MEGACOLON ASSOCIATED WITH VOLVULUS OF

TRANSVERSE COLON*
J. D. MARTIN, JR., M.D. AND CHARLES S. WARD, M.D.
ATLANTA, GEORGIA

T
HE first description of megacoIon is It was noted that stimuIation of the
usuaIIy ascribed to Hirschsprung in Iumbar sympathetic gangIia caused an
1866 and sometimes bears his name. inhibition of peristalsis with a diIatation of
However, it has been shown that this con- the coIon. Prior to this period the Iesion
dition had previousIy been recognized by was thought to be due to inflammation of
Mya and others. Finney,’ in 1908, reviewed the coIon, enIargement of the coIon, actual
the condition and described the pathoIogica1 mechanica obstructions, and congenita1
aspects but did not contribute an etioIogy apIasia of the muscuIar tissue.
of the disease. The neurogenic theory is based on definite
An agreement is now heId as to the gen- physioIogica1 reasoning. It is assumed that
era1 aspects. There is usuaIIy a uniformIy there is a reflex spasm of the internal
enIarged, diIated coIon. However, in some sphincter in the absence of a gross obstruc-
onIy segments of the coIon are involved. It tive Iesion. There is a reIaxation of the
is within and associated with the segmenta interna sphincter and a paraIysis of the
form that mechanica obstruction such as bowe1. This is tenabIe with the knowIedge
voIvuIus may occur. The diIatation is that stimuIation of the sympathetics causes
thought to be a progressive one in which a contraction of the bIadder and rectum
there eventually deveIops a Ioss of motor and a diIatation of the waIIs of these
activity of the intestine. The muscuIature viscera. It is assumed that in norma
and the remainder of the intestina1 waI1 health these structures are functioning
deveIop hypertrophic changes which occur harmoniousIy in aIIowing the fiIIing and
in spite of continued diIatation. There is emptying of the viscera. Depression of the
not infrequentIy found an associated ob- parasympathetic or a stimuIation of the
structive Iesion within the waIL of the gut sympathetic systems wouId produce a
which accounts for the acquired forms. megacoIon.
These obstructions may either be due to an Wade and RoyIe,4 in 1925, performed a
inff ammatory stricture or a long-standing Iumbar sympathectomy for megacoIon
annuIar maIignancy of the Iower Iarge which was soon foIIowed by others.5 Adson
intestine. and Bergen6 made a distinction between
Fenwick, 2 in I 900, proposed the deveIop- the types of the disease and were particu-
menta1 theory with associated diIatation IarIy interested in the contro1 of constipa-
and hypertrophy of the coIon. FoIIowing tion in the atonic forms. A biIaterai
this there were many proponents of the resection of the fn-st and second Iumbar
mechanica idea that the condition was ganglia and the spIanchnic nerves was done.
associated with atresias, vaIves in the A resection of the superior and inferior
rectum and anus, which produced spasms mesenteric gangIia and presacra1 nerves
and were foIIowed by diIatation of the were denervated onIy in the dista1 haIf of
coIon and eIongation of the mesentery. coIon. The cephaIad portion is controIIed
In 1895, LangIey and Anderson3 proposed by the postgangIionic fibers from the celiac
the first possibIe etioIogica1 factors reIative pIexus and mesenteric gangIia. It is, there-
to the present knowIedge of the disease. fore, necessary in order to remove the
* From the Department of Surgery, Emory University School of Medicine.
412
NEW SERIES VOL. LXIV, No. 3 Martin, Ward-Megacolon American Journal of Surgery 413

inhibitory infIuences of the sympathetics choIinergic substance within the nerves

compIetely to in&de a11 of these nerves. limits their usefuIness and benefits. Syn-
Adamson and Aird’ proposed experi- tropanlO was advocated because it had the
menta1 evidence performed on cats to
support the neurogenic theory. Resection
of the parasympathetics to the dista1 coIon
produced a progressive megacoIon.
Burrows8 noted that folIowing injection
of siIica into the mesentery of the cecum of
rats there deveIoped a marked enIarge-
ment of the coIon. It was assumed that this
substance came in contact with the sym-
pathetics and not the parasympathetics
and produced a stimuIation of the sym-
pathetic nerves.
The diagnosis of this condition is accom-
plished both in the acquired and congenita1
forms without much diffIcuIty. In the
congenita1 form the enIargement of the
abdomen is present from birth or soon FIG. I. Preoperative roentgenogram of the
thereafter. There is aIways considerabIe dif- abdomen which shows the megacolon.

ficuIty in having a norma bowe1 movement.

