of localization of deforming changes.

  • Electromyography. The technique of measuring the bioelectrical activity of muscles is widely used in the diagnosis of equine foot.Based on the research data, the contractile potential of the foot muscles can be determined.

  • Magnetic resonance imaging and computed tomography. These methods are used with little information content of other studies.


Treatment of foot deformity

Each type of deformation needs an individual approach. To correct some diseases, conservative treatment is sufficient, and in other clinical cases, the patient is recommended to have surgery.

With the congenital form of the disease, the correction of the foot begins from the first days of the child’s life. The pediatric orthopedist manually guides the baby’s legs into the correct anatomical position, after which it is fixed with a plaster cast. Over time, the cast is changed to a splint, which is applied at bedtime. When the baby turns 3 years old, he is prescribed physical therapy and massage.

Conservative treatment of acquired clubfoot consists in the use of special inserts and orthopedic shoes.Physiotherapy and physiotherapy exercises are used as additional techniques. In case of insufficient effectiveness of this treatment, patients undergo arthrodesis.

Treatment of all types of flat feet is carried out using conservative methods. Such patients are recommended to wear orthopedic insoles, correction with plaster casts, physiotherapy exercises, massage and apparatus physiotherapy.


  • Horse foot

To eliminate this type of deformity, fixing splints and redressing bandages, correctors for the foot and toes, orthopedic shoes, bandages, specialized traction and heel splints are used.If conservative therapy does not give a positive result, then patients are prescribed arthrodesis of the ankle joint.


  • Heel foot

The congenital form of the disease is amenable to conservative treatment with redressing plaster casts and fixation splints. If the deformity is acquired, then only surgical intervention can correct it.


  • Hallux valgus of the first toe

To eliminate bumps on the leg, physiotherapy treatments, therapeutic exercises, massage, anti-inflammatory ointments, fixing bandages and splints are used.If the disease progresses, then the person is prescribed surgical treatment.

Surgical treatment of hallux valgus can be carried out through the following techniques: osteotomy of the proximal phalanx; removal (exostosectomy) of a bone neoplasm; dissection of the muscle that abducts the injured finger; metatarsal osteotomy.

In order to correct the shape of the fingers, such types of devices as orthopedic splints, socks, onlays, inserts and caps are used.Also, therapeutic massage, gymnastics, physiotherapy are recommended for patients. With an advanced course, the hammer-like deformity of the toes is corrected with the help of a surgical operation. This type of treatment can be both radical and symptomatic.

If deforming changes occur, a person may need additional consultation with a neurologist. Throughout the entire period of therapy, constant medical monitoring of the dynamics of the disease is recommended.

Removal of the gallbladder: cost of the operation – Moscow

Cholecystitis, stones in the gallbladder:

operation in the hospital clinic “MedicaMente”

Treatment of stones in the gallbladder involves the operation of cholecystectomy – removal of the gallbladder.Despite the importance of the organ, surgeons recommend doing an operation for cholecystitis as planned, without waiting for bouts of biliary colic and acute inflammation of the gallbladder. With the development of complications, surgery should be carried out urgently (“by ambulance” in the nearest hospital).

For operations on the biliary tract (gallstone disease, cholecystitis), the department of surgery “MedicaMente” is equipped with all the necessary modern equipment.

Operation cholecystectomy

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Comfortable and safe treatment

The surgical hospital of the MedicaMente clinic is equipped with the latest generation of medical equipment that meets the requirements of modern medicine and international international standards.Patients are accommodated in 1- and 2-bed wards. For a comfortable stay in the hospital, the patient is provided with everything necessary (food, wi-fi, TV, towels, bathrobe, slippers, a bathroom in the ward, multifunctional medical furniture). In our clinic, the schemes of resuscitation and intensive therapy are competently worked out. The resuscitation room of the medical center has all the necessary equipment. If necessary, not only hardware resuscitation is carried out, but also blood transfusion to the patient is possible.

