Plastic surgery and syndrome of toxic dilatation of the colon. Toxic megacolon - causes, signs, treatment Introduction of rectal suppositories to children

The large intestine plays an important role in the functioning of the intestines and the entire digestive system as a whole. Diseases of this organ are widespread and account for about 3.5% of all human diseases. Moreover, the greatest incidence is detected in developed countries.
The main problem of diagnosing diseases of the colon is the obliteration of the signs and symptoms of the disease, the ambiguity of the interpretation of certain manifestations. In other words, often the severity and set of specific symptoms can vary significantly in the same disease in different individuals or be absent altogether. But, nevertheless, the general features of the disease of the colon still remain. Add to this modern diagnostic methods - and you can make reliable diagnoses.

Various colon diseases can cause the following symptoms and signs

• Unstable chair. This group of symptoms includes diarrhea and constipation. Both symptoms can be acute or chronic.
• Abdominal pain. The most common symptom that brings a person to a doctor. However, in most cases it is not an early sign of colon disease. Often, abdominal pain manifests itself already with a deeply advanced disease. The pain can be acute and chronic, pulling, stabbing, radiating to other areas.
• Flatulence. The increased formation of gases and their release indicates a violation of the intestinal microflora. Increased gas formation is also not a specific symptom of any disease; it appears over time with most chronic diseases.
• Abnormal discharge from the anus. These include mucus, blood, pus.
• Feeling of discomfort in the abdomen. A rather vague sign, but it is he who is sometimes the first symptom of a disease. It can include a feeling of heaviness, incomprehensible awkwardness, some other sensations that are difficult to describe in words.

The main signs of various diseases of the colon

Expansion and lengthening of various parts of the large intestine is a fairly common symptom complex. Lengthening and expansion of the sigmoid colon - dolichosigma and megadolichosigma - its most common variant. Megacolon occurs in different variations in almost a third of adults.
A classic example of megacolon is Hirschsprung's disease, which consists in a congenital narrowing of the rectosigmoid junction with a secondary expansion of the overlying sections of the sigmoid colon. The cause of this condition is regional agangliosis - underdevelopment or lack of innervation in this area. In some cases, the nerve ganglia, on the contrary, are overdeveloped, but the normal innervation is still impaired. Often this disease of the colon is combined with other congenital lesions of the nervous system.
Adults can have two variants of the disease:

• Idiopathic. Often not accompanied by any symptoms or signs. Only with age, persistent constipation and stool retention increase. The reason has not yet been found out.
• Acquired megacolon. This includes people with clear signs of expansion and lengthening of the colon, confirmed radiographically and endoscopically. Acquired megacolon is provoked by such diseases as abdominal adhesions, myxedema, diabetes, hypoparathyroidism, and the action of certain drugs.

Symptoms of megacolon are persistent constipation, flatulence, diffuse pain in the abdomen.
Constipation as a sign of megacolon is highly dependent on the severity of lengthening and expansion of the colon. In the case of an acquired disease, it progresses with age, since the provoking diseases also develop over the years.
The pain in this case is pulling, oppressive, directly related to the delay in defecation. The longer the constipation, the worse the pain. This symptom subsides significantly after defecation. Pain is localized more often in the left iliac region (lower left)
Flatulence is not always manifested, this symptom is most pronounced with a significant delay in stool, stagnation of feces.
The symptoms listed above are also supplemented over time by loss of appetite, weight loss, and chronic intoxication.

Previously, this disease was considered quite rare, but with the introduction of more advanced research methods, colonic diverticula are found more and more often. Currently, it is believed that hospitalization of patients with an acute abdomen is associated with diverticulitis in frequency in second place after appendicitis.
Diverticular disease is the formation of protrusions in the intestinal wall in the form of pockets of various sizes in weak places. More often, areas of attachment to the intestines of vessels become weak points.
At the initial stages of development, diverticular disease does not cause any symptoms, it is impossible to detect signs of it. However, with the development of the disease, the protrusions increase in diameter and in depth. A direct relationship between chronic constipation and diverticular disease is characteristic, since stagnation of feces and overstretching of the intestinal wall by them accelerate the development and provoke diverticulosis.
There are 2 forms of colonic diverticulosis:

• Spastic - as a result of increased tone
• Atonic - as a result of a decrease in tone and thinning of the intestinal wall

There are 3 stages of the disease:

1. No manifestations
2. with clinical manifestations
3. with complicated course

Without clinical manifestations, diverticulosis is not even a disease, but simply the presence of small, successive protrusions in the intestinal wall.
Diverticular disease with clinical manifestations is characterized by symptoms such as recurrent pain in various parts of the abdomen associated with the accumulation and stuck in the "pockets" of dense stool fragments.

