tag:blogger.com,1999:blog-4968787219619380438.post6438783835896260756..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: A perforated colon case report raises a few issuesSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger19125tag:blogger.com,1999:blog-4968787219619380438.post-78974310698770330612018-11-29T19:17:17.862-05:002018-11-29T19:17:17.862-05:00I'm sorry. Typo. I chose conservative treatm...I'm sorry. Typo. I chose conservative treatment and asked for gastrograffin enema. It helped greatly.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-13312257291473895512018-11-29T09:53:38.331-05:002018-11-29T09:53:38.331-05:00What operation did you do?What operation did you do?Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-17593720001750791082018-11-29T09:18:17.310-05:002018-11-29T09:18:17.310-05:00I had a case similar to this. However, my patient...I had a case similar to this. However, my patient did not have free air. Given my patient's mental issues (mental retardation, profound), I didn't think adding a colostomy or ileostomy would have made his life better. GI doc told me "take out the colon" and, being conservative--without signs of perforation--I said no and opted for surgical treatment. I've had other physicians argue whether or not Hirschsprung's disease can exist, unrecognized, until adulthood. I think it can. But never did a full-thickness rectal biopsy to find out.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32202355587051654192018-09-27T09:00:26.869-04:002018-09-27T09:00:26.869-04:00Thanks for sharing this useful information with us...Thanks for sharing this useful information with us.<br />Michael Sheenhttps://www.blogger.com/profile/06369647443949664210noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-75677003100807171772018-09-05T07:10:47.507-04:002018-09-05T07:10:47.507-04:00I don't think colonoscopy as way to remove a l...I don't think colonoscopy as way to remove a lot of stool would work in cases like this. Perhaps manual disimpaction followed by an attempt to decompress the dilated colon with a scope might have prevented the perforation.<br /><br />However, in looking at the first CT scan again, I think the free air might have been present on admission. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-55919646134022983712018-09-04T22:16:46.679-04:002018-09-04T22:16:46.679-04:00I am curious as to whether the availability of OR ...I am curious as to whether the availability of OR time or a surgical consultant was a factor. As previously stated, there is no role for laxatives from above with this presentation. Initial management is manual disimpaction if tolerated. If unable to tolerate disimpaction at bedside colostomy as primary therapy should be considered, but in the absence of an emergency there may be issues of consent. Based on history of autism spectrum disorder and dilation of rectum and sigmoid this appears to be pelvic floor dysfunction, likely psychogenic. If confirmed and unresponsive to pelvic floor PT then colostomy should be permanent. Phillip G Baileynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-46182703071015230752018-09-02T21:38:33.535-04:002018-09-02T21:38:33.535-04:00Colonoscopy would have never worked. Manual disim...Colonoscopy would have never worked. Manual disimpaction and colonoscopy should not be mentioned in the same paragraph.<br /><br />Look at the scan. This is not Ogilvie's... How will you evacuate a gallon of hard stool with a colonoscopy?Anonymoushttps://www.blogger.com/profile/01470444981455289704noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-77897379145727347562018-09-02T16:52:27.580-04:002018-09-02T16:52:27.580-04:00Autistic,Multiple prior admissions...Oh,impressive...Autistic,Multiple prior admissions...Oh,impressive that 3rd year could BE SURE of diagnosis...I would await "pathology review".(If this had been cecal, you could attribute Bernoulli's...have to assume Not the case ,as colostomy done,(not ileostomy) .With aforementioned history, patient likely with chronically dilated colon and very poor peristalsis.(No mention of bowel sounds,Hyper. or otherwise...but I would not expect b.s.,+/-,to be a prominent factor in this CHRONIC case). If he were VERY stable,I might have added a mucous fistula if there was prominent rectal dilatation,and requested pathological review for any evidence of total or segmental absence of motor deficiency.A small resection of end can be sent for review, along with the perforated segment.(Regardless,best long term Rx is "permanent"* diverting colostomy... (* this can be up for yearly? review,IF there were nothing indicating nerve involvement).This is NOT,in my opinion,a good case for dis-impaction or colonoscopy; risky or temporizing at best with prior hx. of multiple recurrences, and aforementioned complication of iatrogenic perforation. It would have been "nice" to have been told how patient fared. Regarding the site of publication...not big concern with this case report,as facts of case were not "sensationalized", nor uncommon.