Development may be progressive, asso- action of atrophine to stop this choIinergic
ciated with marked atony of the Iarge action but did not have its toxic and drying
intestine. Roentgenograms shouId deter- effects. Prostigmin and physostigmin in-
mine the presence of atresias, vaIves, tensify the action of acetyIchoIine through
tumors, inff ammations, or other organic proIongation of its activity by preventing
disease. BIocking the sympathetics by the the cholin esterase from destroying the
administration of spina anesthesia readiIy acetyIchoIine. This is accompIished in the
demonstrates the existence of a functiona absence of disturbance of the recto-
muscuIar atony (Stabinsg). This tempo- sigmoida1 apparatus. It is concIuded that
rariIy interrupts the refIex and aIIows the seIective drug therapy has proved effective
motor activity to occur with an improve- when neurogenic imbaIance has been estab-
ment in motiIity. This, is, therefore, benefi- lished because of defective inhibitions or
cia1 preoperativeIy to determine the resuIts motor functions of the parasympathetic
before section of the lumbar sympathetics. system.
Prior to 1923 a11 therapy was directed de Takats”l12 used various drugs to
toward the IocaI condition. At first, diets, Iessen the inhibitory influence of the
enema and coIonic irrigations were tried sympathetics and to stimuIate the para-
with indifferent success. Many forms of sympathetics to increase peristaIsis and to
exercise and binders were used with very reIax the sphincters. When there is no
IittIe benefit. More recentIy, with knowl- improvement after three years of conserva-
edge of the chemica1 changes that occur in tive treatment, surgery is advised.
the synapses of the automatic nerves, acet- Since Wade in 1925 advocated sympa-
yIchoIine and simiIar drugs have been thectomy many forms of surgical therapy
advocated. Pituitrin, piIocarpine, physo- have been used. This, in part, may be due to
stigmin, prostigmin, parathomone, arsenic, Iack of knowIedge concerning the sym-
and iron have been given. pathetic and parasympathetics. TeIford
KIingmanlO states that the toxic action of and Stafford13 attempted to cIarify the
the various drugs used to remove the knowIedge of these structures. There is
411 American Journal of Surgery Martin, Ward-MegacoIon JUNE. 1944

yet considerabIe vagueness in regard to the taken. This report is concerned with a
parasympathetic arrangement. problem of this nature. With the use of
The sympathetic cord is supposed to be suIfonamides, particularly succyni1 suIfa-

FIG. 2. Resected specimen of transverse colon which con-

stituted that part of the volvuIus.

derived from segments from the second thiazole, resection of the coIon can be
thoracic to the third Iumbar. Therefore, accompIished with Iess mortaIity and
wide ranges of operative procedure are morbidity. If the megacoIon becomes
performed; perivascular sympathetic or acuteIy obstructed, operative treatment is
aortic pIexus and inferior mesenteric sym- imperative; and the protective benefit of
pathectomies, Iumbar sympathectomy, this form of chemotherapy cannot be
ram&ectomy of the medialIy directed rami, obtained at the time of operation.
and resection of the presacra1 nerves. The
use of the Iatter procedure has the disad- CASE REPORT

vantage of producing the Ioss of ejacuIatory J. B., age twenty-two, a white, male, gave a
functions. Weeks14 advocates, therefore, in history of having a marked enIargement of the
younger individuals ganghonectomy, and abdomen al1 his Iife. He had no difficulty unti1
some type of resection in oIder individuaIs. 1939, when he was admited to Emory Univer-
In the presence of gross obstructive sity HospitaI by Dr. WiIliam H. TrimbIe. On
pathoIogica1 Iesions surgica1 care must be admission there was marked abdominal pain,
directed to the IocaI probIem.15 Dilatations nauska, vomiting and distention. The treat-
ment consisted of mecoIy1 bromide, hot fomen-
of the ana sphincter, correction of fissures,
tations, colonic irrigations and supportive
remova of vaIves and atresias shouId be
measures. Under this treatment he improved
beneficia1 where there is no derangement of
but remained in the hospita1 for several weeks.
the autonomic nervous system. He did fairIy we11unti1 March 2, 1942, when he
The size and mobiIity of a megacoIon began to have cramp-like pains in the abdomen,
may aIIow a voIvuIus to occur. It is for this marked distention, nausea and vomiting. A
reason primariIy that resections of the MiIIer-Abbott tube was inserted, fluids were
coIon, either in part or totaIIy, are under- given intravenously, and some improvement
NEW SERIES VOL.LXIV, No. 3 Martin, Ward- -MegacoIon American Journal of Surgery 413

was noted. On March 22, 1942, the pains be- The convalescence from this procedure was
came more severe and distention was more uneventful. The clamp on the proximal side
marked. The same measures as had been pre- of the colon was removed on the fourth day. A

