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Purpose: Prospective evaluation was undertaken of surgical findings, complications, morbidity, and hospital stay between initial nonsurgical management versus early surgical intervention of an appendicular mass., Methods: A prospective, nonrandomized study was conducted of 82 consecutive patients (mean age, 6.9 +/- 3.3 years) presenting with an appendicular mass over a 5-year period. They were categorized as group 1, 58.5% (48 of 82) nonsurgically managed and an interval appendectomy performed at a mean period of 8.6 +/- 4.6 weeks and group 2, 41.5% (34 of 82) appendectomy at presentation., Results: An appendix was identified in all 82 patients in both groups at operation. In-group 1, recurrent episodes of abdominal pain necessitated interval appendectomy in 39.6% (19 of 48) patients at a mean 4.3 +/- 0.8 versus 11.5 +/- 3.7 weeks in 60.4% (29 of 48) who underwent scheduled interval appendectomy. Periappendiceal abscesses present at interval appendectomy in group 1 was (38 of 48) 79.2% versus 100% (34 of 34) at appendectomy in group 2. Adhesions at interval appendectomy in group 1 was 81.3% (39 of 48) versus 100% (34 of 34) at appendectomy in group 2. In-group 1, superficial wound infection was observed in 0 versus 4 wound infections in group 2. Overall morbidity rate between group 1 and group 2 was statistically significant (P <.05). Total mean hospital stay in group 1 was 13.2 +/- 1.5 versus 4.8 +/- 0.4 days in group 2. Of the 48-interval appendectomy specimens, 37 of 48 (77%) appendices had a patent lumen, and 11 of 48 (23%) showed fibrosis and obliteration of appendicular lumen. There was no correlation (r = 0.22) between the histopathologic findings and the interval between abscess treatment and interval appendectomy., Conclusions: Early surgical intervention was beneficial over nonoperative management in this cohort of patients. Interval appendectomy is recommended after nonsurgical management of an appendicular mass., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

In a retrospective analysis of 161 consecutive adult patients with de novo acute myeloid leukemia undergoing induction therapy, including cytarabine, etoposide and anthracyclines, seven patients (4.3%) developed typhlitis. All presented severe neutropenia, fever, abdominal pain and tenderness within 16 days from starting chemotherapy (median 11 days; range 5-16). Three patients underwent surgery and survived, four were treated only with supportive therapy: two recovered and two died. In our experience early recognition of typhlitis and rapid recovery of the neutrophils are the most important determinants of the results of surgical and/or medical approaches. The management of typhlitis, a life-threatening condition, is controversial and depends on many factors characterizing each patient, which must be evaluated in collaboration between the surgeon and the hematologist.

Cecal volvulus is second only to sigmoid volvulus in its frequency of occurrence. Diagnostic doubt is not uncommon in cecal volvulus; nonoperative decompression is rarely achievable; and if gangrene supervenes, mortality rises appreciably. Resection is mandatory for gangrene and a grossly distended, thin-walled cecum. Cecopexy and cecostomy seem less-effective and more morbid options than resection and anastomosis for viable bowel. However, their role needs reappraisal in the light of advances in minimally invasive techniques.

A case of a periappendiceal actinomycosis, seen in an 83-year-old woman, clinically mimicking a right ovarian neoplasm penetrating the right colon, is presented. The patient's complaints led to the discovery of a right abdominal mass. Explorative laparotomy and right hemicolectomy were done. Histological examination revealed periappendiceal actinomycotic abscesses. We discuss a possible pathogenesis and the therapeutic modalities.

Objective: To evaluate the outcome of patients treated for appendiceal abscess, and managed either conservatively or surgically, and to describe the short and long-term outcome as well as incidence of interval appendicectomy in those treated conservatively., Design: Retrospective study., Setting: University hospital, Sweden., Patients: Ninety-three patients with the diagnosis of appendiceal abscess, 50 treated conservatively and 43 who were operated on, with a mean age of 46 (14-93) years. Mean (range) follow-up for patients operated on was 65 (11-135) and for those treated conservatively 66 (6-136) months., Main Outcome Measures: Course of acute disease, recorded complications, recurrence of appendicitis and incidence of interval appendicectomy during follow-up., Results: The duration of pain before admission was 4 (0.5-82) days for those operated on and 7 (2-60) days for those treated conservatively. A palpable mass was more common in the conservatively managed group. Complications were common among patients who were operated on. No interval appendicectomies were done during the second half of the study period. 4 of the patients treated conservatively (8%) had an underlying tumour diagnosed at follow-up., Conclusions: Operative management of patients with appendiceal masses seems to be associated with a high risk of postoperative complications and the risk of a more extensive surgical procedure. If possible, a conservative approach should be advocated. Because of inaccurate radiological imaging during the acute phase and the risk of an underlying malignancy, routine follow-up is necessary. Routine interval appendicectomy cannot be recommended.

