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Total colectomy 2011.2

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Posted 2/16/2011 10:50 PM (GMT 0)
How can they determine any rectal issues? What are the etsts specifically for that? I dont think I have any rectal issues, but who knows, what I consider normal could be a problem lol. Was reading through some of the past threads and read the rectal inertia stuff and that is scary too.

I know I have multipled BMS when I do get that strong urge and have the rare BM, but its not like they are small. They are each moderate to large (as I usually end up filling most of the toilet lol). Most of the time my BM's are soft as well so I squeeze them out when I get the urge, but if I dont use the osmotics and let things get dried out my BMS are large and still come out without a lot of difficulty (so they arent narrowed/being squeezed through any strictured or narrow area I dont think).

Is rectal inertia also called anismus or are they different, and would the anal rectal manometry and MRI pelvic floor defecography ruled that out?

Post Edited (boatnerj) : 2/16/2011 4:12:55 PM (GMT-7)

Posted 2/17/2011 12:13 AM (GMT 0)
Boat,

If once all that poop gets to your rectum, your rectum is able to empty even if the poop gets hard, I would say that your rectum and pelvic floor muscles are in excellent shape :-)

Anismus can also be called non-relaxation of the puborectalis muscle. This is the sling-like muscle that allows your rectum to straighten for defecation and angle for continence. Yours is obviously working just fine. On your dynamic MRI and defecogram you should see that mentioned. In numbers, at rest, the anorectal angle is approximately 90 degrees. When you poop the stuff out, the angle widens to about 150 degrees or so; then after you poop, the anorectal angle returns to 90 degrees for continence.

Look on your reports and you should see what I am talking about. Also, you were able to poop out the balloon on the balloon expulsion test as I remember it, so your rectum is golden :-)

Sometime, when you are not in need of answers for your project, I will give you the short form of my story and how I ended up as an ileostomate, then will be lucky if I stay OK in the state I'm in. As a future medical student, you will be aghast at how I ended up having to have an ileo to save my life. Scary story.

Anyway, the function of your rectum sounds just fine.

Rosemary
Posted 2/17/2011 2:48 PM (GMT 0)
The only thing that concerns me is looking at one of the xrays from my sitzmarker test, my rectum looks fairly big. Do you think this could be megarectum (look at the width of the stool in my rectal area)??

Would they have been able to see megarectum in the pelvic floor mri defecography?

http://s1142.photobucket.com/albums/n607/boatnerj/?action=view¤t=colon.jpg

Post Edited (boatnerj) : 2/17/2011 7:56:21 AM (GMT-7)

Posted 2/17/2011 4:31 PM (GMT 0)
Hi Boat,

I never can access these pics in photobucket for whatever reason. But, you are very on top of this situation. If I were you I would ask the surgeon you plan to see and your GI and your primary care doc. Remember, you want ONE surgery and ONE only. What you do has to work and you have excellent insight.

Rosemary
Posted 2/17/2011 10:10 PM (GMT 0)
Well my sensory threshold to rectal distension on my manometry was 50-55 mL, where normal was 15-20, so I obviously have a rectum that is a little bit hypo sensitive. Some of the studies I have read use stapling of the rectum to increase sensitivity (dont know the procedures name). IS that something the surgeon would be able to do during my colectomy? Simultaneously doing the sub total along with stapling the rectum to increase sensitivity I mean.
Posted 2/17/2011 11:00 PM (GMT 0)
i dont see a megarectum on these! images. the rectum is always somewhat wider than the rest of the colon apart from the caecum and sigmoid.it may be slightly wider, but i would consider this as not significant.

Post Edited (pelztier86) : 2/17/2011 4:10:57 PM (GMT-7)

Posted 2/17/2011 11:19 PM (GMT 0)
Boat,

Oh, I see what you mean about those thresholds. I think the procedure is STARR but I have no clue.

(My transit and sensitivities etc were just fine. My ending up with an ileostomy was due to irrevocable damage to my rectum, colon, and pelvic floor muscles in a surgery which on reveiw should not have been done in the first place. Long story, but having not had any of these issues, I'm not one to advise.)

BUT you should tell your surgeon that you noticed this threshold issue and that yours are not the norm and ask about the stapling procedure. If they literally use staples keep in mind these can cause inflammatory reactions and strictures (narrowings).