Complicated diverticular disease

Diverticulitis. Inflammation of the diverticulum is characterized by such signs as acute intense abdominal pain, which is often confused with acute cholecystitis, appendicitis.
Perforation. With a significantly thinned wall of the protrusion and the presence of inflammation, the diverticulum can break into the abdominal cavity. Against this background, there is an abscess of the abdominal cavity, peritonitis, internal bleeding. All this is accompanied by severe pain in the area of ​​perforation and a systemic inflammatory response. The intestinal infiltrates which are sometimes formed at the same time can have chronic character.

Irrigoscopy shows "pockets" filled with contrast in the wall of the colon

Bleeding. Since the weak points of the intestinal wall are often areas of vascular germination, inflammatory changes, stretching can provoke a rupture of the vessel. This is accompanied by bleeding into the lumen of the colon, from insignificant to quite massive. A sign of bleeding from a diverticulum is the presence of blood in the stool, and in severe cases, the release of a large amount of blood from the rectum.
Fistulas. When a diverticulum is perforated, fistulas can form in the process of an inflammatory response - unnatural channels from one hollow organ to another. For example, a colonic fistula will lead directly from the loops of the small intestine to the large intestine.

Colitis

Colitis is a diverse group of colon diseases, which include chronic and acute, infectious and non-infectious inflammatory lesions of the wall.
All of them are manifested by general symptoms, and signs characteristic only for a particular disease.
Common symptoms of colitis include:

• Diffuse pain in the abdomen along the colon, irregular and non-localized.
• Flatulence
• Unstable chair. Diarrhea, constipation or their alternation.

This diagnosis is increasingly common in people from developed countries. Its feature is the absence of any gross changes in the mucosa or intestinal wall, histologically confirmed inflammation is also not detected. This disease can be considered a disease of exclusion - that is, it can be recognized only if no organic pathology is found.
The reason in most cases are neuropsychiatric disorders, stress, malnutrition.
Signs of this lesion of the colon are common to all colitis - abdominal discomfort, abdominal pain, unstable stools, flatulence.

Nonspecific ulcerative colitis and Crohn's disease

These two non-infectious diseases of the colon are still fraught with many mysteries, the root cause of their occurrence is not known for certain. Most likely, the pathogenesis is hidden in damage to immune mechanisms, the formation of autoantibodies (the body attacks itself)
Mostly urban residents of developed countries are affected, which suggests the nature of the diet of this population group, lifestyle. However, no risk factor has been scientifically proven.
With these diseases, foci of inflammation are formed in the mucous membrane and intestinal wall, specific ulcerative lesions. The intensity can be very variable, as well as the episodic exacerbations.
The main symptoms of these diseases are:

• Non-localized abdominal pain
• Frequent soft or loose stools during flare-ups
• flatulence, discomfort
• Blood inclusions in the stool
• During exacerbations or in severe forms - fever, weakness, intoxication.
• There are other symptoms, depending on the specific factors and the extent of the lesion.

A form of inflammation of the colon wall associated with impaired blood circulation in the arteries that feed it. More typical for older people with atherosclerosis and other vascular diseases. It can also be provoked by mesenteric artery embolism.
Symptoms and signs can range from dull abdominal pain not associated with eating (“abdominal sore throat”) to massive bloody diarrhea associated with gangrene of the intestinal wall.
The intensity of symptoms directly depends on the degree of decrease in blood flow and the volume of the involved vascular bed. The lesion may be only a small area of ​​the colon, or the entire intestine may be involved.
As a result of malnutrition, tissue starvation, their function is impaired, exhausted, and dying. In severe situations, extensive bleeding ulcers form or an entire segment of the intestine dies.

colon cancer

Taking a biopsy of a colon tumor during a colonoscopy

Unfortunately, in the early stages of its development, colon cancer does not manifest itself in any way. Only in exceptional cases, a tumor of 1-2 degrees can be manifested by streaks of blood in the stool. Signs of colon cancer become noticeable only when the tumor begins to grow into other organs or create a significant obstacle to the passage of feces. During germination, pain appears in the area of ​​​​the neoplasm, with palpation, a seal is felt. With growth into the lumen of the intestine and narrowing of its lumen by more than half, the passing intestinal contents can injure the surface of the tumor, causing bleeding, and also create a violation of the patency. This leads to increased constipation, the appearance of ribbon-shaped stools (especially in cancer of the sigmoid colon and rectosigmoid junction). Stagnation of contents provokes the alternation of loose stools and constipation.

