Systemic vasculitis is generally believed to be an immune complex deposition in blood vessels. Gastrointestinal com­plications of vasculitis have been described as pain, diarrhea, rectal bleeding and abnormal liver enzymes. Taken in isolation, the symptoms are difficult to distinguish from in­flammatory bowel disease, infectious colitis or ischemic coli­tis, although gastrointestinal vasculitis rarely presents without other clinical evidence of systemic vasculitis. Histo- logical proof is difficult to obtain because biopsies from the gastrointestinal tract usually show only nonspecific inflam­mation and ulceration. Camilleri and Pusey suggested that this may be because endoscopic biopsies are too superfi­cial and proposed that endoscopic examination was the best method to determine extent of disease. Diagnosis is often made clinically from the involvement of other organ systems because biopsies frequently show no evidence of a specific vasculitis. Therapy is aimed at treating the systemic vasculi- tis with immunosuppressive medications and with surgical intervention in the event of gastrointestinal complications such as hemorrhage or perforation.

Vasculitic involvement of the gastrointestinal tract is more common in polyarteritis nodosa and microscopic polyarteritis (50% to 70%) and Chrug-Strauss syndrome (20%) than in Wegener’s granulomatosis. Walton published autopsy studies of patients with Wegener’s granu- lomatosis and found gastrointestinal involvement in 24%, although none of these patients had symptoms referable to the gastrointestinal tract. Two large groups of patients with We- gener’s granulomatosis have been followed for over 20 years, and neither study describes gastrointestinal complica­tions throughout the course of the disease. Case reports of gastrointestinal involvement in Wegener’s granulomatosis have described cases of enterocolitis, gastrointestinal hemor­rhage, intestinal perforation and recurrent pancreatitis.

…..Click here to read more

Initial laboratory studies revealed a white blood cell count of 10.7×10⁹/L (4.4 to 11.0×10⁹/L), hemoglobin level of 111 g/L (normocytic, normochromic) and platelet level of 599×10⁹/L. Electrolytes and liver enzyme levels were normal and her creatinine level was 98 pmol/L. The erythrocyte sedimentation rate was 125 mm/h. Urinalysis showed many red blood cells with no white blood cells or casts, and prote- inuria of 0.27 g/day. Her estimated creatinine clearance was 70 mL/min.

Esophagogastroduodenoscopy two days after admission revealed multiple discrete and punched out ulcers starting at 20 cm and extending to the esophagogastric junction (Fig­ure 1). The ulcers were atypical for ulcerative esophagitis and appeared vasculitic in nature. Because of the endoscopic findings, prednisone therapy was initiated. Within 24 h, im­provement was noted in her gastrointestinal symptoms, as well as the ulcerations in the nose and oropharynx. Esophag- eal biopsies revealed fibrinoid necrosis with ulceration and inflammatory cell infiltration surrounding small vessels, in keeping with a vasculitic process (Figure 2). Biopsy of a skin lesion showed fibrinoid degradation of small arteries with acute inflammatory cell infiltration (Figure 3). Granulomata were not noted in either biopsy.

…..Click here to read more

Esophageal involvement in Wegener’s granulomatosis: A case report and review of the literature

Wegener’s granulomatosis is characterized by agranulo- matous arteritis involving the upper and lower respi­ratory tracts, progressive glomerulonephritis and systemic symptoms attributable to small vessel vasculitis. Although multisystemic manifestations are frequent, involvement of the gastrointestinal tract is uncommon. A patient whose initial presentation of Wegener’s granulomatosis was odynophagia secondary to esophageal vasculitis is described. Stan­dard therapy for systemic Wegener’s granulomatosis resulted in resolution of the gastrointestinal complications.

CASE PRESENTATION

A 34-year-old female presented to hospital with a four-day history of severe odynophagia for solids and liquids, with in­ability to eat due to pain. She also had developed ischemic lesions in her feet and fingers, palpable petechiae on both forearms, dry cough, bilateral scleral injection and arthralgias of the fingers, wrists and ankles. In the four weeks before presentation, she was treated for otitis media after de­veloping decreased hearing acuity in the left ear. She subse­quently developed purulent drainage from the ear and was treated with a week of trimethoprim/sulphamethoxazole. This was followed by a week of treatment with amoxicillin after the patient failed to respond to the initial course of an­tibiotics.