Background: The management of an appendix mass in children is controversial. An experience of conservative management of appendix masses in a paediatric population over the last 19 years is reviewed., Methods: The medical records of all children who presented with an appendix mass to one of three children's hospitals between 1982 and 2000 were reviewed. In that interval 427 children with a mean age of 7.3 years (range from 2 months to 18 years) presented with an appendix mass. Sixteen children had an immediate appendicectomy. The remaining 411 children were treated conservatively by close observation and antibiotics, with intravenous fluids and nasogastric suction if required. Once the child was well enough for discharge home, elective appendicectomy was booked for 4-6 weeks later., Results: Three hundred and forty-six (84.2 per cent) of the children responded to initial conservative management and were discharged after a median stay of 6 (range 3-24) days. The children returned 4-6 weeks later for elective appendicectomy. The complication rate for elective appendicectomy was 2.3 per cent (eight patients). Those who had an uncomplicated elective appendicectomy had a median hospital stay of 3 (range 1-6) days. Histological examination demonstrated acute or subacute inflammation in 50.8 per cent of appendices removed at elective appendicectomy., Conclusion: Non-operative management of an appendix mass followed by elective appendicectomy is a safe and effective method of management.

Purpose: To evaluate percutaneous embolotherapy in the treatment of lower gastrointestinal hemorrhage., Materials and Methods: Twenty-one patients who underwent attempted percutaneous embolization for acute lower gastrointestinal bleeding between 1982 and 1997 were retrospectively studied. Hemorrhagic sites included jejunum (n = 4), ileum (n = 4), cecum (n = 4), and the remaining colon (n = 9)., Results: Embolization was not technically possible in four patients (19%). Hemostasis was achieved in 15 patients (71%) with prolonged hemostasis in 10 (48%). All embolizations distal to the cecum resulted in prolonged hemostasis. Three of four patients with jejunal bleeding had recurrent bleeding after apparent successful embolization. Only one of four cecal embolizations achieved prolonged cessation of bleeding. No ischemic complications were identified., Conclusion: Based on these data, it would appear that the risk of bowel ischemia/infarction in the lower gastrointestinal tract may not be as high as has been suggested. Two regions (cecum and proximal jejunum) were associated with poor results, suggesting these areas may not be as responsive to embolotherapy as other sites in the lower gastrointestinal tract.

Objective: To review the breed, age, gender, clinical and laboratory findings, treatment and outcome of horses with caecal disease presented to a referral centre., Design: Retrospective study of 96 cases., Procedure: The breed, age, and gender of the study population were compared with the corresponding hospital population for the same period. The means (+/- SD) for clinical and laboratory findings were recorded for each caecal disorder. Treatment was categorised as medical or surgical, and outcome was recorded., Results: Caecal diseases included impaction (40% of total cases), rupture associated with concurrent unrelated disease (13%), rupture with parturition (9%), rupture with no associated disease (5%), infarction (11%), torsion (9%), abscess or adhesion (7%), tumour (3%), and miscellaneous conditions (3%). The breed or gender of affected horses did not differ from the hospital population, although horses > 15 years were more frequently represented (P < 0.05). This age group was specifically more predisposed to caecal impaction (P < 0.05), as were Arabian, Morgan, and Appaloosa breeds (P < 0.05). In horses with caecal impaction transrectal examination was the most useful diagnostic procedure; 90% of affected horses treated medically were discharged while horses treated by typhlotomy alone, or typhlotomy and blind end ileocolostomy, had survival rates to discharge of 71% and 86%, respectively. Horses with caecal rupture associated with concurrent un-related disease showed no signs of impending rupture; all were receiving phenylbutazone, all were euthanased, and 50% had caecal ulceration at necropsy. Of horses with caecal rupture with parturition 56% had prior dystocia; in two-thirds the site of rupture was the ileocaecal junction and all were euthanased. Horses with caecal rupture with no associated disease died or were euthanased; rupture was idiopathic. Horses with caecal infarction usually had signs of abdominal pain and abdominal fluid changes consistent with peritonitis; transrectal examination was nonspecific, and typhlectomy was successful in seven of eight horses. Horses with caecal torsion had signs of severe, acute abdominal pain and typhlectomy was successful in three of five horses. Diagnosis of caecal adhesion or abscess was assisted by transrectal palpation in two of seven horses and surgical treatment was successful in two of five horses. A caecal tumour was diagnosed in three horses aged 20 years or older that presented with chronic weight loss. Other caecal diseases were uncommon., Conclusion: Caecal disease is uncommon in equids but some specific features of the history and physical findings can alert the veterinarian to the possibility of caecal involvement in horses with gastrointestinal dysfunction. Medical or surgical therapy can be effective in horses where caecal rupture has not occurred.

