Rectal prolapse and Ischemic colitis

  1. Anatomical defect in rectal prolapse?
    • Diastasis of the levator ani
    • Abnormally deep cul-de-sac
    • Redundant sigmoid colon
    • Patulous anal sphincter
    • Loss of rectal sacral attachment
  2. Difference between rectal prolapse and mucosal prolapse?
    The mucous membrane and submucosa of the rectum protrude outside the anus for approximately 1–4 cm. When the prolapsed mucosa is palpated between the finger and thumb, it is evident that it is composed of no more than a double layer of mucous membrane. 

    In rectal prolapse, the protrusion consists of all layers of the rectal wall and is usually associated with a weak pelvic floor. It is more than 4 cm and commonly as much as 10–15 cm in length. On palpation between the finger and thumb, the prolapse feels much thicker than a mucosal prolapse, and obviously consists of a double thickness of the entire wall of the rectum.
  3. Difference between rectal prolapse and prolapsed incarcerated internal hemorrhoids?
    • From direction of prolapsed tissue folds – rectal prolapse is concentric, hemorrhoidal tissue fold is radial
    • Prolapsed incarcerated hemorrhoids is extremely painful and can be accompanied by fever and urinary retention. Unless it is incarcerated, rectal prolapse is easily reducible and painless.
  4. Treatment of mucosal prolapse?
    • • Digital repositioning - especially useful for infants.
    • • Submucosal injections. If digital repositioning fails after 6 weeks’ trial, injections of 5 per cent phenol in almond oil are carried out under general anaesthetic.
    • • Surgery - rectum is sutured to the sacrum.
  5. Treatment of rectal prolapse?
    • Abdominal approach - Ripstein repair and anterior mesh repair, resection rectopexy
    • Perineal approach – Perineal proctosigmoidectomy and Altemeirs procedure, Anal encirclement (Thiersch)
  6. What is Ripstein Repair?
    • Also called as anterior mesh repair or Wells Rectopexy.
    • Placement of the prosthetic mesh around the mobilized rectum (upto levator ani) with attachment of mesh to presacral fascia below the sacral promentary.
    • After mobilization of rectum, a 5cm band of rectangular mesh is placed around its anterior aspect at the level of peritoneal reflection and both sides of mesh are sutured to presacral fascia approximately 1cm from the midline.
  7. Complications of Ripstein repair?
    • Large bowel obstruction
    • Erosion of mesh through the bowel
    • Ureteric injury and fibrosis
    • Small bowel obstruction
    • Rectovaginal fistula
    • Fecal impaction and constipation
  8. Improvement of fecal incontinence after mesh rectopexy?
    • Improvement in 50% cases of fecal incontinence
    • No rectal prolapse operation should be advocated as a procedure to restore incontinence.
    • Cases of prolapse of >2 yrs should be warned that incontinence may persist even after operation
  9. Steps of Frykman Goldberg procedure?
    • Also called as anterior resection and rectopexy
    • Sigmoid colon and rectum are mobilized at the level of levators – Lateral ligaments are divided, elevated from deep pelvis and sutured to presacral fascia – resection of redundant sigmoid colon – anastomosis
  10. What is Altemeire’s procedure?
    • Also called as perineal proctosigmoidectomy with anterior leveratoplasty
    • Full thickness circumferential incision 1.5 cm proximal to dentate line – peritoneum entered – redundant rectum and sigmoid colon cut – anastomosis
  11. What is Delorme’s operation?
    • Rectal mucosa is removed circumferentially from the prolapsed rectum over its length.
    • The underlying muscle is then plicated with a series of sutures, so that, when these are tied, the rectal muscle is concertinaed towards the anal canal.
    • The anal canal mucosa is then sutured circumferentially to the rectal mucosa remaining at the tip of the prolapse.
  12. What is Thiersch operation?
    • Steel wire or  a silastic or nylon suture around the anal canal. 
    • [@ DTPA - Delormes, Thiersch, Perineal, Altemeier's Procedure]
  13. Connection between SMA and IMA?
    • Marginal artery of Drummond – runs parallel to colon
    • Arc of Riolan – Connect middle colic and left colic
  14. Griffith point and Sudeck point?
    • These are the watershed areas that are susceptible to ischemia during period of low blood flow
    • Griffith point – the region of the splenic flexure where the circulations of the IMA and SMA meet.
    • Sudeck point - area in the sigmoid colon at the junction of the sigmoid and superior hemorrhoidal vessels

    [@ Griffith - Proximally, Sudeck - Distal, G and S in alphabetical order]
  15. Causes of ischemic colitis?
    • Occlusive causes - thromboembolism from the left side of the heart, particularly as a result of atrial fibrillation, after aortic aneurysm repair.
    • Nonocclusive causes – age > 65 years, cardiac arrhythmias, irritable bowel syndrome, constipation, and chronic obstructive pulmonary disease. Vasculitis, sickle cell disease.
  16. Classification of Ischemic colitis?
    • Partial-thickness ischemia – involves mucosa and submucosa, is generally transient if treated early and resolves without the need for acute surgical intervention. May result scarring and stricturing that may eventually require segmental colectomy if symptomatic, can also progress into a chronic, segmental ischemia with recurrent sepsis and colonic ulceration.
    • Full-thickness ischemia - the entire thickness of the bowel wall is compromised, colonic perforation is common, and urgent surgical intervention is necessary.
  17. What is thumbprint sign?
    Radiographic sign of large bowel wall thickening, usually caused by oedema. The normal haustra become thickened at regular intervals appearing like thumbprints projecting into the aerated lumen. Important causes are inflammatory bowel disease, infection (i.e. pseudomembranous colitis), ischaemic bowel
  18. Diagnosis of ischemic colitis?
    • CECT
    • Colonoscopy
  19. CECT findings of colonic ischemia?
    • Colon wall thickening
    • Pneumoatosis
    • Pericolonic stranding
    • Portal vein air
  20. Indications of surgery in colonic ischemia?
    • Acute Indications - Peritoneal signs, Massive bleeding, Universal fulminant colitis, with or without toxic megacolon
    • Subacute Indications - Failure of an acute segmental ischemic colitis to respond within 2 to 3 weeks,
    • with continued symptoms or a protein-losing colopathy, Apparent healing but with recurrent bouts of sepsis
    • Chronic Indications - Symptomatic colon stricture, Symptomatic segmental ischemic colitis
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Rectal prolapse and Ischemic colitis
Rectal prolapse, Ischemic colitis