Early rehabilitation

Since MedicaMente surgeons use modern minimally invasive methods of performing operations, the rehabilitation process after removal of the gallbladder is short-lived; nevertheless, after the operation, the patient needs inpatient observation. The necessary care during this period will be provided by the qualified nursing staff of our clinic under the supervision of the anesthesiologist and the surgeon who operated on you. In “Medicament”, active management of the postoperative period is adopted, aimed at reducing pain, accelerating tissue regeneration and recuperation.As a rule, by the evening after the operation, the patient can get out of bed and move around the ward … Center photo

Your doctor is always there

After the operation, if necessary, our patients can contact the operating surgeon by phone at any time, consult and receive the necessary recommendations … our doctors

Reception of nonresident patients

For nonresident patients, an operation to remove the gallbladder is performed on the day of arrival at the clinic (if the necessary tests are available).You can find out about the conditions of the operation from the surgeon during a telephone consultation. Fill out the application on the website, the doctor will contact you within 24 hours.

How is the operation to remove the gallbladder

Today, in most cases, gallbladder surgeries in Moscow clinics are performed using modern laparoscopic technologies.

Laparoscopy of the gallbladder in MedicaMent

High-tech equipment and the professionalism of MedicaMente surgeons make it possible to remove the gallbladder without incisions (laparoscopy), in just four punctures with minimal damage to tissues and blood vessels.Laparoscopy of the gallbladder does not cause severe pain and patients recover quickly after surgery.

General anesthesia is used for laparoscopic surgery. Using a laparoscope, the surgeon examines the abdominal cavity, identifies the gallbladder, carefully separates it and removes it through one of the holes. Drainage is installed (for 12-18 hours), the wounds are sutured.

We use the ERBE BeClamp instrument to remove the gallbladder. This is the most modern device that allows the operation to be carried out almost bloodlessly, without thermal burns, which significantly increases the efficiency of the operation and the course of the postoperative period without complications.

In time, the operation of laparoscopy of the gallbladder lasts from 40 minutes to 2 hours.

Abdominal operation of the gallbladder in “Medicament”

In some cases, laparoscopy is contraindicated in the patient, and doctors have to remove the gallbladder during open surgery. In public hospitals, during traditional (abdominal) surgery, the removal of the gallbladder occurs through a large incision of 15 cm or more under the right costal arch and requires long-term rehabilitation.

The surgeons of the MedicaMente clinic in Korolev adhere to the principles of minimally invasive surgery and perform cholecystectomy from a mini-access – through a short, no more than 8 cm incision. At the end of the operation, the wound is sutured in layers. If possible, a cosmetic intradermal suture is applied. The total time of stay in the clinic is up to 3 days.

Tests for an operation to remove the gallbladder

Can be taken at our Center, local polyclinic or any commercial laboratory.

1. Analyzes

  • General urine analysis
  • Clinical blood test
  • Biochemical blood test (protein, urea, creatinine, bilirubin)
  • HIV, test for hepatitis B and C, RW
  • Blood group and Rh factor
  • Coagulogram (platelets, clotting time, bleeding)

2. CT or Rg-chest organs

3. ECG with interpretation, conclusion of a cardiologist

4.Conclusion of the therapist on the possibility of surgical treatment

Additionally, the following can be prescribed: ultrasound of the abdominal organs, x-ray of the gallbladder (cholecystography).

90,000 Blockage of the rectum in humans: causes, symptoms, how to treat

Rectal blockage is a serious problem. The rectum is located near the end of the large intestine, where it plays an important role in temporarily retaining stool before defecation. Like any other part of the intestine, the rectum can be blocked.As a result, stool movement is impeded, and a person may perceive this blockage as constipation. Without intervention, a blockage in the rectum can become serious and even rupture the walls of the intestines. Blockage of the rectum is the topic of the next article on gastritinform.ru.

Rectal blockage symptoms

Usually the blockage is partial and develops gradually. Complete blockage is rare. Hence, symptoms become apparent over time and may be missed in the early stages. Some of the symptoms of rectal blockage include:

  • Constipation is difficult stool, often hard and dry.
  • Tenesmus – Desire to defecate despite having a bowel movement.
  • Pain, discomfort and burning sensation in the rectum.
  • Fecal incontinence.
  • Blood and / or mucus in stool.
  • Pencil chair.

In addition, there may be other signs and symptoms specific to the causative condition.

Constipation caused by blockage of the rectum

Constipation is one of the symptoms that can occur when the rectum is blocked. However, in most cases, constipation is not due to a blockage, and often the cause of constipation is unknown. Constipation is often associated with dietary and lifestyle factors such as low fiber intake, inadequate water intake, and a sedentary lifestyle. There are various other conditions in which constipation can occur as a symptom, and often these conditions are not associated with any blockage.