The incidence of appendiceal diverticulosis in pathologic specimens is 0.004-2.1%. Diverticular disease of the appendix is classified as congenital (true) or acquired (false). The clinical presentation differs from that of acute appendicitis. The average age is older, the pain is often intermittent, and while localized in the right lower abdominal quadrant, is of longer duration. No further treatment besides appendectomy is needed. Since a high rate of perforations, peritonitis and lower gastrointestinal bleeding have been reported as complications, it is recommended that in those with an incidental finding of diverticula of the appendix during surgery, that appendectomy be performed. It is not recommended to perform prophylactic appendectomy when diverticula of the appendix are found on barium enema.

Typhlitis (from Greek, "typhlon", cecum) is an inflammatory process involving the cecum and ascending colon--in neutropenic patients after chemotherapy. Early diagnosis and treatment is of great importance, since the mortality is high. In the past decade there has been an increasing number of reports, as well as impressive improvement in diagnosis, and treatment. We describe 2 patients treated in our department. We emphasize the evolving changes in the management of these patients, from early surgical intervention to conservative treatment, and the problem of prophylactic treatment for those who survive an episode of typhlitis.

The authors report a case of ileocaecal tuberculosis in a 27-year-old man with no particular risk factor for this disease. The initial diagnosis was terminal ileitis discovered at appendicectomy. The diagnosis of ileal tuberculosis was suspected in the presence of giant cell follicles on ileal biopsies, and was confirmed by the presence of AFB in the gastric intubation fluid. This patient presented known atypical pulmonary images for several years, which had never been investigated in more detail. A favourable course was observed in response to triple-agent, then double-agent antibiotic therapy. This case illustrates the fact that ileal tuberculosis still exists today, and that it does not exclusively affect "high-risk" patients.

Appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. The latter occurs rarely after open appendectomy (0.133%), but accounts for 10% of the morbidity rate. The authors reviewed 22 cases of these fistulas, treated during a 24-year period (January 1970 to December 1993). The aim of these retrospective study was to precise their clinical features, to evaluate paraclinical examinations in diagnosing these complications and to give guidelines for their treatment. Fistulas occurred at day 14 in the postoperative course. In 21 case, appendicitis was severe (suppurative, gangrenous or perforated) or appendectomy quoted as technically difficult. Location of the appendix was atypical in 7 cases. Drainage of the site was performed in 17 cases at the time of appendectomy. Diagnosis was made on the aspect of the drainage fluid in 14 cases. Diagnosis workup of the fistula associated plain abdominal radiograph and abdominal ultrasonography (n = 22). Fistulography (n = 6) confirmed the clinical diagnosis of fistula, showing the leaking in all cases. Medical treatment was attempted first in 14 cases and was successful in 11 cases with a healing time from 13 to 72 days. Surgical treatment (open drainage of the site) was attempted first in 11 cases, and was mandatory in 3 other cases because of medical treatment failure: one patient died and 5 patients underwent re-operation (right colectomy in 3 cases, bypass in 1 case and re-drainage in 1 case). Fistulography in our experience, is highly reliable and is considered to be a great assistance in management of these fistulas. Medical treatment remains the best initial treatment modality. Surgery must be contemplated in case of established external fistulas, and of purulent or faecal fistulas. Nevertheless, prognosis remains poor (50% re-operation rate).

