Many people have experienced constipation, some recover quickly, while others have become "protracted war". Mr. Liu, 52, was tortured by constipation for 30 years. He went to the colorectal and anal surgery department of Wuhan University Zhongnan Hospital to seek medical treatment and found that there was a "giant python" hidden in his stomach...
PART1
PART1
Smooth toilet trip to the hero
Every Tuesday morning is Director Jiang Congqing's expert clinic. On that day, the clinic welcomed an old friend, "Professor Jiang, don't recognize me, I have gained more than 10 pounds! I'm eating, drinking, defecating, everything is fine!" Mr. Liu, who came to the review of Ezhou , gave Professor Jiang Congqing a thumbs up and greeted Director Jiang Congqing enthusiastically.
Have you ever thought that a few months ago, smooth bowel movements and normal diet were all luxury for Mr. Liu!
"I felt so uncomfortable before. It is common to not understand stool for seven or eight days. Kaised lucidum and lactulose have been used a lot, but they have no effect. I have tried all kinds of laxative methods. I usually want to eat more, and I will have abdominal pain and bloating. Only when I defecate can I dare to eat more." Mr. Liu recalled.
It turns out that Mr. Liu is a "senior" constipation patient. He has been troubled by stubborn constipation for 30 years. Due to long-term difficulty in defecation and eating less, Mr. Liu was very thin when he visited the hospital half a year ago, but his stomach was not small, and he could even touch the shape of a hard stool on his stomach.
It is understood that over the years, in addition to severe constipation, Mr. Liu has also suffered from intestinal obstruction of and was repeatedly hospitalized for treatment. But every time I was hospitalized, I only had a simple intestinal clearance, which temporarily relieved the condition, but the disease could not be eradicated. Mr. Liu sought medical treatment everywhere and spent a lot of money on medical expenses, but it was still difficult to find the cause of the disease. As he grows older, he also has a gradually worsening constipation, which has greatly troubled Mr. Liu's life.
"Genius python" was found in the abdomen
"I was tortured to death by constipation. People with inconstipation cannot understand this kind of pain and despair. I heard from a friend that Zhongnan Hospital colorectal anal surgery department is quite experienced in constipation treatment. With a try-making mentality, I came to see the disease quickly." Mr. Liu recalled.
At the beginning of this year, Mr. Liu came to the Department of Colorectal and Anal Surgery of Zhongnan Hospital. Professor Jiang Congqing tailored a careful examination plan for Mr. Liu, including physical examination and a series of specialized examinations such as barium enema, abdominal pelvic CT, anal canal rectal pressure measurement, colonoscopy and other specialized examinations.
When the doctor in the imaging department told Mr. Liu: "The entire colon in his belly expands significantly, with a maximum diameter of 20cm, like a giant python, This is not a simple constipation . " Every word is like a heavy burden pressing on his heart.
After the system inspection, Professor Jiang found Mr. Liu and considered that Mr. Liu was an adult giant colon.
"Isn't this just simple constipation?" "What is giant colon ?" "Is it a tumor?" "How can the good intestines become so thick?" "Is it not cured?" Countless questions passed through Mr. Liu's mind.
From the concept of the megacolon, the cause of the disease, the treatment plan and the prognosis, Professor Jiang gave Mr. Liu a detailed introduction to the ins and outs of the megacolon, and at the same time comforted him to calm down and respond positively.
"When I heard this diagnosis, I felt that the sky was about to fall, and my head was buzzing. I remember Professor Jiang chatted with me for more than 40 minutes, which made me regain my understanding of the giant colon who had been with me for more than 30 years. Professor Jiang even regained my confidence in treatment. There is one sentence that I was particularly impressed by me - rest assured! The MDT team of the colorectal and anal surgery department of Zhongnan Hospital can provide you with very professional treatment advice."
Surgery "catching the python" ended 30 years of abdominal distension and constipation
After discussion by the MDT team, Mr. Liu was recommended to undergo colectomy surgery.
"Don't worry, the surgery will be completed after a sleep." Before the anesthesia, Professor Jiang encouraged him.
After sufficient preoperative preparation, on January 20, Professor Jiang Congqing, Dr. Hu Hang, and Dr. Ren Xianghai's team performed a laparoscopic minimally invasive surgery on Mr. Yang. During the operation, it was found that the ascending colon, transverse colon and partial descending colon were significantly expanded, and the intestinal wall became thinner, like a "giant python", but the morphology and function of the patient's rectum were basically normal. In order to improve the quality of life of patients and protect the patient's postoperative stool control function as the greatest possible, Professor Jiang Congqing decided to retain the rectum with a sufficient function and perform laparoscopic assisted total colectomy + ileal rectal anastomosis . , with the tacit cooperation of the team, the operation process went smoothly. After more than 2 hours of surgery, the lesion intestinal duct was completely removed by , .
The surgical team removed the complete from Mr. Liu's body, which was about 150 cm long and weighed 8 kg.
The giant colon removed from his abdomen
The day after the operation, Mr. Liu's abdominal distension disappeared and he gradually began to resume his exhaust and defecation.
