Group 2:Leader: Hershee Izell J. AbayaMembers: Rez P. GuerreroAdrian Eleazar M. ConchinaChester CruzRichard Nixon Avena

Distal Colonogram

Meaning: It is a procedure in which water-soluble contrast is instilled into a

defunctioned colon via a stoma.

A small balloon catheter is inserted into the distal stoma, the balloon inflated, and contrast injected by hand to adequately distend the defunctioned loop and the case of anorectal atresia to demonstrate any fistula.

Prior to definitive reconstructive surgery in children with a colostomy, a distal colonogram is required to assess the length of distal colon and to identify a fistula.

•Therefore the indication for a distal colonogram is it is done prior to a definitive reconstructive surgery in children with defunctioned distal colon to assess the length of the distal colon and identify a fistula.

It is also called distal colography or loopography. Important step in the reparative management malformations of the

anorectal (ARMs) with imperforate anus, Hirschsprung’s disease and colonic atresia in children and obstructive disorders of the distal colon (colitis with stricture, carcinoma or complicated diverticulitis) in adults.

It serves to identify or confirm the type of ARM, presence or absence of fistulae, leakage from anastomoses, or patency of the distal colon.

It is also called distal colography or loopography. Important step in the reparative management malformations of the

anorectal (ARMs) with imperforate anus, Hirschsprung’s disease and colonic atresia in children and obstructive disorders of the distal colon (colitis with stricture, carcinoma or complicated diverticulitis) in adults.

It serves to identify or confirm the type of ARM, presence or absence of fistulae, leakage from anastomoses, or patency of the distal colon.

4 Sections of the Colon:

Ascending Colon- extends upward on the right side of the abdomen. Transverse Colon- extends from the ascending colon across the body

to the left side. Descending Colon- extends from the transverse colon downward on the

left side. Sigmoid Colon- named if its S-shape; extends from the descending

colon to the rectum.

ANATOMY:

THE LARGE INTESTINE

Left Colic (Splenic) FlexureTransverse MesocolonEpicloic AppendagesDescending ColonCut edge of

mesenteryTenia ColiSigmoid Colon

Right Colic (hepatic) FlexureTransverse ColonSuperior

Mesenteric Artery

HaustrumAscending

Colon IleumIleocecal

ValveCecumAppe

ndixRectumAnal canal

External anal sphincter

Indication: Bleeding Abdominal pain and constipation Anorectal atresia Necrotizing entercolitis Hirschsprung’s Disease Obstruction of Bowel Presence of Cyst Adhesions Extravasation Presence of Fistula

Imperforate Anus/ Anorectal Atresia Congenital The opening of the anus

is missed, blocked or Stenotic. The Rectum may not connect to the Colon. The Rectum may have opening to the other structures “RARE”

Signs and Symptoms:• Opening very near to the vagina.• No Meconium within first 24-48°• Swollen Belly• Stool passes out of the Vagina/ Base of the Penis• Missing Anus

Treatment:• Reconstructive Surgery Colostomy• If fistula is present, give a broad spectrum antibiotic within the first

48°.

Anorectal atresia

Necrotizing Enterocolitis

• Premature infants during 1st 2 weeks of life, when milk feeding has begun, thru NGT.

• 3 lbs baby• Portions of bowel undergo necrosis.• 2nd most morbidity in premature infant• Idiopathic• Due to weak mucosal integrity the bacteria can invade the weak wall and get

infected.• Weak wall occur due to the oragn is immature and low blood supply, this

supply goes to vital organs instead of GastroIntestinal Tract, thus making it weak.

• air in the bowel wall in Small Intestine• Long segment usually.

Signs and Symptoms:• Abdominal Distention• Blood in the Stool• Diarrhea• Feeding Intolerance• Temper Instability• Lethargy• Vomitting

• Colostomy Ileostomy on Xray:• Bubbly Appearance of the gas in the walls of intestine

Necrotizing enterocolitis

Hirschsprung's Disease (Congenital Intestinal Aganglionosis)

is a disorder of the abdomen that occurs when part or all of the Large Intestine or antecedent parts of the Gastrointestinal Tract have no nerves and therefore cannot function.

• Harold Hirschsprung• Aganglionic Megacolon• The Colon cannot relax and pass stool through the colon creating an obstruction.• can be confirmed through suction biopsy of Rectal Mucosa which is sent for

cytogenetic analysis.• Common in Boys (1/5000)

Signs and Symptoms:• Abdominal Pain • Ribbon like Stool• Poor Feeding

2 Types• Short Segment - Last Segment of Large Intestine (80% MEN) • Long Segment - Most of the Large Intestine (20% MEN & WOMEN)

Treatment:• Short Segment: Resection of the Aganglionic Segment with Anastomosis.• Long Segment: Colostomy

Hirschsprung’s Disease

Contraindication:

Patient unwilling to give consent Uncooperative patient Fulminant colitis Pregnancy

Ulcerative Colitis• Inflammatory Bowel Disease.• Recurrent in Inflammation of the Mucosal Layer of the Large Bowel.• Non related to an Intestinal Infection/ NSAIDS• it is in the Rectum and can extent proximally in a continuos fashion.