There are also a large number of other colon diseases, each with their own signs and symptoms. You can read more about them on our website.

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HOW TO SIGNIFICANTLY REDUCE THE RISK OF CANCER?

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1. Can cancer be prevented?
The occurrence of a disease such as cancer depends on many factors. No one can be completely safe. But everyone can significantly reduce the chances of a malignant tumor.

2. How does smoking affect the development of cancer?
Absolutely, categorically ban yourself from smoking. This truth is already tired of everyone. But quitting smoking reduces the risk of developing all types of cancer. Smoking is associated with 30% of cancer deaths. In Russia, lung tumors kill more people than tumors of all other organs.
Eliminating tobacco from your life is the best prevention. Even if you smoke not a pack a day, but only half, the risk of lung cancer is already reduced by 27%, as the American Medical Association found.

3. Does excess weight affect the development of cancer?
Keep your eyes on the scales! Extra pounds will affect not only the waist. The American Institute for Cancer Research has found that obesity contributes to the development of tumors in the esophagus, kidneys, and gallbladder. The fact is that adipose tissue serves not only to store energy reserves, it also has a secretory function: fat produces proteins that affect the development of a chronic inflammatory process in the body. And oncological diseases just appear against the background of inflammation. In Russia, 26% of all cancer cases are associated with obesity.

4. Does exercise help reduce the risk of cancer?
Set aside at least half an hour a week for exercise. Sport is on the same level as proper nutrition when it comes to cancer prevention. In the US, a third of all deaths are attributed to the fact that patients did not follow any diet and did not pay attention to physical education. The American Cancer Society recommends exercising 150 minutes a week at a moderate pace or half as much but more vigorously. However, a study published in the journal Nutrition and Cancer in 2010 proves that even 30 minutes is enough to reduce the risk of breast cancer (which affects one in eight women in the world) by 35%.

5.How does alcohol affect cancer cells?
Less alcohol! Alcohol is blamed for causing tumors in the mouth, larynx, liver, rectum, and mammary glands. Ethyl alcohol breaks down in the body to acetaldehyde, which then, under the action of enzymes, turns into acetic acid. Acetaldehyde is the strongest carcinogen. Alcohol is especially harmful to women, as it stimulates the production of estrogen - hormones that affect the growth of breast tissue. Excess estrogen leads to the formation of breast tumors, which means that every extra sip of alcohol increases the risk of getting sick.

6. Which cabbage helps fight cancer?
Love broccoli. Vegetables are not only part of a healthy diet, they also help fight cancer. This is also why recommendations for healthy eating contain the rule: half of the daily diet should be vegetables and fruits. Especially useful are cruciferous vegetables, which contain glucosinolates - substances that, when processed, acquire anti-cancer properties. These vegetables include cabbage: ordinary white cabbage, Brussels sprouts and broccoli.

7. Which organ cancer is affected by red meat?
The more vegetables you eat, the less red meat you put on your plate. Studies have confirmed that people who eat more than 500 grams of red meat per week have a higher risk of developing colon cancer.

8. Which of the proposed remedies protect against skin cancer?
Stock up on sunscreen! Women aged 18-36 are particularly susceptible to melanoma, the deadliest form of skin cancer. In Russia, in just 10 years, the incidence of melanoma has increased by 26%, world statistics show an even greater increase. Both artificial tanning equipment and the sun's rays are blamed for this. The danger can be minimized with a simple tube of sunscreen. A study published in the Journal of Clinical Oncology in 2010 confirmed that people who regularly apply a special cream get melanoma half as often as those who neglect such cosmetics.
The cream should be chosen with a protection factor of SPF 15, applied even in winter and even in cloudy weather (the procedure should turn into the same habit as brushing your teeth), and also do not expose yourself to sunlight from 10 to 16 hours.