"I remember that my stomach was not swelling after the operation! Apart from some incision pain, there was almost no discomfort. I was hospitalized for 8 days after the operation. In more than 30 years, I had my first good year and had a New Year's Eve dinner!" Mr. Liu was a little excited. He happily patted his stomach and sighed: "The stool is smooth, and he defecated 3 to 4 times a day. Thanks to Professor Jiang Congqing for getting rid of me the 'giant python' and giving me a new life!"
After Professor Jiang's outpatient physical examination and imaging examination, Mr. Liu recovered well after the operation and satisfactory surgery.
PART2
Acknowledge constipation and megacolon
Constipation = megacolon? What is a megacolon?
constipation is closely related to the megacolon, but the concepts of the two are different. Constipation is a disease and an important clinical manifestation of many diseases. Clinically, constipation treatment cannot ignore the causes of constipation. For patients with megacolons, constipation is the main symptom and the result of intestinal lesions.
Most of the time, constipation can be relieved through appropriate dietary adjustments or simple constipation, but stubborn severe constipation has not improved through systematic treatment. Beware of the possibility of the megacolon! Megacolon is rare in clinical practice, but patients with megacolon are often very painful. It is typical of difficulty in stool discharge, so it is prone to misdiagnosis or misdiagnosis as simple constipation and intestinal obstruction, and delayed treatment.
As the name suggests, the megacolon is a description of the intestinal morphology. According to its type, it can be subdivided into adult congenital megacolon , idiopathic megacolon, ganglion cell deficiency (types I and II), toxic megacolon, acute pseudocolon obstruction syndrome (Ogilvie syndrome), and iatrogenic megacolon. How to diagnose the megacolon?
medical history collection and detailed physical examinations including anal diagnosis are the primary steps in diagnosing the megacolon; in addition, imaging examinations are an important means of examination of the megacolon.
imaging diagnostic criteria for megacosis. British scholar Preston compared the degree of dilation of the midgut duct of megacolon patients and normal people as early as 1985, and proposed that the normal diameter of sigmoid colon /rectal /rectal should be 6.5 cm at the entrance of normal people. The intestinal duct is greater than 6.5 cm, the diameter of the ascending colon is >8 cm, and the diameter of the cecum is >12 cm, and the possibility of the megacolon should be suspected [1-2]; the diameter of sigmoid colon 10 cm can also be used as the basis for diagnosis of megacolon [1,3,4]; in addition, if 1 is the calculated value of the color colon index after barium enema (the widest diameter of the rectum / the widest diameter of the sigmoid colon) is helpful for the diagnosis of congenital megacolon [5]; however, it should be noted that due to the variability of X-ray examination, the possibility of the megacolon is still not completely ruled out.
Imaging examination of patients with megacolon
Where does the megacolon go?
Different types of megacolons can manifest as abdominal distension, chronic refractory constipation and large intestinal dilation. As mentioned earlier, there are multiple subtypes of megacolons, and the pathogenesis and clinical manifestations of different subtypes of megacolons when causing intestinal dilation are different. Correspondingly, the treatment plans and strategies of each subtype may be very different.
Therefore, it is very important to accurately judge the category of megacolon. It is strongly recommended that megacolon should be treated in an experienced hospital for regular diagnosis and treatment.
megacolon, treatment is not easy. The differences in treatment regimens are attributed to the different pathogenesis of the megacolon in adults.
common types of megacolon
01
adult congenital megacolon
adult congenital megacolon
adult congenital megacolon patients generally have difficulty defecation since childhood. It is the more common type of adult megacolon.
When seeking medical treatment, experienced doctors will ask the patient's parents about the defecation of the newborn and early childhood. If the baby has not defecated 48 hours after birth, you must think about the possibility of a congenital megacolon. Most patients with congenital megacolons show obvious intestinal obstruction during the neonatal period and are diagnosed and treated in time. Only a few children with short stenosis and mild symptoms in childhood delayed their visits to the doctor after growing up, and most patients have difficulty defecating from childhood than their peers.
adult congenital megacolon is an abnormal developmental disease of intestinal neurons. The distal (near the anal side) intestinal duct is spastic and stenosis due to the lack of autonomic ganglion cells, resulting in secondary expansion of the proximal intestinal duct to form a megacolon. If a doctor conducts a rectal diagnosis, it can sometimes pave the annular intestinal stenosis or anal blast-like exhaust and defecation during a finger diagnosis; anal rectal pressure test will often indicate the disappearance of the rectal inhibitory reflex; the spastic stenosis, transitional and dilated intestinal canals can be seen in the X-ray barium enema. In treatment, not only should the obviously dilated intestinal canal be removed, but the narrow segment of intestinal canal should also be completely removed. Intraoperative rapid pathological section technology helps to ensure that ganglion cells are completely removed, such as intestinal segment (the root of the disease) are found.
congenital megacolon
02
ganglion cell deficiency
ganglion cell deficiency patients with ganglion cell deficiency have a higher age relative to the onset, and the proportion is higher in women. It is divided into type I and type II. Type I is a segmental ganglion cell deficiency, manifested as segmental intestinal stenosis and proximal expansion, which is similar to the congenital megacolon. However, unlike the congenital megacolon, the stenosis segment of congenital ganglion deficiency type I is often located in the descending colon or sigmoid colon, while the rectal morphology is normal and the rectal anus inhibits reflex exists (the stenosis segment of the congenital megacolon in adults is usually in the rectum). This type of disease is often diagnosed by pathological examination after intestinal resection. It is similar to the congenital megacolon in the key points of the surgery. The stenosis and dilated intestinal canal must be removed together. Type II is even rarer, manifested as diffuse intestinal ganglion cells, which are often characterized by chronic intestinal obstruction. In terms of treatment, if such patients do not need surgical intervention urgently (such as intestinal perforation , bleeding or such risks), conservative treatment is usually selected.