FIG. 4. Photograph of the opened descending

colon, noting the site of the intrinsic annular
inflammatory stricture.

crushing clamp was placed on the spur of the

coIostomy, which cut through, but no feces
were passed normally. The patient was aIIowed
FIG. 3. Shows barium enema in the
Iower segment of colon after colos-
to Ieave the hospital using a colostomy bag. He
tomy. The point of constriction is was readmitted to the hospita1 JuIy 13, 1942,
noted below the coIostomy. for closure of the colostomy. After readmis-
sion a barium enema reveaIed an enormous
viously used were instituted, but the patient dilatation of the sigmoid coIon. About three
became progressiveIy worse. When seen on inches beIow the site of the colostomy stoma
March 27, 1942, the pain was of the peristaltic an annuIar constriction was noted, through
type. There was marked dehydration and the which no barium could escape.
abdomen was tremendousIy distended. On JuIy 18, 1942, an eIIipticaI incision was
On March 28, 1942, under spinaI anesthesia, made around the coIostomy, which had been
a Iong upper left rectus incision was made. On temporariIy cIosed. The peritonea1 cavity was
opening the abdomen the large intestines were opened and the site of the colostomy delivered.
enormously distended. The transverse colon About two inches beIow the opening of the
was rotated near the spIenic flexure one com- coIostomy the constriction in the sigmoid was
pIete time. There was an oId adhesion which noted. Below this point the gut was thickened
extended horizontally across to the transverse and dilated. The remaining portion of the
mesocoIon. This was reIeased and the voIvuIus ascending coIon, cecum and appendix were
untwisted. Due to the extreme thickening and dilated and hypertrophied. Due to the exten-
friabiIity of the gut, a resection of this portion siveness of the disease and the obstruction, the
was done. The ascending coIon was sutured to remaining portion of the coIon was resected. A
the descending coIon and the mesocolon side-to-side anastomosis of the rectum and
mobiIized. The cIamps were pIaced on the termina1 iIeum was done. Nine Gm. of suI-
ascending coIon and the upper descending faniIamide was placed in the abdomina1 cavity,
coIon and the intervening segment was excised. which was cIosed without drainage. Convales-
The ends of the gut were brought on the ab- cence was uninterrupted. On the seventh day
domina1 wall with the cIamps in place. The postoperativeIy the patient passed a soft Iiquid
abdomen was then cIosed around the proxima1 stool and had soft bowe1 movements thereafter.
and dista1 stomata. The patient reacted very ConvaIescence continued normaIIy and the
we11 from this procedure. He was given 500 cc. patient was dismissed from the hospita1
of .8 per cent SuIfaniIamide subcutaneously and August 12, 1942.
200 cc. of .8 per cent SuIfaniIamide were given HistoIogicaI examination of the resected
subcutaneously every eight hours. colon and the site of the constriction reveaIed
416 American Journal of Surgery Martin, Ward-MegacoIon JUNE,1944

an inflammatory process. There was no evi- 2. The methods of cIass&cation and

dence of maIignancy. diagnosis of the condition is outIined.
3. The medica and surgica1 treatment is
COMMENT summarized.
4. A case is reported in which the
ConsiderabIe experience has been gained patient deveIoped an acute voIvuIus, neces-
to evaluate the present treatment of mega- sitating resection of the transverse coIon.
coIon. The progressive congenita1 neuro- 5. The etioIogica1 factor was shown to be
genie type can be improved with Iumbar an inffammatory constriction of the de-
sympathectomy in the absence of gross scending coIon. This was corrected by the
pathoIogica1 defects of the coIon. These resection of the remainder of the coIon. A
defects are not infrequentIy an accompani- successfu1 anastomosis of the termina1
ment of these Iesions and must aIways be iIeum to the termina1 coIon was performed.
determined prior to undertaking any form
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SUMMARY
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