Just more to throw into the mix. But now is the time to think it through as you are doing. Rosemary
Posted 2/17/2011 11:26 PM (GMT 0)
Have you had a defecography and x-ray enema? these tests will better show function and anatomy, respectively than a simple plain x-ray.
Posted 2/17/2011 11:29 PM (GMT 0)
I wasnt referring to the right image, but the left. Looking at it inside my pelvic brim the diameter of the rectum area looks around 10cm and anything over 6.24 is diagnostic. Looking at it though it appears that my descending colon droops down a bit where it would normally turn into the rectum, thus it is essentially hanging next to my rectum making it look wider then it is. What do you think peltz, you seem to have an eye for this stuff.

Though you do seem to be very well studied on all sorts of GI maladies and conditions peltz, so you words are assuring. I will still have to bring it up with my colo-rectal doc though.

I see him tommorow so I will bring up the rectal sensitivity questions and size of my rectum. What spurred me to do this was a particular study that mentioned that patients with decreased rectal sensitivity must have the size of the rectal stump to be left "in situ" carefully thought about, and it seems to indicate around 6 inches of rectum to be good (though I dont know if they are including the anus in this measurement because if they are not then it would be about 8 inches total). What seems to be the amount of anus+rectum left behind to attach the SI to with good outcome? Around 6-8 inches?

http://www.springerlink.com.ezproxy.lib.vt.edu:8080/content/yk61xt7fmaw080y4/fulltext.pdf

pelztier86 said...
i dont see a megarectum on these! images. the rectum is always somewhat wider than the rest of the colon apart from the caecum and sigmoid.it may be slightly wider, but i would consider this as not significant.

Post Edited (boatnerj) : 2/17/2011 4:34:45 PM (GMT-7)

Posted 2/17/2011 11:36 PM (GMT 0)
Also peltz, what would you make about my sensory threshold to rectal distension on anorectal manometry being 50-55 mL when it says 15-20 is the norm. Is that really high, or insignificant? Gah, another question for the surgeon lol.

And would rectal compliance be the same thing as sensory threshold to rectal distension?
Posted 2/18/2011 12:14 AM (GMT 0)
yes, the threshold thing seems to be more significant to me.
basically, rectal compliance is the same as the threshold for feeling the urge to go subsequently to rectal distension. your result means that you notice this urge later than normal.
http://www.ncbi.nlm.nih.gov/pubmed/10869000

the images are not significant for megarectum to me, but its hardly to tell from these images. constipation itself can reduce/induce rectal sensivity per se, though rectal hyposensivity may be also caused by a malfunction of the rectum itself. however, if there is a concomitant rectal dysmotility/inertia or malfunction of the pelvic foor muscles you would rather have an increased muscle tone and loss of or incomplete relaxation
Posted 2/18/2011 12:21 AM (GMT 0)

Boat, you do have a couple questions for your surgeon, but your defecography was normal, you pushed the balloon out, etc. I haven't seen much that would indicate you have a rectal or pelvic floor issue. If you had a significant problem, believe me, you would know! And you wouldn't need a test or scan to tell you! Pelvic floor/rectal problems result in a defecography where you can't get anything out, failing the balloon expulsion test, having biofeedback numbers so high the machine quits registering them; things like that.

 

Sarah, how are you doing with the antibiotics now? Any difference a few days later?

 

Lizzie might get to go home tomorrow, pending some test results. Regular labs kept coming back fine, no UTI, etc. They finally started a blood culture because those fevers are still hanging around. They also did a WBC tag scan today. Pretty cool how they do this...they draw blood, spin it down to separate out WBCs and mix the WBCs with a radioactive isotope. Those marinade for a bit, and then they are infused back into the patient. They do CT scans at timed intervals to see where the glowing WBCs are accumulating, thus finding where any infection is hiding out. Pray they find what is going on! She is still in quite a bit of pain...pray this new med kicks in (it can take awhile) and keeps her comfortable.

 

My GI doc had a cancellation, so I saw him today. We're trying a different med for nausea and doing a round of Xifaxan just to see if some bacterial overgrowth is causing problems. He said all tests are pointing to rectal inertia, and he is going to call my surgeon to compare notes. I have another EGD scheduled for March; it may not be needed, but it's on the books just in case. He also said that since we know surgery is probably going to be what it comes down to, there is no reason to delay surgery and prolong the pain. I loved that he said that while my mom was sitting there! My only concern is that I think both my GI doc's and my surgeon's first choice would be a loop ileo, which I want to avoid at all costs because it guarantees more surgery. My surgeon gave me four different options, and he sounded like it was up to me...I just really hope my putting my foot down and saying I want an end ileo doesn't cause issues. I think they both just want me to be happy and they want to give me the option to reverse it, but I can't imagine that I would want to do that. The abdominal pressure has gotten so bad that it has been incorporated into my dreams, and I hardly ever remember dreams!