03
Idiopathic megacolon in adults
Idiopathic megacolon in adults also has difficulty defecation, abdominal pain and bloating, etc. The idiopathic megacolon does not have obvious narrow intestinal segments, and the dilated intestinal segments are the lesion intestinal segments. The characteristic is that the data on myometriosis cells of the intestinal wall are reduced, and clinically manifested as thinning intestinal smooth muscles, that is, weak intestinal peristalsis. The cause of idiopathic megacolon is not yet clear; the main feature of this type of patient is the existence of rectal anal inhibitory reflex. When conservative treatment fails to undergo surgical treatment, in principle, the dilated intestinal canal should be completely removed, and if necessary, the stoma can be performed first and the intestinal resection can be performed at an optional stage.
04
toxic megacolon
toxic megacolon is the most serious complication of severe colitis, which is common in ulcerative colitis. However, other intestinal infections such as ischemic enteritis, collagenic colitis, and difficulty in the context of abuse of antibiotics Clostridium infection with pseudomembranous enteritis can all cause toxic megacolon. Patients usually show segmental or full-course colon dilation, and conservative treatment can be tried first. The timing of surgical intervention is generally intestinal perforation, major bleeding or corresponding risks. The surgical methods are generally colorectal resection and ileostomy .
05
Acute pseudocolonal obstruction syndrome (Ogilvie syndrome)
This type of disease was first proposed by Ogilvie in 1948. It is a group of syndromes in which primary or secondary colon dilation, while colon itself has no lesions. Ogilvie syndrome is not rare in clinical practice. The annual incidence of Ogilvie syndrome was reported in a retrospective study of national inpatient data in the United States. Imaging examinations suggest that the intestinal cavity dilation is changed like a megacolon. Studies have shown that this syndrome has caused a variety of causes (surgery, trauma, or infection) to cause an unbalance between the sympathetic and parasympathetic nervous system that innervates the movement of the large intestine, resulting in colon relaxation and pseudo-obstruction. Conservative treatment is preferred for Ogilvie syndrome, and colonoscopic decompression and intestinal obstruction catheter insertion can have good therapeutic effects.
It is not difficult to see that not all megacolons require surgery, and the megacolons that require surgery are different in specific surgical methods and resection ranges: for example, in adult congenital megacolon and ganglion cell deficiency type I patients with lesions = narrow segment + dilated segment (including transit segment), thorough resection of them is the key to ensuring efficacy; adult idiopathic megacolons generally have dilated intestinal tract resection.
[Reminder]
Adult megacolon is rare in clinical practice, with a low incidence rate, but patients are often very painful. Long-term constipation and recurrent intestinal obstruction seriously affect the patient's quality of life, and excessive intestinal tract expansion can be at any time at risk of intestinal rupture and life-threatening.
There are currently two more prominent problems in the diagnosis and treatment of megacolon:
First, some megacolon patients have not undergone systematic etiological evaluation and have even been misdiagnosed as simple constipation. Clinically, for patients with stubborn constipation, gastrointestinal transmission tests should be carried out as much as possible for , barium enema, fecal defecation angiography, rectal anal canal pressure measurement, abdominal pelvic CT and other specialized examinations to clarify the cause.
The second is to accurately grasp the treatment plan and the timing of the surgery; for some megacological patients who are manifested by acute intestinal obstruction, conservative treatment can be performed first under close monitoring (including routine conservative treatment measures, reflux enema, small intestinal decompression tube placement, colonoscopy decompression, etc.), to reduce the chance of emergency laparotomy, reduce the accumulation of intestinal content, and reduce the occurrence of intraoperative contamination and postoperative complications; effective conservative treatment, turning emergency surgery into elective surgery, can greatly reduce the chance of enterostomy and second-stage surgery.
Professor Jiang introduced: Adult megacolon is rare in clinical practice and is prone to misdiagnosis and misdiagnosis; different types of megacolon treatment plans and strategies may be completely different; and patients who need surgery also need to choose different surgical plans based on the patient's cause and lesion range. Patients with megacolon often have malnutrition and excessive intestinal dilation can be at risk of intestinal perforation. Constipation is no small matter. If there is stubborn constipation or repeated intestinal obstruction, it should be taken seriously. It is recommended to go to a regular hospital for diagnosis and treatment as soon as possible.
Author / Jiang Congqing Ren Xianghai
Supervisor / Zhang Yifei
Editing / Ding Yanfei
Source: Wuhan University Zhongnan Hospital