The diverticulum of the right colon is a rare disease in Western Countries but is very common in Eastern races. The etiology is usually congenital in the lesions limited to the cecum (true diverticulum). The diagnosis is rarely made preoperatively. The most useful help is from CT and US. Because the clinical features suggest an acute appendicitis, in most cases of appendicectomized patients the intervention is made without any other investigations. At laparotomy, when the diverticulum is surely identified, a conservative treatment is recommended (diverticulectomy or invagination). If there are some doubts an ileo-colic resection is more opportune. After recovery it is useful to study the colon with an Rx clisma.

Three cases of acute ulcers of the cecum causing massive bleeding with hemodynamic impact are reported. These three cases involve young subjects (28, 31 and 51 years old). Bleeding occurs after an aggression (post-traumatic context in 2 cases, postoperative in 1 case). For these three patients, the angiographic location of arterial bleeding allows elective colic exeresis without rebleeding. From a pathogenetic point of view, the most likely hypothesis seems to be that of ischemic lesions following an aggression.

A review of 152 cases of acute intestinal intussusception shows a dramatic evolution in its management within the last 15 years. Ultrasound is the main procedure utilized, and in the hands of a trained-radiologist, it allows a safe non-surgical treatment via barium or pneumatic reduction. Surgery is now limited to the rare cases of failure of the above treatment, and to advanced or complicated cases.

The records of 22 children (sex rate boy/girl 1.75, mean age 2 7/12 year) treated for intussusception in Randers Central Hospital during the period 1975-1989 were reviewed. In 27% of the cases this diagnosis was made before admission, gastroenteritis being the most frequent differential diagnosis (18%). The mean duration of symptoms before admission was 24 hours. No significant correlation between low age and late diagnosis was found. Symptoms were vomiting (100%), abdominal colic (95%), palpable abdominal tumour (73%), diarrhoea with blood and mucus (63%) and low-grade fever (64%). Treatment by barium enema had a low success-rate (29%); the best results were recorded in children with symptoms for less than 24 hours. The mean duration of the hospital stay was 3.5 days in children treated by barium reduction and 8.5 days in children treated surgically. Early diagnosis seems to increase the success-rate of non-operative treatment. Absence of the classical triad of paroxysmal pain, abdominal mass and red currant jelly stool (found in 41% of the cases) does not exclude the possibility of intussusception.

The clinical problems facing the medical practitioner in the presence of an aspecific granuloma of the caecum were studied. Clinical and aetiopathogenic aspects are analysed as are the indications for surgery. The difficulty of diagnosis and the importance of histopathological assessment for accurate diagnosis are emphasised.

Over a 10-year period, cecocolic intussusception was diagnosed in 11 of 842 horses undergoing surgical treatment for colic at the New York State College of Veterinary Medicine. Eight horses died or were euthanatized because of poor prognosis determined at surgery or because of postoperative complications. Three horses recovered without complication after manual reduction of the intussusception and partial typhlectomy, using an intestinal stapling device.

Meconium ileus equivalent is a common complication of cystic fibrosis in the postneonatal period. Because of the added risks of surgery in these patients, conservative management is preferred. We describe here a method of monitoring the conservative treatment of this condition using CT and suggest that its application will reduce the need for potentially dangerous surgical intervention.

Three cases of intestinal malrotation presenting in adults are reported. Each illustrates various aspects of symptomatology, investigation and treatment which are discussed.

Torrential hemorrhage is rare in tuberculous affection of the bowel. The traditional method of treatment has been immediate surgical intervention aimed at bowel resection. To our knowledge, this is the first report of successful control of such life-threatening hemorrhage by transcatheter embolisation.

