Материал: Advanced Imaging of the Abdomen - Jovitas Skucas

Prevalence of intussusception is increased in patients with AIDS-associated gastrointestinal disease. Crampy, intermittent abdominal pain is a typical presentation. Either CT or a barium enema is diagnostic.

A colitis mimicking ulcerative colitis can develop in an occasional AIDS patient with a low CD4 T-cell count.

Examination and

Surgical Complications

ADVANCED IMAGING OF THE ABDOMEN

Barium inspissation after a barium enema is rare. In most reports it is due to underlying constipation,poor radiographic technique resulting in the overfilling of a dilated, hypotonic colon, or the lack of post-enema hydration.

Colonoscopy

Colonoscopic complications consist of bleeding, sepsis, perforation, and transmural burn injuries, with the onset of symptoms occurring an average of 30 hours after colonoscopy. Bleeding is managed conservatively in approximately three quarters of these patients.

Barium Enema

A retrospective study of over 700,000 barium enemas performed between 1992 and 1994 in the United Kingdom found an overall mortality rate of one in 56,786 (230); only three of 30 (10%) patients with bowel perforation died, compared with nine deaths among 16 (56%) patients with cardiac arrhythmia. One death was related to vaginal intubation.

In a setting of incomplete or failed sigmoidoscopy or colonoscopy, a double-contrast barium enema can be performed the same day if no biopsy or only a superficial biopsy (using small biopsy forceps) is obtained; the risk of perforation increases if biopsies are taken from diseased mucosa. A barium enema should be postponed, however, for at least 14 days if a deep biopsy is obtained. A similar delay in performing barium enema also appears warranted if a polypectomy is performed.

Focal barium extravasation, either intramural or extrinsic to bowel, results in an exuberant fibrotic reaction around barium sulfate crystals. An experimental study in rats concluded that any effect of barium sulfate on gastrointestinal tract transmural wound healing is minimal (231). At times prior focal extravasation is unsuspected; thus in one patient a tumor in the gallbladder fossa was believed to represent an advanced gallbladder cancer, but resection revealed foreign-body barium granulomas (232).

Venous barium embolization during a barium enema is a rare but highly lethal complication. Embolization can be either into systemic veins (usually from a rectal perforation) or into portal venous system.

Disinfection Related

Colonoscopic cleansing is typically achieved with glutaraldehyde or hydrogen peroxide. Both agents produce tissue necrosis. Bloody diarrhea develops within a day or so after these agents contact colonic mucosa, mimicking ischemic or infectious colitis. Imaging in patients with glutaraldehyde-induced colitis reveals circumferential left-sided colonic wall thickening and heterogeneous wall contrast-enhancement; these findings resolve on follow-up. Ultrasonography also identifies colonic wall thickening, consisting of hypoechoic mucosa and hyperechoic submucosa.

An unusual colitis due to hydrogen peroxide developed while colonoscopy was still being performed; it consisted of opaque plaques or pseudomembranes, a condition called pseudolipomatosis by pathologists (233). To prevent such disinfectant colitis, the authors recommend an additional preprocedure rinse of colonoscopic channels.

Septicemia

Approximately 10% of patients develop transient bacteremia after colonoscopy. Septicemia is not common, although the risk of septicemia increases in immunocompromised patients.

Perforation

Three mechanisms are associated with colonoscopic perforations (234): (1) mechanical causes due to colonoscopic manipulation, (2) barotrauma from overinsufflation, and (3)

COLON AND RECTUM

perforation related to therapeutic procedures. In general, perforation occurring during diagnostic colonoscopy tends to result in large lacerations; those associated with polypectomy tend to be smaller. Cecal perforations tend to be due to overinsufflation; sigmoid perforations involve mostly technical problems. Some perforations are difficult to understand. Why should a jejunal or ileal perforation develop after colonoscopy? Some perforations are not diagnosed for several days.