9. Do you think stress affects the development of cancer?
By itself, stress does not cause cancer, but it weakens the entire body and creates conditions for the development of this disease. Research has shown that constant worry alters the activity of the immune cells responsible for turning on the fight-and-flight mechanism. As a result, a large amount of cortisol, monocytes and neutrophils, which are responsible for inflammatory processes, constantly circulate in the blood. And as already mentioned, chronic inflammatory processes can lead to the formation of cancer cells.

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Clinic of nonspecific ulcerative colitis

Toxic dilatation of the colon

Colon perforation

colon cancer

Diagnosis and differential diagnosis of nonspecific ulcerative colitis

Complications of nonspecific ulcerative colitis are extremely diverse. Under them, one can mean both severe conditions that arose as a result of intestinal damage, and various systemic diseases that develop against the background of autoimmune aggression.

In this article, we talk about the first group of negative consequences of NUC. They deserve special attention, because. many of them pose a serious risk to life.

Dangerous consequences of ulcerative colitis

If the complication is detected at an early stage, the chances of a successful elimination of the problem will increase significantly. Each patient with a diagnosis of UC needs to know, at least in general terms, what are:

• toxic megacolon;
• perforation (perforation) of the intestine;
• massive bleeding;
• colon strictures;
• malignant degeneration of ulcers.

Development of toxic megacolon

This concept refers to toxic dilatation of the colon. Against the background of a significant violation of neuromuscular regulation, the tone of its walls may fall, because of this, pressure in the lumen increases. A similar effect sometimes gives a strong narrowing of the lower sections of the large intestine and the intake of certain drugs.

Toxic megacolon develops in 3-5% of patients with total UC (pancolitis). In about 20% of cases, the process is fatal.

This complication is manifested by a significant deterioration in the patient's condition - a temperature of 38 degrees, intense abdominal pain, signs of intoxication of the body and encephalopathy (lethargy, confusion).

Perforation in UC

Perforation means rupture of the intestinal wall with the release of the contents of the lower gastrointestinal tract - by default bacterial - into the abdominal cavity. At the same time, peritonitis, an acute inflammation of the peritoneum, begins very quickly. It is possible to save a person only under the condition of emergency and competent medical care.

Most often, perforation is the result of the toxic megacolon mentioned above.

The characteristic features of perforation are excruciating pain in the abdomen, a rapid increase in heart rate, and a noticeable tension in the muscles of the anterior abdominal wall.

Massive bleeding in ulcerative colitis

Patients with UC often find an admixture of blood in the feces. Sometimes it is also separated with tenesmus, false urge to defecate. Most often, one-time blood loss is small, but in 1% of patients it reaches a critical volume of 300 ml. per day.

The process is accompanied by symptoms posthemorrhagic anemia- lack of iron-containing elements in the plasma. Shortness of breath begins, the heartbeat quickens, the skin turns pale. The patient feels dry mouth, it darkens before his eyes. Vomiting is also possible. Depending on the severity of the condition, the patient is given iron supplements or a blood transfusion.

Attention: sometimes increased bleeding in UC indicates toxic megacolon.

Strictures in the large intestine

Stricture is narrowing of the organ, which has a tubular structure. The formation of intestinal narrowing is most likely in those people who have UC for a significant period. It is caused by thickening of the walls, outflow of the submucosal layer, fibrosis.

According to the symptoms, the phenomenon resembles intestinal obstruction. There is a severe general state of health, pain and seething in the abdomen, an obvious retention of stools and gases, asymmetric bloating.

The presence of a stricture can be reliably established through colonoscopy and irrigoscopy.

Bowel cancer - the first manifestations

colorectal cancer is a very common continuation of non-specific ulcerative colitis. The longer the "experience" of life with NIBD, the higher the risk of oncological consequences.

If, with a 5-year duration of NUC, malignant degeneration of ulcers occurs in 2-3% of cases, then with the course of the disease for more than 25 years, cancer affects the intestines of 42% of patients. Patients with pancolitis, a total intestinal lesion, are especially susceptible to this complication.

It is difficult to assume the formation of a tumor based on some external symptoms - cancer does not make itself felt immediately, and even at the later stages, its individual manifestations can be easily attributed to the overall clinical picture of UC.

To avoid a tragedy, it is necessary to regularly, at least once every three years, undergo a control endoscopic examination with a biopsy.