This study was undertaken to ascertain the role of colonoscopy and surgery in patients with pseudo-obstruction of the cecum. Twenty-eight patients developed cecal pseudo-obstruction (cecal diameter ave., 13.6 cm +/- 2.0; range, 10-18 cm) and 25 of these 28 (89%) were hospitalized for nonabdominal problems. Significant comorbidities existed in all patients. Multimodal therapy was used in most: nasogastric (NG) suction (100%), rectal tube (64%), laxatives (64%), enemas (57%), Colonoscopy (57%), and surgery (25%). Twelve of 18 patients receiving rectal tubes, 14 of 18 receiving laxatives, 11 of 16 receiving enemas, and 12 of 16 (75%) undergoing colonoscopy avoided surgery; colonoscopy cured 44 per cent of the patients, was useless in 38 per cent, was detrimental in 6 per cent, and was temporizing in 12 per cent. Seven of the 28 patients (5 cecostomy, 2 right hemicolectomy) underwent surgery. Four of the seven patients (57%) had significant surgical complications such as wound infection, incisional hernia, cecal prolapse with infarction/death, and evisceration/death. Twenty-four patients of the 28 (86%) survived the index admission; Two of four patients died of the systemic problems that brought on cecal pseudo-obstruction and two of four patients died as a result of cecostomy complications. Pseudo-obstruction occurs in older, debilitated patients generally hospitalized because of nonabdominal problems. Treatment should be aimed at correcting the underlying cause; multimodalities often temporize until underlying problems are corrected and pseudo-obstruction resolves. Colonoscopy is often curative, occasionally helpful, and rarely harmful. Surgery is curative but carries significant risks. Uncomplicated cecal dilatation to 10-18 cm is tolerated; early operative intervention should not be dictated by cecal size alone.

The authors treated for intestinal invagination 726 children: conservatively--528, surgically--198. In conservative treatment, 0.96% of the patients developed complications, there were no lethal outcomes. After the operation, the complications were noted in 19.69% of the children, who were mainly operated 2 days after onset of the disease and later.

Lyophilized and rehydrated Saccharomyces boulardii yeasts were administered to young rats previously inoculated into the cecum with Entamoeba histolytica. The numbers of diseased young rats and the severity of the infection, assessed from the appearance of the cecum and its content of mucus and amebae, were significantly reduced by the treatment. The lesions observed resembled those seen in the untreated controls, although healing was faster in the treated animals. Saccharomyces boulardii had no intrinsic amebicidal action in vitro.

Cecal volvulus is a malrotational abnormality of the intestine that causes obstruction. Diagnosis is difficult and, if delayed, the results may be intestinal ischemia, perforation, sepsis, and even death. Cecal ischemia or gangrene cannot always be determined from physical and laboratory findings. Although not always conclusive, contrast radiography may be helpful; however, laparotomy is often required for definitive diagnosis and therapy. If vascular compromise of the cecum is found, right hemicolectomy is the treatment of choice. In the absence of ischemia, decompressive tube cecostomy, simple detorsion, and cecopexy have all been recommended, but the optimal treatment is a matter of controversy.

Pseudo-obstruction of the colon is a problem of bowel motility that predominantly involves the large intestine and that can mimic the clinical and radiographic features of mechanical obstruction of the colon. It must not be confused with the much more common and less dangerous complication of post-operative ileus. Although it is most often seen in elderly patients who are confined to bed, it can occur in younger patients. Cecal dilation can develop rapidly to dangerous proportions, and recognition by thorough physical examination and early abdominal radiographs is essential if operative intervention is to be avoided. Nasogastric suction, intravenous fluids, and frequent turning of the patient are often successful if begun early, but are unlikely to be of benefit once cecal dilation approaches fourteen centimeters on plain radiographs. In these advanced cases, tube cecostomy or colostomy may be the only way to avoid necrosis of the bowel wall, perforation, and sepsis.

Pseudoobstruction of the large bowel occurs as acute distention of the colon, usually in a high risk and seriously ill patient without any mechanical obstruction. Massive distention of the colon results in perforation of the cecum and fecal peritonitis and is associated with a very high mortality rate. Laparotomy with cecostomy is the recommended surgical therapy for this problem which carries a mortality rate of over 20 percent. We have used the colonoscope to decompress the distended colon, and especially the cecum, in 10 patients with Ogilvie's syndrome, with a 90 percent success rate and no deaths or complications. The surgeon should follow the several technical guidelines mentioned herein for successful and safe performance of the procedure. These guidelines include a tap water enema of about 1,000 ml before the procedure, avoidance of the liberal use of air insufflation during the procedure, and blind insertion of the colonoscope. This procedure is not indicated in any patient with signs of peritonitis and perforation.

