obstructed defecation

65 y.o. lady P/W 10 year history of poor gastric emptying facilitated by manual evacuation.

Past medical history is extensive with a high gastric reduction performed for obesity 30 years ago. Since then, she has lost considerable weight but required a reversal due to erosions. She then had a sub-total gastrectomy and roux-en-y bypass with a JJ stent put in for gastric paresis. 

(More details about High Gastric Reduction can be found in an abstract presented at the 11th World Congress of the International Federation for the Surgery of Obesity in 2006.)

On examination, her abdomen was non-tender, and there was a 4cm by 5cm incisional hernia through a midline laparotomy scar. PR exam revealed multiple skin tags, normal sphincter tone. (That was all i got as i did not do it myself).

The registrar called in the colorectal surgeon and he likened the obstructed defecation symptoms to rectal intussusception (image credit), or paradoxical contraction of the anus. He performed a PR and rigid sigmoidoscopy. 

When the rigid sigmoidoscopy was performed, the poor lady was feeling quite uncomfortable when air was pumped in her rectum. I would imagine it to be quite uncomfortable. However, another male patient i saw at another outpatient clinic did not make much fuss about the rigid sig. He had a cancerous rectal lesion just 3cm above his dentate line.

 

 

Arrangements were made for a defecating proctogram (in layman’s terms, “inserting some material up your back passage and having you pass it out while some XR films are taken to understand how you defecate”) and an endo-anal ultrasound (image credit). It is a variation of endorectal ultrasound, where the balloon, which surrounds the transducer, has been replaced with a plastic cone. The shape and the dimensions of this cone facilitate its painless insertion in the anal canal while the acoustic contact is optimal with minimal deformation of the anal canal walls. With ultrasonic examination, a depth of 5 cm is visualized, especially the subepithelium, the internal and external sphincter and the puborectalis muscles.

Further management depending on the results of the investigations could range from pelvic floor muscle therapy to train the ?paradoxically contracting anal sphincters with biofeedback, or an operation to fix the bowel in the case of rectal intussusception. Perhaps Dr Parks (buckeye surgeon) or Bongi (other things amanzi) could comment on further management, especially surgical options. 

Pretty cool stuff. Totally worth skipping my Environmental Medicine tutorial for Colorectal Outpatients.