1. Colon perforation. One of the most severe complications of UC is observed in 19% of patients with a severe course of the disease. Colon ulcers can perforate, and multiple perforations of an overstretched and thinned colon against the background of its toxic dilatation are also possible.

Perforations occur in the free abdominal cavity and may be covered.

Main symptoms perforations colon are:

• the appearance of sudden sharp pain in the abdomen;
• the appearance of local or widespread tension in the muscles of the anterior abdominal wall;
• a sharp deterioration in the patient's condition and aggravation of symptoms of intoxication;
• detection of free gas in the abdominal cavity during plain fluoroscopy of the abdominal cavity;
• the appearance or strengthening of tachycardia;
• the presence of toxic granularity of neutrophils;
• pronounced leukocytosis.

Peritonitis may develop without perforation due to extravasation of intestinal contents through the thinned wall of the colon. To clarify the diagnosis of perforation of the colon and peritonitis, you can use laparoscopy.

2. Toxic dilatation of the colon. A very severe complication characterized by its excessive expansion. The development of this complication is facilitated by narrowing of the distal colon, involvement in the pathological process of the neuromuscular apparatus of the intestinal wall, smooth muscle cells of the intestine, loss of muscle tone, toxemia, and ulceration of the intestinal mucosa.

The development of this complication can also contribute to glucocorticoids, anticholinergics, laxatives.

The main symptoms of toxic dilatation colon are:

• increased pain in the abdomen;
• a decrease in the frequency of stools (do not consider this a sign of an improvement in the patient's condition!);
• increase in symptoms of intoxication, lethargy of patients, confusion;
• increase in body temperature up to 38-39°C;
• decrease in the tone of the anterior abdominal wall and palpation (palpate carefully!) of a sharply dilated large intestine;
• weakening or disappearance of peristaltic intestinal noise;
• identification of swollen areas of the colon on plain radiography of the abdominal cavity.

Toxic dilatation of the colon has a poor prognosis. Mortality in this complication is 28-32%.

3. Intestinal bleeding. The admixture of blood in the feces with NUC is a constant manifestation of this disease. Intestinal bleeding as a complication of NUC should be discussed when blood clots are released from the rectum. The source of bleeding are:

• vasculitis at the bottom and edges of ulcers; these vasculitis are accompanied by fibrinoid necrosis of the vessel wall;
• phlebitis of the intestinal wall with the expansion of the lumen of the veins of the mucous, submucosal and muscular membranes and ruptures of these vessels (V.K. Gusak).

The clinical picture of severe bleeding is similar to that described in "".

4. Colon strictures. This complication develops when the duration of NUC is more than 5 years. Stictures develop over a small area of ​​the intestinal wall, affecting a 2–3 cm long area. Clinically, they manifest as intestinal obstruction of varying severity. In the diagnosis of this complication, irrigoscopy and fibrocolonoscopy play an important role.

5. Inflammatory polyps. This complication of UC develops in 35-38% of patients. In the diagnosis of inflammatory polyps, irrigoscopy plays an important role, while revealing multiple filling defects of the correct form along the colon. The diagnosis is verified by colonoscopy and biopsy, followed by histological examination of biopsy specimens.

6. Colon cancer. Currently, a point of view has been formed that NUC is a precancerous disease. G. A. Grigoryeva indicates that patients with total and subtotal forms of ulcerative colitis with a disease duration of at least 7 years, as well as patients with a left-sided localization of the process in the colon and a disease duration of more than 15 years, have the highest risk of developing colon cancer. Symptoms of colon cancer are described in "" (section "Differential diagnosis"). The basis of diagnosis is colonoscopy with targeted multiple biopsy of the colon mucosa.

Laboratory and instrumental data

one. . NUC is characterized by the development of anemia of varying severity. With massive intestinal bleeding, acute posthemorrhagic anemia develops. With a constant small blood loss in the chronic course of the disease, chronic iron deficiency anemia develops. Some patients develop autoimmune hemolytic anemia due to the appearance of autoantibodies to erythrocytes. In the analysis of peripheral blood, reticulocytosis appears. The acute course and exacerbation of the chronic form of UC are characterized by the development of leukocytosis, a significant increase in ESR.