Idiopathic ulcer of the cecum has been considered a rare condition requiring surgical treatment because of a high incidence of complications, including bowel perforation. Cecal ulcerations are usually diagnosed at the time of surgery for presumed appendicitis or peritonitis of unknown origin. Preoperative diagnosis of cecal ulcer by barium enema has been unreliable and previous literature cites only one case diagnosed by colonoscopy. We describe four cases in which the diagnosis was made at colonoscopy. Three of our four patients were treated conservatively and did not require laparotomy. Idiopathic cecal ulcer should be considered in the differential diagnosis of lower gastrointestinal hemorrhage as well as atypical appendicitis. If the diagnosis of cecal ulcer is made by colonoscopy in a patient without evidence of an acute abdomen, conservative management may be followed by complete healing, avoiding unnecessary surgery.

A case of caecal actinomycosis presenting as a lump in the right iliac fossa is discussed. A right hemicolectomy was performed with complete cure. Clinical awareness of this condition is necessary for proper management and to differentiate it from tumour.

Neutropenic typhlitis is a frequently fatal disease most commonly reported in leukemics. The authors have treated eight such patients over the last 18 months. All patients had abdominal pain and sepsis during chemotherapy-induced neutropenia. CT scanning was diagnostic in six patients thought to have typhlitis. Two patients were not diagnosed before exploratory laparotomy. The authors have found nonoperative treatment highly effective in patients who do not manifest signs of peritonitis, perforation, gastrointestinal hemorrhage, or clinical deterioration. Recurrent typhlitis was frequent after conservative therapy (recurrence rate, 67 percent), however. One patient underwent an elective right hemicolectomy after a second episode, and typhlitis did not recur despite neutropenia associated with a subsequent course of chemotherapy. It is concluded that successful treatment of this disease hinges on: 1) early diagnosis provided by a high index of suspicion and the use of CT scanning, 2) nonoperative treatment for uncomplicated cases, and 3) elective right hemicolectomy to prevent recurrence.

This report describes seven cases of nonspecific colon ulcers and analysis of the additional 120 cases reported in the literature through 1980. The total current series is compared with the two earlier reviews. Our findings showed that nonspecific colon ulcers occur in all age groups, predominantly 40 to 60 years, with slight predilection to female sex. The man clinical manifestations include abdominal pain mimicking appendicitis (50%), lower gastrointestinal hemorrhage (33%), perforation (19%), and abdominal mass (16%). The usual location of the ulcers is the cecum and ascending colon (67%), then transverse, hepatic, and splenic flexures (18%), and descending and sigmoid colon (15%). The diagnosis is best established by colonoscopy. The nonoperative conservative management is probably indicated in the uncomplicated cases with follow-up colonoscopic studies to ensure complete healing. The etiology of this condition is still unknown.

The records of 84 cows with cecal dilatation or cecal volvulus were reviewed. The diagnosis was made by exploratory laparotomy or necropsy in 21 cows with cecal dilatation, and in 45 cows with cecal volvulus. Eighteen of the cows with cecal dilatation responded to medical management and the diagnosis was made by physical examination alone. The most useful criteria for determining that surgery was necessary were the presence of a high heart rate, apparent abdominal pain, scant or absence of feces, and the apex of the cecum rotated cranially on rectal examination. The prognosis for cattle with cecal dilatation and volvulus was good following medical therapy or decompression at surgery unless there was severe vascular compromise of the cecum. There was a 10% recurrence rate, and in these cows a partial typhlectomy was performed.

Segmental dilatation of the colon without obstruction is an unusual but recognizable entity, distinct from mechanical obstruction and paralytic ileus. Cases of ileus of the colon with cecal dilatation following delivery and gynecologic surgery are collected from the literature, and 3 recent cases are presented: 1 following cesarean section and 2 following abdominal hysterectomy. The etiology of this condition is still obscure and the clinical features are deceptive. The occurrence of this entity in obstetric and gynecologic patients is by no means a rarity and warrants a familiarity with and early recognition of this entity on the part of the physician in order to avoid serious sequelae.