Q) 75 year old man complains of obstipation for 2 days. He has taken laxatives but continues to have worsening pain and distension associated with vomiting. He underwent b/l knee replacement  2 weeks back. He was on Inj fentanyl for pain control. He is on antihypertensives and lipid lowering agents for the past 15 years.

On examination  he is afebrile, oriented, pulse rate of 100 min/, BP 120/60 and abdomen is distended with mild tenderness. There are no signs of peritonitis, bowel sounds are sluggish.

TLC is 6,500, and  potassium is 3.2 . All other blood tests are normal. X ray abdomen and CT abdomen shows dilated large bowel loops and oral contrast upto splenic flexure.

What is the probable diagnosis

a) Ischemic colitis

b) CMV colitis

c) Colonic Pseudoobstruction

d) Caecal volvulus

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Altemeier procedure

Q) True about altemeier procedure?

a) It is proctosigmoidectomy with posterior levataroplasty

b) Done in left lateral position

c) Recurrence rate can be as high as 50%

d) Altemeier was the 1st person to do it

Ans a

The Altemeier procedure, also known as perineal rectosigmoidectomy, is a surgical technique used to treat rectal prolapse.

Altemeier procedure is a perineal surgical procedure in moribund and old patients.

It combines proctosigmoidectomy with posterior  levatorplasty.

A disadvantage of the perineal proctosigmoidectomy is the increased recurrence rates of
12% to 24% compared with the abdominal approach.

It is done in prone jack- knife position It was initiated by Mikulicz in 1899 and popularized by Altemeier in 1920s

Hirchsprung’s disease

Q) False statement about Hirchsprung's disease is:

a) Male and Female have equal incidence

b) In approximately 8% of the patients entire colon is affected

c) After surgery constipation is the most common problem

d) Down syndrome can be seen in up to 3-5% patients 

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Hirchsprung's  disease is a developmental disorder characterized by absence of ganglion cells in both Auerbach's and Meissner's plexus and males are more frequently affected than females

Absence of these ganglion  cells lead to a very tight anal sphincter with resultant constipation.

This aganglionosis which is similar to Achalasia cardia  begins at anorectal junction and involves rectosigmoid in 80% and entire colon in 8% of cases.

Various surgical options like Duhamel, Swenson and Soave procedures can be done and in all constipation is a common problem

Down's syndrome is associated in 5%

Ref: Sabiston 20th edition page 1876


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