2. OAM. In severe cases of the disease and its systemic manifestations, proteinuria and microhematuria are detected.

3.: the content of total protein, albumin decreases, an increase in the content of alpha2- and y-globulins is possible, with liver damage, hyperbilirubinemia is observed, an increase in the activity of alanine aminotransferase; with the development of sclerosing cholangitis - y-glutamyl transpeptidase; with the development of iron deficiency anemia, a decrease in iron content is characteristic.

4. Coprological analysis. The degree of the inflammatory-destructive process in the mucous membrane of the large intestine is reflected in the severity of changes in the coprocytogram. NUC is characterized by the detection in feces during microscopic examination of a large number of leukocytes, erythrocytes, large clusters of cells of the intestinal epithelium. The reaction to soluble protein in feces (Triboulet reaction) is strongly positive.

Bacteriological research feces detects dysbacteriosis:

• the appearance of Proteus microorganisms, hemolyzing Escherichia, staphylococci, fungi of the genus Candida;
• the appearance in a large number of strains of Escherichia coli with weakly expressed enzymatic properties, lactone-negative enterobacteria.

Macroscopic examination of feces reveals characteristic changes - mushy or liquid nature of feces, blood, a large amount of mucus, pus.

5. Endoscopic examination (sigmoidoscopy, colonoscopy) and histological examination of biopsy specimens of the colon membrane. P. Ya. Grigoriev and A. V. Vdovenko describe endoscopic changes depending on the severity of chronic UC as follows.

Mild severity:

• diffuse hyperemia of the mucous membrane;
• lack of vascular pattern;
• erosion;
• single superficial ulcers;
• localization of the pathological process mainly in the rectum.

Moderate form:

• "granular" mucous membrane of the large intestine;
• easy contact bleeding;
• multiple non-confluent superficial ulcers of irregular shape, covered with mucus, fibrin, pus;
• localization of the pathological process mainly in the left sections of the colon.

Severe form:

• pronounced necrotizing inflammation of the mucous membrane of the colon;
• pronounced purulent exudation;
• spontaneous hemorrhages;
• microabscesses;
• pseudopolyps;
• the pathological process captures almost all parts of the colon.

Colonoscopy the study also reveals the rigidity of the intestinal wall, narrowing of the colon.

At histological the study of biopsy specimens reveals the presence of inflammatory infiltrates only within the mucosa and submucosal layer. In the early stage and the period of exacerbation of ulcerative colitis, lymphocytes predominate in the inflammatory infiltrate, with a long course - plasma cells and eosinophils. In the area of ​​the bottom of the ulcers, granulation tissue and fibrin are found.

6. X-ray examination of the colon (irrigoscopy). NUC is characterized by edema, changes in the relief (granularity) of the colon mucosa, pseudopolyposis, lack of haustration, rigidity, narrowing, shortening and thickening of the intestine; ulcerative defects. Mucosal granularity is considered an early radiological sign of UC. Due to edema, the surface of the mucous membrane becomes uneven.

In the case of toxic dilatation of the colon, irrigoscopy is not performed due to the risk of perforation. Plain abdominal radiography is recommended in this situation, and it is not uncommon to see distended segments of the colon.

Page 3 of 9

Congenital aganglionosis of the colon. Constipation and even obstruction of the colon in newborns are found in many diseases. In most cases, they are caused by congenital diseases, cerebral hemorrhage, shock, sepsis, hypoxia. Meconium leaves a healthy child during the first day. Constipation for several days leads to repeated vomiting and bloating. If a digital examination of the rectum is accompanied by a passage of meconium, then it is considered very likely that constipation and functional intestinal obstruction are associated with colonic aganglionosis.
This disease was first described in the 17th century. In 1886, the Danish clinician Hirschprang demonstrated to the Berlin Pediatric Society the results of his observations on two boys who died at the age of 7 and 11 months and who from birth had a large belly and suffered from partial intestinal obstruction. He was the first to point out the connection of chronic constipation with dilatation of the large intestine and hypertrophy of its wall. It is now established that the disease described by Hirschprang is caused by congenital aganglionosis, which in mild cases is found only in the rectum, and in more severe cases extends to part or even the entire colon. Dilatation of the intestine is always accompanied by its general elongation and thickening of the wall; the intestine increased in all sizes was designated by the term "megacolon".