 

Rosemary, one of these days I'm going to send you instructions on how to post pictures on facebook so we can see your cruising adventures :) Where to next?

 

Allie

Posted 2/18/2011 1:06 AM (GMT 0)
Allie, unfortunately, I am still strugglying both with my stomach/gut and the increased nerve pain. I am terrified when thinking these nerve pain/damage can become irreversible. This sometimes happens to cancer patients receiving chemo agents which act the same way special antibiobiotcs and all antibiotics do in higher doses, particularly when you can't wean off/stop the drugs.
My bladder pain is better under control, but still more than prior to this excarbaration and I am an such a high doses. And the price I have to pay increases with each passing day.
Posted 2/18/2011 1:17 AM (GMT 0)
and allie,

I just dont get why they don't test her for auto-immune diseases with her fevers etc? does she still have joint pain?
But I get many things as far as the medical proceedings and opinion of docs are concerned.

My nerve pain is 100% drug induced, I never had an issue with that before the round on an antiniotcs that is highly known to cause neuropathy (but had no chance to quit that either - had 2 septicemias in 2 weeks last year. Its really bad now and I will get an injection of vitamine b12 and b1 which are known to be important for proper nerve function - in an attempt to alleviate the symptoms and prevent permanent damage (I wonder if there is already some permanent damage done; I am so afraid of this issue)

I am feeling like stucking in the mud of the last year. Everything repeats oneself - I am really donw right know; have not made a single step forward, but several steps backwards in the last year.

I also have/had rectal interia with spasms, as you know. So what do your surgeon say regarding the small bowel motility? Does he feel that it is aggravated or even that the rectal inertia play a major role in your delayed small bowel transit?

Post Edited (pelztier86) : 2/17/2011 6:57:01 PM (GMT-7)

Posted 2/18/2011 1:27 AM (GMT 0)
Allie,

Good news you got seen this soon. Great. Go for the end ileo if an ileo is what this comes to. Remember, the less surgery, the fewer adhesions even with lap surgery. And with a loop ileo, you would definitely be heading for more surgery to convert to an end ileo. I think Gilda, Hodaya, and Tracy all have had either retractions or peristomal hernia (Tracy) with loop ileo's. So if a permanent deal, the end ileo is the way to go.

I have an Imac Apple and have iphoto for my photo program. So when you send the instructions, PC instructions don't seem to work on my computer.

Hoping I stay OK, I have a March 12-21 trip to Bahamas planned.

Rosemary
Posted 2/18/2011 1:29 AM (GMT 0)
"The effect of painless intermittent rectal distension on the rate at which a standard meal passes through the stomach and small intestine was investigated in normal volunteers using noninvasive techniques. Rectal distension significantly retarded the entry of the head of the meal into the cecum and the emptying of the meal from the stomach, although it had no significant effect on basal gastric acid secretion. After administration of the H 2 -receptor antagonist, ranitidine, there was no significant effect of rectal distension on gastric emptying, but the delay in small bowel transit time induced by rectal distension remained. These data indicate that events occurring in the rectum may influence the function of more proximal regions of the gut."
http://www.springerlink.com/content/v7762641h1l66884/

I'd guess this effect is even more marked when rectum is directly reconnected to the small intestine and distension is NOT painless but induces non-pragating spastic contractions like in rectal inertia
Posted 2/18/2011 1:50 AM (GMT 0)
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T0P-482RNNH-4C&_user=10&_coverDate=11%2F30%2F1992&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1646163642&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=5905e3e0e286b657a4bc8197eec103bd&searchtype=a