( Even the New York Times is error-prone!).Damien Joy,M.D.noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-6743063083251310222018-09-02T12:17:56.244-04:002018-09-02T12:17:56.244-04:00Decompressive colonoscopy likely the best initial ...Decompressive colonoscopy likely the best initial intervention here. After repeated admissions for disimpactions you have to offer colostomy.Anonymoushttps://www.blogger.com/profile/04247207757689323813noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-8673083076161812662018-09-02T12:01:58.241-04:002018-09-02T12:01:58.241-04:00That was quite a case. That was quite a case. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-81102253287703634622018-09-02T11:48:33.534-04:002018-09-02T11:48:33.534-04:00I've done a few impressive disimpactions in my...I've done a few impressive disimpactions in my office back in the day. Had to air out the room for a while before re-use. Also, I wrote about a memorable case of stercoral perforation. Didn't need much in the way of tests, either: http://surgeonsblog.blogspot.com/2006/07/memorable-patients-part-one.htmlSid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32192686666264597242018-09-02T11:23:48.961-04:002018-09-02T11:23:48.961-04:00Very few. These were surgeons who should have been...Very few. These were surgeons who should have been able to disimpact the patient even if general anesthesia was needed. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-61987377843826994762018-09-02T08:20:16.795-04:002018-09-02T08:20:16.795-04:00How many doctors, particularly GI, do you know who...How many doctors, particularly GI, do you know who can do a rectal exam more or less a disimpaction?? Kenthttps://www.blogger.com/profile/17237993616996048146noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-30352117596262833942018-08-24T10:33:55.947-04:002018-08-24T10:33:55.947-04:00Should have gone straight to the OR, no and, ifs, ...Should have gone straight to the OR, no and, ifs, or buts!Ruggerhttps://www.blogger.com/profile/06098113624490857426noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-56866004491536045052018-08-24T08:20:13.272-04:002018-08-24T08:20:13.272-04:00Robert, yes tests are easier to do.
Anon from 12...Robert, yes tests are easier to do. <br /><br />Anon from 12:31 pm, Lancet is a respected journal.I don't understand the comparison to the Daily Mail.<br /><br />Unknown, from Medscape "If the dilatation persists or worsens, colonoscopic decompression can be attempted, with consideration of placement of a decompression tube, per rectum, to the right side of the colon. Unfortunately, following decompression, the dilatation usually recurs; therefore, decompression with colonoscopy must be carefully considered, as it is not without risk in an unprepared, dilated colon." Link: https://emedicine.medscape.com/article/180955-treatment<br /><br />Anon from 9:16, It could have been a stercoral ulcer or could simply have blown out due to the pressure and thin wall of the colon.<br /><br />Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-12482918324074435922018-08-23T21:16:53.492-04:002018-08-23T21:16:53.492-04:00It's called a perforated stercoral ulcer and i...It's called a perforated stercoral ulcer and it's not that uncommon. I've seen it twice and I'm a 4th year resident. How did this get published in BMJ? Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-20290857172306712342018-08-23T16:37:10.547-04:002018-08-23T16:37:10.547-04:00Sorry but how colonoscopy would help ? Sorry but how colonoscopy would help ? Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-64394990196555797172018-08-23T12:31:09.855-04:002018-08-23T12:31:09.855-04:00The Daily Mail is even less credible than Lancet, ...The Daily Mail is even less credible than Lancet, if that's possible. It regularly features click-bait medical stories, usually horrendomas from dermatology, bad dietary advice, and appalling insects. Like other bad habits, reading such stories should only be indulged in private and under an assumed name. And wash your hands after.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-35569814314329527482018-08-23T12:12:44.260-04:002018-08-23T12:12:44.260-04:00But tests are SO much easier than actually laying ...But tests are SO much easier than actually laying on hands and DOING something for the patient. If it were the US you could make arguments about financial recompense for multiple testing, but this was the NHS so probably no similar incentives. Just laziness. Sloth knows no boundaries. Anonymoushttps://www.blogger.com/profile/07169346105886304386noreply@blogger.com