Causes of rectal block

The blockage is usually partial and develops gradually. Complete blockage – rare

There are many possible ways of blocking the rectum. This includes neoplasms, foreign bodies, strictures and, more commonly, feces. This blocking can be partial or complete. As a result, it can, to varying degrees, make it difficult for stool to move through the rectum and out of the anus. As the rectum passes into the large intestine, causes of obstruction of the colon can also contribute to the blockage of the rectum.

Learn more about blockages in the colon.

Fecal damage

Fecal blockage is a condition in which stool forms a hard, dry mass in the intestines and causes obstruction because it cannot be evacuated. It is more common in people with constipation. Sometimes people with feces may have a small amount of watery stool, as some stool seeps around the mass. Without proper treatment, the passageway can compress intestinal tissue and affect blood flow to the intestinal wall.

Polyps

Intestinal polyps are abnormal growths that can occur in any cavity in the body. Colon polyps are common and more common in the last parts of the colon, such as the sigmoid colon and rectum. Large polyps and / or multiple polyps can cause obstruction of the colon and rectum. Although most polyps are benign (not cancerous), there is always a risk that some of these polyps will become cancerous (cancerous).

Foreign bodies

Foreign bodies are any objects from the external environment that can get into the body. In the rectum, these may be suppositories that do not dissolve properly, or even objects that may be deliberately inserted through the anus. If the foreign body is not expelled during a bowel movement, it can cause obstruction of the rectum. This can be further complicated by faecal damage.

Hemorrhoids

Inflamed and swollen veins in the rectum are common.It is also known as hemorrhoids (hemorrhoids). Sometimes these veins can be dilated to the point that it can cause partial obstruction of the rectum and worsen any other blockage. In addition, pain and discomfort can lead to anxiety about bowel movements, which in turn can contribute to constipation and thus lead to complications such as stool blockage.

Compression

Compression of the rectum can occur from adjacent organs and structures.This can include the prostate in men and the uterus in women. An enlarged prostate (benign prostatic hypertrophy) and uterine fibroids are two possible causes of external pressure on the rectum. Sometimes cancers of these organs can also press on the rectum, resulting in a blockage of the rectum, which is usually partial.

Narrowing

Anorectal strictures occur where there is a narrowing at the point where the rectum meets the anus, and thus causes a blockage in the anus and / or rectum

Stricture refers to any narrowing of a passage in the body.Anorectal strictures occur where there is a narrowing at the point where the rectum meets the anus, and thus cause a blockage in the anus and / or rectum. In addition to compressing adjacent organs against the rectum, as discussed above, anatomical abnormalities and scar tissue can also cause constriction, which can lead to blockage.

Occupied and deviated intestines

Any abnormality in the position and orientation of the intestines can lead to partial or complete intestinal obstruction.This may not always only affect the rectum, but should be considered as possible causes. First, part of the intestine can become stuck in the hernia of the abdominal wall, making it difficult to move in this position. Another possibility is that there may be bowel twisting, where one segment is “squeezed” together, as seen in the volvulus.

“False” obstacle

A pseudo-obstacle is not an actual blockage by any mass, height or object. On the contrary, it is a place where muscles or nerves in a part of the intestine are disrupted and a part of the intestine becomes very wide, thus preventing movement through it.This is known as acute pseudo-obstruction (ACPO) or Ogilvy’s syndrome. If left untreated, it can rupture the intestinal wall, and complications can even lead to death.

Colorectal cancer

Colorectal cancer is one of the most common and fatal cancers in the world. Depending on the size of the malignant neoplasm, it can cause a blockage in the rectum. If colorectal cancer is not diagnosed and treated promptly, it can become life-threatening within a short period of time.Any change in bowel habits, rectal bleeding, unintentional weight loss, and fatigue for no known reason should raise concerns about colorectal cancer.

Diagnostics and treatment

It is imperative that any blockage in the rectum is diagnosed by a healthcare professional. Signs and symptoms on their own can be misleading, as several conditions can manifest in a similar way despite the absence of obstruction in the rectum or elsewhere in the colon.

The following diagnostic tests may be considered to diagnose rectal obstruction:

Other tests that may also be considered include computed tomography or MRI. A biopsy of any neoplasm can also be taken and sent for histological examination. Appropriate treatments will then be reviewed based on the results of these diagnostic tests.