The effect of prolonged (6 h), continuous rectal distention on mouth-to-cecum and colonic transit time was studied in four unrestrained pigs. Mouth-to-cecum transit time was determined from samples of cecal efflux using the phenol red dye technique. Colonic transit time was assessed with radiopaque markers that were injected into the cecum before each trial. Rectal distention was applied 2-Image h before feeding, during feeding, and 3-Image h after feeding. No distention was applied during control conditions. Stools were collected for 48 h after marker application. Rectal distention increased mouth-to-cecum transit time (p<0.05). Colonic transit time was also prolonged by rectal distention as shown by a significant decrease in the number of markers excreted within 36 h (p<0.05). Rectal distention for 6 h increased colonic transit time up to 30 h following distention and prolonged mouth-to-cecum transit of a high fat liquid meal.
Posted 2/18/2011 1:51 AM (GMT 0)
Allie, do you have a dilated and/or loopy rectum which I eventually had?
Posted 2/18/2011 1:52 AM (GMT 0)
i guess these studies make it understandable that everyone with rectal problems should go ahead with an ileo - especially when there is concomitant small bowel dysmotility
.
Posted 2/18/2011 11:11 PM (GMT 0)
Got the results of my last test in. It was a gastric emptying and small bowel transit scintigraphy (he said this was better then the barium swallow for looking at emptying and transit)

My gastric emptying was slightly faster then normal, and my small bowel transit was right on the edge of normal (almost slow). I had 10% colon filling of the isotope at 6 hours which is the cut off. However there is more to it. At 2.5-3 hours all of the isotope was at my terminal ileum, it just didnt start going through until after a little while. This happened with my small bowel follow through as well. It got to the very end really quick then just hung out for a while. We think this is because I have so much stool in my colon, especially in the cecal area that he thinks it is delaying the emptying. I have read about that in several studies as well. ANyone ever hear of that?

We are still going through with surgery as stuff actually seems to move through me normal, if not slightly fast up until the ileocecal region.

Post Edited (boatnerj) : 2/18/2011 4:19:25 PM (GMT-7)

Posted 2/18/2011 11:22 PM (GMT 0)
yes, thats very likely that a colon full of stools hampers emptying of the terminal ileum. it just means that probably all of your colon is affected, and not only the descending part.
Posted 2/19/2011 1:40 AM (GMT 0)
Cool. And pretty much all sub total colectomies are performed by leaving the entire rectum and attaching the SI to the top of it right? Do they eer take part of the rectum as well or is it normally all left? He said he will remove all of the colon and attach it to the top of my rectum/the recto sigmoid junction (and said rectal length can very but typically falls anywhere from 8-10 inches). Do they typically take out the recto sigmoid junction as well or is that what is usually connected to the ileum?

Post Edited (boatnerj) : 2/18/2011 6:52:00 PM (GMT-7)

Posted 2/19/2011 6:41 AM (GMT 0)
no. they dont take parts from the rectum, even if you do have a megarectum (which you dont have). they would be afraid of uncontrollable diarrhea.
Posted 2/22/2011 1:45 AM (GMT 0)

Hi Everyone,

I know I haven't been on here like I used to and it isn't because everything is all great and I've moved on.  I stayed on here and supported many people for a long time but things have been rough for quite a while and I haven't had time/energy to post.  I've got an extremely challenging class this year which takes a lot of my time and energy.  I have also been having some ongoing health issues; I've had extreme diarrhea since the middle of November.  We (my gi dr & I) have tried the BRAT diet a bland diet, imodium, lomotil,  & questran, nothing has helped.  I'm also severely anemic and needed 2 units of bloods on Thursday.  Had a scope on Friday, dr went up 3 feet and found some weak blood vessels that he cauterized.  He was going to do an endoscopy today but I've been having pain in my foot that traveled to my thigh and ended up going to ER on Sat. because I had a red streak from groin to knee that ended up being a blood clot.  They couldn't put me on blood thinners bc of the weak veins in the small intestine so they did emergency surgery and sucked the clot from then tied off the vein.  Now my whole leg is red and swollen down to my foot so they are worried about infection.  Had to cancel endoscopy and are still worried about blood count and diahhrea, so basically things are a mess but I have faith they will get BETTER!!!!!!! I know I'm in great hands and my dr will find the answer:)

Am hoping to catch up on here now that I will be home for at least the rest of the week.  Have REALLY missed EVERYONE.  I/we (my husband too) pray for everyone each night and continue to hope for good health for all of you.

 Hodaya,Lizzie, Marisa, Janie, Tracy-miss you and love you!!!!!

Rosemary, Pelzt, Allie-Thanks sooo much for all the info and support XOXOX

Boat-Aren't these the BEST people EVER!!!!!!

Will talk soon! Peace and Prayers my friends,

Judy

Posted 2/22/2011 3:45 AM (GMT 0)
Judy,

Like you I don't come her that often, but check in regularly to see how everyone is doing. I'm so sorry you're having these issues now. Just know that you're in my prayers, as are all of you who are having difficulties! Miss you, still would love to have a meeting one of these days with everyone!!

Hugs,
Janie
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