Colon pelvic

Constipation can be due to primary and secondary causes (Table 18-1). Primary or idiopathic constipation is typified by normal-transit constipation, slow-transit constipation, and dyssynergic defecation. In the normal-transit type, colonic motility is unchanged and patients tend to experience hard stools despite normal movements. In the slow-transit type, motility is decreased leading to infrequent harder, drier stools. In dyssynergic defecation (also known as pelvic floor dysfunction), patients have lost the ability to relax the anal sphincter while coordinating muscle contractions of the pelvic floor. Some causes of secondary constipation are listed in Table 18-1. 

More important possibly from the standpoint of function is the diversity of the anatomy of the pelvic colon itself. Figure 5 shows the various types of anatomical structures and the percentage occurrence of each. These percentages should be taken as indicative rather than accurate since they are based upon examination of only 210 specimens. If these percentages were accurate for the whole population of the United States, each of the least common forms (represented at the bottom of Figure 5) would exist in about 600,000 persons. It seems obvious that with this array of different types of pelvic colons (as well as transverse colons), people should differ tremendously (as they do) with respect to their problems of elimination. It is interesting to note in this connection that healthy newborn ba-... 

Pelvic colon. Variation in form and position. Diagrammatic. Major types (I to IX) are illustrated, together with varieties (A to C, etc.) within the more inclusive categories. The percentage occurrence of each type and subtype is recorded, as determined from an examination of 210 specimens. From Barry J. Anson, Atlas of Human Anatomy, p. 349. 

Based on the successful experience in colon carcinoma, the most recent Intergroup trial (INT-0114) explored the role of biomodulation of 5-FU in rectal cancer. This four-arm trial randomized patients to pelvic irradiation and 6 mo of bolus 5-FU vs bolus 5-FU and levamisole, leucovorin, or both (30). There was no significant difference in disease-free survival and overall survival (78-80%) among the four treatment arms in a prelimi-... 

Willett CG, Badizadegan K, Ancukiewicz M, Shellito PC. Prognostic factors in stage T3N0 rectal cancer do all patients require postoperative pelvic irradiation and chemotherapy Dis Colon Rectum 1999 42(2) 167-173. 

Large-colon impaction is characterized by distention of the large intestine with desiccated digesta. All segments of the large colon can be involved but the pelvic flexure and right dorsal colon are the most frequent sites of impaction. Impactions of the large colon are probably a combination of motility and fluid-balance disorders and most cases are treated with laxatives or hydration solutions. 

The adult worms of S. haematobium cause urinary schistosomiasis (bilharzi-asis) and live in the portal system, pelvic veins, particularly in the vesical and pelvic plexus and occasionally in the veins of the colon and rectum. The worms excrete their eggs in the urine of man but rarely in the faeces. The other three schistosomes (S. mansoni, S. japonicum, S. intercalatum) are responsible for intestinal bilharziasis and live in the portal blood system, mesentric veins and haemorrhoidal plexus. Unlike the S. haematobium worms, these three blood flukes pass their eggs in the faeces and rarely in urine. 

Metronidazole has been shown to be of great value in the management of anaerobic bacterial infections [20,27,75,76]. The role of this drug in the prophylaxis and treatment of various anaerobic bacterial infections, which may develop following appendectomy, elective colonic surgery, colo-rectal surgery and hysterectomy [20,77,78]. Mebendazole is equally useful in cases of endocarditis, osteomyelitis, lung abscess, empyema, peritonitis, septicemia and pelvic infections [79]. 

Radiographic imaging studies evaluate the extent of disease involvement. A chest x-ray should be performed to rule out the presence of metastatic spread to the lungs. A CT scan of the abdomen and pelvis is often performed to evaluate hepatic and retroperitoneal involvement and occult abdominal and pelvic disease, and to determine the depth of tumor penetration into the bowel wall and/or invasion to adjacent organs. Detection of lymph node involvement with either smdy is limited by the difficulty of distinguishing inflammatory or reactive lymph nodes from those infiltrated with tumor. Because CT scans may not adequately detect peritoneal seeding, small distant lymph node metastasis, or liver metastasis in colon cancer, an occasional patient may... 

There is currently no definitive role for adjuvant XRT in colon cancer because most recurrences are extrapelvic and occur in the abdomen. Although local recurrence and debilitating pelvic pain are uncommon, a subset of patients with T3 or T4 tumors located in the cecum, hepatic and splenic flexures, and sigmoid are at increased risk of local recurrence and may benefit from postoperative XRT and chemotherapy. Early trials using effective doses of whole abdominal XRT were limited by considerable toxicity. However, results from studies combining abdominal XRT plus fluorouracil are promising. To date, postoperative local XRT may reduce the risk of local recurrence and improve survival compared to adjuvant chemotherapy alone, but should only be considered for select patients with colon cancer. ... 

Plain film shows numerous dilated loops of bowel occupying the entire abdominal cavity, including the pelvic portion, and multiple air-fluid levels in upright film (Fig. 1.19). With this degree of distension the mucosal pattern of the small bowel is effaced and it is impossible to differentiate the small bowel from the colon (Winters et al. 1992). Examination of the colon is then warranted to disclose the presence or absence of a colonic lesion. In ileal atresia, the colon is normally placed but has an abnormally small caliber, the so-called functional microcolon typical of distal small bowel obstruction (Dalla Vecchia et al. 1998) (Fig. 1.19d,e). The presence of pneumoperitoneum indicates that perforation has occurred and a colon examination is contraindicated. Intraperitoneal calcifications, indicative of meconium peritonitis, are not uncommon in ileal atresia. 