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90,000 Curl of the uterus … an obstacle to conception? – Lada Clinic

Gynecologists call a bend of the uterus a condition in which the body of the uterus deviates relative to its cervix and its normal anatomical location in the small pelvis.

Bend of the cervix (retroflection) is not a disease, but a pathology. A similar anomaly can be in a woman from birth, or it can be the cause of the postponed inflammatory process.

The normal position of the uterus in the small pelvis is as follows – the body of the uterus is located approximately in the middle in the depth of the small pelvis, parallel to the vagina. This anatomical position of the uterus is specially provided by nature so that there are no obstacles in the path of sperm.That is why, due to the kink, many women cannot get pregnant.

Some women visit an IVF clinic in order to solve this problem with medical intervention.

A medical examination will reveal various options for the pathological location of the uterus in the small pelvis:

  • Retroflection of the uterus , when the body of the uterus is pulled back towards the rectum. It is by retroflection that the bend of the uterus is understood;
  • Anteflexia of the uterus , a slight bend of the uterus forward to the bladder.The result is a small obtuse angle. In nulliparous women, this is considered the norm, since after childbirth, as a rule, the body of the uterus returns to its normal position;
  • Leteroflexia of the uterus , the body of the uterus is bent either to the right or to the left to one of the ovaries;
  • Anteversion of the uterus , a deviation similar to anteflexia, differs in that the cervix also deviates along with the body of the uterus.

Uterine bend – causes of appearance

If such a state of affairs was from birth, this is simply an individual anatomical feature as a result of any irregularities in your mother’s pregnancy.

Usually, this bend is negligible and may not affect sexual function, reproductive health, or the ability to conceive and carry a child in any way. This bend of the uterus will not manifest itself in any way, and you may never know about it, since after childbirth it will most likely cease to exist at all.

And if the bend of the uterus arose after the birth of a woman, it is necessary to determine the reason that caused such a phenomenon:

  • inflammatory diseases, this includes endometriosis, inflammation of the appendages, andexitis, etc.
  • sweetness of the pelvic muscles, as well as weak ligament tone;
  • 90,086 bowel diseases;

  • tumors of the uterus, ovaries;

Uterine retroflection and pregnancy

The main symptoms of retroflection can be – painful menstruation, profuse menstruation, painful sensations during intercourse, the appearance of clots.

Uterus bending at the present stage of technology development is easily diagnosed on examination by a gynecologist and confirmed by ultrasound, during examination with a vaginal sensor.

As soon as a woman finds out about her diagnosis, her main question becomes – how to get pregnant when the uterus is bent and is conception possible in a natural way at all? Gynecologists do not consider this condition an obstacle to the onset and carrying of pregnancy, although they confirm that in the presence of this pathology, it is somewhat more difficult for the patient to conceive.

With congenital, or physiological bend, no therapeutic measures are required, the woman lives and has sex as usual, and pregnancy is not difficult.

In case of pathological bends of the uterus, the tactics of treatment are determined based on the reasons. Usually, in the adhesions process, laparoscopic operations are performed (through small punctures in the abdominal wall) to dissect the adhesions. If the curvature of the uterus is caused by inflammation, antibiotics, anti-inflammatory drugs, and physical therapy are needed. In case of problems of prolonged non-pregnancy with a diagnosis of uterine bending, the IVF program (Odessa) can also be recommended, but in most cases this problem is not so threatening.

If it is important for a couple to get pregnant in the near future, then it is worth considering such a service as intrauterine insemination. The price of Ukraine for this procedure is not as high as for the IVF program.

In order to increase the chances of pregnancy, a woman is prescribed special physical exercises, physiotherapy exercises, depending on the side to which the uterus is deflected, a married couple is recommended different positions during intercourse, which most contribute to the onset of pregnancy.When bending from behind, the position of a woman on her stomach is considered to be a favorable position for conception. The partner at this time is behind. When the body and cervix are bent in front, conception occurs only when having sex in the missionary position – the woman is lying on her back, the partner is on top. After the end of the act, a pillow is placed under the woman’s buttocks in this case, and she should lie for another 15-20 minutes.

Uterine curvature is not a diagnosis, and does not require treatment, but lifestyle modifications!

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