Distal colitis, potentially treatable with enemas:

• Proctitis: Involvement limited to the rectum.

• Proctosigmoiditis: Involvement of the rectosigmoid colon, the portion of the colon adjacent to the rectum.

• Left-sided colitis: Involvement of the descending colon, which runs along the patient's left side, up to the splenic flexure and the beginning of the transverse colon.

Extensive colitis, inflammation extending beyond the reach of enemas:

• Pancolitis: Involvement of the entire colon, extending from the rectum to the cecum, beyond which the small intestine begins.

• Inflammation is Characterized by Ulceration.

• Idiopathic

Ulcerative Colitis

Risk Factor:

• Genetics

• Ethnicity

• Cigarette Smoking

• Diet

• Isotrerinoin

Signs and Symptoms:

Rectal Bleeding (Bright Red) Tenesmus (urgent desire to evacuate stools but with little passage of it) Lower Abdominal Pain < 4x / day bowels>

It can lead to Fulminant Colitis

Signs and Symptoms:

10x / day bowels Continuous Bleeding Abdominal Tenderness/ Distention Anemia

Medication: Mesalamine (lialda)

Amino Salicylates

Relieve inflammation of intestines and help prevent recurrence.

Steroid may be added if symptoms continues. It help relieve inflammation

DexamethasoneAn anti inflammatory agent.

Colovesical Fistula/ Rectovesical Fistula/ Vaginovesical Fistula

Presence of Communication between the Colon and Bladder.

Most Common Cause Diverticulitis

Signs and Symptoms: Fecalisis Recurrent UTI Passage of Urine in the Rectum Pneumaturia

Location: At the posterior part of the Bladder.

Medication: Resection of the Fistula and AB Segment of the Bowel is required for

Anus.

Patient Preparation:

Fasting of at least 8 hours No bowel preparation The patient will be asked to change clothes and wear a patient gown

Prior to Procedure:

The physician will explain the procedure to the patient and off the patient the opportunity to ask questions that are related to the procedure.

The patient will be asked to sign a consent form that gives permission to do the procedure. The patient should read it carefully and ask questions if something is unclear.

Notify the physician if there is any suspected pregnancy.

Notify the physician if there is hypersensitivity to any medication, latex, tape and anesthetic agents (local and general).

Notify the physician of all medications (prescribed and over the counter) and herbal supplements that the patient has taken or is taking. The physician will temporarily withhold such medications prior to the procedure.

Based on the patients condition, the physician might request other specific preparation.

Materials:

Foley cathether

Size of FC per age: - 1 day old to 1 month = f10 - 2 months to 6 months = f14 - 7 months to 2 years old= f16 - 3 years to above = f18

5cc syringe 60 cc syringe (asepto syringe) Gloves KY jelly Plaster (leukoplast) 1” -OS (operating sponge) Cotton balls Sterile Kidney Basin Aspirating needle G18 CM non ionic

Foley catheter

Aspirating needle g18

Lubricating gel

Plaster (leukoplast)

1”

Sterile gauze swab

Cotton balls

Contrast Media

Barium Sulphate Water Soluble

Procedure:

A marker is placed over the anal dimple or the expected position of the anus. Another marker is placed at the point where urine or fecal material is seen to be discharging. Ask the doctor to check the image

before proceeding to the procedure.

Sterile glovesasepto syringe

5cc syringe

Barium sulfate

Water soluble

Ask the doctor when to start the procedure

The catheter through the stoma leading to the distal colon, its balloon is inflated and it is pulled back during injection of the contrast to avoid any spillage.

The distal blind end of the colon gets filled progressively and pressure is maintained till the contrast fills the fistulous tract.

Water-soluble contrast is used. In administering the Cm, patient will be asked to change position. Images are obtained under fluoroscopy.

Right Lateral

•Best demonstrate the “up” medial side of the ascending colon and the lateral side of the descending colon, when the colon is inflated with air due to gravity. •CR at the level of the L4 or at the level of the iliac crest 

PA or AP Projection

Structures Shown: The transverse colon should be primarily barium-filled on the PA and air-filled on the AP with a double-contrast study. Entire large intestine, including the left colic flexure, should be visible. 

Left Lateral

•Best demonstrate the “up”, medial side of the descending colon and the lateral side of the ascending colon, when the colon is inflated with air.  •CR is at the level of the L4 or at the level of the iliac crest 

Lateral AP

AP AP

lateral lateral