The appearance and sequelae of colonic perforation are myriad and are related both to the extent and site of perforation and amount of peritoneal soilage. In addition to a pneumoperitoneum, some patients develop pneumothoraces, pneumopericardium, pneumomediastinum, scrotal swelling, and even subcutaneous emphysema. A tension pneumothorax can lead to acute respiratory failure.

The current trend is toward fewer surgical interventions for colonoscopic perforations; some patients with clinically and radiographically evident perforation heal under medical management. In fact, medical therapy leads to a shorter hospitalization than with comparable surgical management. In patients believed to require surgery, either primary repair or resection and anastomosis are the procedures of choice, assuming no contamination is evident.

Other

A number of splenic ruptures have been associated with colonoscopy. Acute appendicitis developed in a 69-year-old man immediately after colonoscopy (235); no signs or symptoms of appendicitis were evident prior to colonoscopy.

Transient myocardial ischemic episodes develop during colonoscopy; these appear to be associated with tachycardia and hypoxemia.

Postresection

Mostly Rectosigmoid Complications

Although colonic ischemia and anastomotic dehiscence is not uncommon after colon surgery, rectal ischemia is rare. Rectal necrosis, however, has developed after anterior resection of a rectosigmoid carcinoma; presumably inferior mesenteric artery ligation in a setting of

atherosclerosis results in an inadequate blood supply to the residual colorectum.

Extraperitoneal emphysema is not uncommon after a low anterior resection or fullthickness excision, raising the question of whether it represents benign emphysema or a postoperative leak. At times abdominal wall emphysema develops and persists for a considerable time. These entities can usually be distinguished with a contrast enema. Computed tomography findings of a leak consist of gasfluid collections adjacent to the rectum and extending along tissue planes. With resolution of a perforation these collections should gradually diminish.

Presacral space widening is common after rectosigmoid surgery.

Hartmann’s Pouch

Based on established surgical indications, either a Hartmann’s pouch or a double-barrel colostomy is created to protect an anastomosis, with surgeons in the United States favoring the former. Complications related to a Hartmann’s pouch include leaks, strictures, adhesions, and, on a more chronic basis, recurrent tumor and diversion colitis. A contrast study is often requested prior to colostomy takedown, which is generally several months or longer after the initial surgery. Occasional debate surfaces among radiologists about whether barium or a water-soluble agent should be used; I prefer barium because of its higher contrast and ability to detect more subtle detail, unless the study is being performed shortly after resection and the possibility of rupture and intraperitoneal spill are considerations. The presence of barium in a leak is not an issue—after all, if barium enters a sinus tract or cavity, so can infected colonic content, which produces more damage than inert barium sulfate. A more pertinent issue is that the enema balloon should not be inflated to the same degree as during a normal barium enema; these patients have decreased rectal pain sensation and, especially with the presence of a stricture, a major rectal perforation can occur.

Strictures in a Hartmann’s pouch are amenable to transrectal dilation. Most small leaks heal with time, although an occasional silent leak is detected by a barium study even months later.

Stricture

Benign postoperative colonic strictures are not uncommon, most being due to ischemia. These strictures are amenable to balloon catheter dilation, either via colonoscopy or, with distal colonic and rectal strictures, simply using fluoroscopic control. A preprocedure barium enema aids in defining the site and length of a stricture. Procedure complications are rare and stricture recurrence uncommon.

An occasional ischemic stricture is treated with a self-expandable metallic prosthesis, but, in general, stricture dilation is preferred even in high-risk patients.

Postlaparoscopy

Laparoscopic resections of sigmoid diverticulitis leads to a severalfold increase in operative time over open resection but a decrease in intensive care. Length of hospital stay, complications, and operating time decrease with experience.

Abdominal wall tumor recurrence at a trocarsite scar does occur after laparoscopic carcinoma resection. This complication is rare in a laparotomy scar.

Port site hernias are an uncommon complication of laparoscopic colectomy. Superior mesenteric and portal vein thrombosis occurred after a laparoscopically assisted right hemicolectomy.

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