Approximately 90%-95% of cases of childhood constipation are likely to represent functional constipation. Rectal distention is present in nearly all cases and failure of the external anal sphincter and/or pub-orectalis muscle to relax during defaecation attempts has been found in the majority of these children. Whilst delayed colonic transit time may be part of the problem, pelvic floor dysfunction seems to be the dominating factor (Loening-Baucke 1993). 

Beer-Gabel M, Teshler M, Barzilai N, LurieY, Malnick S, Bass D, Zbar A (2002) Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders. Dis Colon Rectum 45 239-248... 

Roediger WEW, Hicker WG (1986) Thickening of the pelvic fascia in carcinoma of the rectum. Dis Colon Rectum 29 117-119... 

Posterior tumor growth leads to infiltration of the presacral space and sacral bone or of the perirectal space and rectum. Recurrent cervical cancer is associated with rectal infiltration in about 17% of cases. The most common site is the rectosigmoid junction. Laterally, recurrent tumor may extend to the pelvic sidewall. If the recurrent local tumor grows anteriorly along the peritoneal fold, there will be infiltration of the urinary bladder. Advanced recurrent cervical cancer may involve the remaining colon or the small intestine and is typically associated with adhesion of bowel loops and may cause intestinal obstruction. 

Fig. 7.5 la,b. Recurrent tumor of the pelvic sidewall after hysterectomy. A T2w TSE image in transverse orientation. At the right pelvic sidewall, a solid, heterogeneous mass (arrows) is depicted that infiltrates the pelvic wall and extends to the iliac bone. TUmor adhesion to the sigmoid colon, b Tlw TSE image with FS transverse orientation 1 min after administration of Gd-DTPA. MRl depicts an enhancement on the postcontrast image and central necrosis... 

Crohn s disease is a chronic inflammatory condition that may occur in any part of the gastrointestinal tract but commonly involves the terminal ileum or right colon frame. Gynecologic involvement with inflammation of the organs of the true pelvis or of the vulva is not uncommon. Another manifestation are fistulas between the vagina and the colon or rectum [5]. MRI is the method of choice for the diagnostic evaluation of pelvic fistulas. 

Rentsch M, Paetzel C, Lenhart M, et al. (2001) Dynamic magnetic resonance imaging defecography a diagnostic alternative in the assessment of pelvic floor disorders in proctology. Dis Colon Rectum 44 999-1007... 

Fig. 17.6a-c. Abscess involving ovaries and sigmoid colon. Three consecutive CT scans (a-c) in and above the acetabular level in a 36-year-old woman with pelvic pain and leukocytosis. A multiseptate cystic lesion (arrow) with perilesional fat stranding is identified lateral of the uterus (a, b) involving the left adnexa and sigmoid colon. The tiny spot of free air (small arrow) is highly specific of the inflammatory nature of this process (b)... 

Fig. 17.16 Sigmoid diverticulitis. Multiple air-containing diverticula are found along the sigmoid colon. In this patient with acute pelvic pain, focal wall thickening, stenosis, and paracolic fat stranding (arrow) are signs of acute diverticulitis involving the distal sigmoid colon. R, rectum...

CTC in symptomatic patients is to be considered when colonoscopy can not be completed or carried out this may occur due to mechanical hindrance such as pelvic adhesions, in cases of high risk of perforation as in complicated diverticular disease, when there is an obstruction due to cancer or extracolonic diseases, when the cecum cannot be reached in extreme dolicocolon conditions, or in patients with poor tolerance to colonoscopy in whom heavy sedation may be dangerous (elderly patients or patients with severe co-morbidity). Such indications are similar to those of double contrast barium enema (DCBE) however, CTC has been shown to be both more accurate and better tolerated than DCBE, and should be used preferentially whenever available (Rocket et al. 2005 Taylor et al. 2005 Taylor et al. 2006). Furthermore, in cases of obstructing colonic cancer, CTC is a valuable tool, as it can be conveniently performed at the time of a contrast-enhanced abdominal CT scan for staging purposes to detect synchronous colorectal carcinomas, metas-... 

The contraindications to CTC are few and, in general, different than these encountered with conventional colonoscopy (Rex et al. 1987). Weight and girth limitations of the scanner, artifacts from metal prosthesis and claustrophobia are examples of contraindications unique to CT. Absolute contraindications to instrumentation of the colon include presence of an acute abdomen, recent abdominal or pelvic surgery, colonic hernia, and acute diverticulitis (Fig. 2.3). Relative contra-indications include pregnant patients, patients with hip replacements, claustrophobia and an incompetent ileocecal valve (Fig. 2.4). 

A patient with an acute abdomen should not he inflated with room air or CO2, and a consultation with a surgeon is most appropriate. Patients with active diverticulitis should not he referred to CT colonography. If an abscess or free air is suspected, a CT of the abdomen and pelvis can be performed with oral and IV contrast. Insufflation of the colon is contraindicated and may cause perforation and widespread peritonitis. Similarly, if a patient has recently undergone pelvic or abdominal surgery. 

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