The severity of the clinical picture of Hirschsprung's disease depends on the length of the aganglionic segment of the colon. In mild cases of this disease, especially in breastfed infants, normal soft feces easily pass through the short aganglionic segment. In more severe cases, constipation appears, the severity of which depends on the length of the affected segment of the intestine and on the consistency of the fecal masses that come to it. In some cases, persistent constipation begins only in the second decade of life.

Initially, they are mistaken for simple constipation, since colonostasis can be overcome with enemas. Gradually, constipation becomes more and more persistent, and the patient develops the classic signs of the disease: a large belly, vomiting. When defecation occurs spontaneously, feces are released in the form of a thin cylinder and their volume is much less than normal.
Gradually, the large intestine, located proximal to the aganglionic segment, overflows with feces, expands and is palpated in the left iliac region in the form of a thick cylinder. An increase in her peristalsis can be easily detected by auscultation or even examination. The abdomen is noticeably stretched, its skin becomes thin and shiny. In more severe cases, bowel movements occur once every few days and usually only after an enema or after taking a laxative. Sometimes there is vomiting and partial intestinal obstruction, as a rule, emaciation and anemia are found.
Finger examination reveals normal anal sphincter tone. The rectal ampulla is empty or contains small, pea-sized lumps of feces. Colonoscopy reveals normal size and normal appearance of the distal colon mucosa. The colonoscope or rectoscope passes freely into the enlarged colon. The mucosa of this department is thickened, hyperemic, usually small superficial ulcers are often found on its surface. A barium enema reveals a normal diameter of the distal colon and a significantly enlarged proximal colon. In doubtful cases, a biopsy of the intestinal wall is performed. For Hirschsprung's disease, the absence of ganglion cells in the Auerbach plexus of the distal segment of the intestine is pathognomonic.

Prolonged stagnation of stool in the colon, located proximal to its aganglionic section, is complicated over time by the formation of coprolites. The pressure of the latter on the intestinal wall leads to the formation of ulcers. These ulcers are in most cases superficial, but occasionally they are complicated by bleeding or perforation of the intestine. One of the rare complications is enterocolitis - diarrhea with fever, vomiting and even more severe distension of the abdomen.
The diagnosis of Hirschsprung's disease can be assumed in every patient suffering from constipation since childhood. This assumption should be considered justified if, simultaneously with constipation, feces in the enlarged abdomen are palpated in the patient, and the rectum is free of feces. The final diagnosis is based on biopsy data.

Achalasia of the rectum. A sharp narrowing of the lumen of the distal segment of the rectum, as well as a sharp narrowing of the terminal esophagus, is commonly referred to as "achalasia". The clinical picture of this developmental anomaly is no different from the picture of colon aganglionosis. Carriers of this anomaly suffer from persistent constipation from infancy. The accumulation of a large amount of feces in front of the narrowed segment of the rectum leads to the expansion of its proximal sections.

Simultaneous pronounced expansion of the colon is accompanied by a pronounced increase in the abdomen. Prolonged stagnation of fecal masses is often complicated by the formation of coprolites, which in turn can lead to the formation of stercoral ulcers and even perforation of the intestine and peritonitis. From time to time the disease is complicated by partial intestinal obstruction. A digital examination of the rectum reveals signs identical to those of colon aganglionosis.

The rectum sometimes turns out to be narrowed over only a distal 2-5 cm. In such cases, its narrowed section and transition zone are located in the small pelvis and cannot be detected by conventional X-ray examination. To diagnose this anomaly, the response of the internal sphincter to rectal distension or rectal sensitivity to acetylcholine and its analogues is more often examined.

The tone of the internal sphincter during stretching of the rectum in a healthy person decreases sharply, and in a patient with colon aganglionosis and rectal achalasia it increases. Parenteral injection of acetylcholine results in relaxation of the normally innervated colon. Injection of acetylcholine does not affect the height of intra-intestinal pressure in the segment of the intestine devoid of ganglion cells.

The wall of the narrowed section of the rectum in a patient with achalasia contains a normal number of ganglion cells, however, in functional terms, this section of the intestine is similar in everything to the intestine, devoid of ganglion cells. After the injection of acetylcholine, peristalsis and pressure in this area of ​​the intestine remain unchanged. The tone of the internal sphincter during stretching of the rectum in these patients increases. The clinical picture of colonic aganglionosis and rectal achalasia are identical, they can be distinguished from each other only by biopsy data.