…..Click here to read more

A recently published method may offer a promising alternative to increase the (neo) rectal compliance follow­ing low resection. A Swiss group described a new pouch cre­ated in an experimental pig model designed by performing a mere longitudinal colotomy of the taenia libera coli followed by a transverse closure. Although the pouch volume of this new pouch was significantly smaller than that obtained with a J-pouch, the frequency of defecation was comparable.

Clinical application of this new method may overcome severe technical problems in obese patients or in patients with a long anal canal in whom the distal resection margin and the anastomosis are situated in the dentate line, and in whom construction of a J-pouch is almost technically impos­sible.

Although dynamic graciloplasty has provided excellent results in patients who were operated for fecal incontinence due to major sphincter defects, the use of this technique for sphincter restoration following APR is regarded as a compro­mise.

Despite sufficiently high sphincter pressures created by the transformed gracilis muscle, defecation disorders, includ­ing incomplete evacuation and subsequent episodes of in­continence, are the major functional problems following this procedure. Most patients require periodical enemas or irriga­tion following APR to empty their neorectum sufficiently. Although a satisfying functional result can be achieved in 60% to 75% of patients by this method, an intensive preoperative interview as well as a close follow-up after the proce­dure are mandatory to avoid disappointment.

…..Click here to read more

By using this technique, resection of the rectum may be extended into the anal canal by removing the internal sphincter completely or partially (‘intersphincteric resec­tion’), thus offering the opportunity for sphincter-preserving resections of tumours below 5 cm from the dentate line.

In general, ultralow resection of rectal cancer with coloanal anastomosis is associated with an acceptable post­operative morbidity and oncological results in the literature. Mortality in most series is below 10%, and the most common complications are urinary and sexual problems (comparable with those associated with APR). Interestingly, clinically relevant insufficiency of the coloanal anastomosis seems to be a rare problem, and pelvic sepsis is observed in larger series in less than 10% of cases. The explana­tions for this finding are mainly speculative and include the high experience in rectal surgery of most of the authors, the use of a protective stoma in most series or the (extraperito- neally performed) anastomosis outside the abdomen in the anal canal.

It is widely accepted that oncological results achieved with ultralow resection of rectal cancer are acceptable and that the local recurrence rate is in the range of 10%. How­ever, there are still candidates for APR. In a series of 134 patients treated by ultralow resection and coloanal anasto­mosis at the Memorial Sloan-Kattering Cancer Center, the following parameters correlated with a high risk for local re­currence: tumour size, perineural or vascular invasion of tumour cells, high histological grade (G III), carcinomatosis of the mesentery and tumour invasion of the resection mar­gins. Therefore, patients having tumours with infiltration of the external anal sphincter as well as of the Musculus levator ani, or with a high grade malignancy close to the anus cer­tainly need APR.

…..Click here to read more

Surgery is the most important form of treatment for rectal cancer by radical local tumour control. Despite that recurrence-free survival is still the major goal of surgical therapy, it is also widely accepted that the surgeon should re­lieve distressing symptoms associated with the procedure.

A major concern of patients with colorectal cancer is the possibility that surgery leads to a permanent stoma. In the ‘early days’ of rectal surgery, abdominoperineal resection (APR) of the rectum with construction of a permanent colo- stomy was the treatment of choice for patients with cancer located in the middle or lower third of the rectum. Intramu­ral spread of cancer and the possibility of lymphogenic spread via the aboral route were major concerns and led to the recommendation of a safety distance of at least 5 cm from the distal tumour margin to prevent local recurrence.

As a result of more recent studies, it is now widely accepted that intramural spread rarely exceeds 1 cm and that patients in whom an intramural spread wider than 1 cm is observed are usually diagnosed in a more advanced tumour stage, including the lymph node metastases stage. This knowledge, as well as the knowledge that the lymphogenic spread of rectal cancer has a cephalad direction and occurs along the mesorectum to the inferior mesenteric artery, have led to a change in the surgical approach for local control of rectal cancer.
Complete excision of the mesorectum and a distal tumour-free margin of 2 cm are the essential criteria for minimizing the risk of local recurrence.
Removal of the sphincter apparatus does not substantially increase the radicality of the surgery, provided that the sphincter is not infiltrated by the tumour. Is sphincter-saving surgery, therefore, less radical than APR?

…..Click here to read more