ABSTRACT
Persistent mesocolon is a rare embryological anomaly that occurs when the primitive dorsal mesocolon fails to fuse with the posterior lateral parietal peritoneum allowing for volvulus of the cecum and colon. In malrotation of the gut, the normal rotation of the embryonic gut is arrested or disturbed during in-utero development. To our knowledge, this is the first case of isolated colon gangrene with persistent ascending mesocolon to be reported, although earlier studies have documented cases of persistent mesocolon of both ascending and descending mesocolon. This case had signs of acute intestinal obstruction and peritonitis, and preoperative imaging was suggestive of sigmoid volvulus. Explorative laparotomy revealed a hugely dilated and gangrenous ascending colon; the fixed part of the small intestine was found in the subhepatic space, and the hepatic flexure was at a level below the transpyloric plane in the midclavicular line. Findings were suggestive of isolated colon gangrene with persistent ascending mesocolon and malrotation of the gut. Right hemicolectomy with terminal ileostomy was performed and postoperative follow-up showed no complications. For a young patient with no prior co-morbidities, a volvulus of ascending mesocolon diagnosis was deemed unlikely because ascending colon is a retroperitoneal organ. The medial position of ascending mesocolon and small bowel loops to the right side was a crucial intra-operative clue for diagnosis. Such cases are difficult to diagnose pre-operatively through imaging alone, hence explorative laparotomy becomes necessary. Intra-operative findings led to performing a right hemicolectomy and ileostomy to relieve the obstruction. Therefore, among other congenital reasons for intestinal obstruction, surgeons should consider persistent mesocolon and volvulus as differential diagnoses when evaluating young patients. Emergent surgery is the only approach to address this.
ABSTRACT
Trichobezoars are concretions of retained, undigested material, mostly hair or hair-like fibers in the stomach. Rapunzel syndrome is the condition when trichobezoars extend into the small bowel, leading to various complications including bowel obstruction, and perforation due to pressure necrosis. We present an interesting case of trichobezoar in a 15-year-old female patient, who presented with abdominal pain for one month duration. The exam was notable for a firm palpable mass in the epigastric area associated with localized tenderness and guarding. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar, dilated duodenal loops, and clumping of proximal jejunal loops. Upper gastrointestinal endoscopy showed a trichobezoar extending from the oesophagogastric junction to the pylorus. Endoscopic removal of the trichobezoar was not successful. An elective laparotomy was performed, during which the stomach, duodenum, and proximal jejunum were dilated. The trichobezoar, measuring 35 cm in length, extended from the body of the stomach to the proximal jejunum and caused jejunal perforation due to pressure necrosis. The trichobezoar was removed and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunostomy was done. There were no postoperative complications. The patient followed up with psychiatry in the clinic after discharge, she was diagnosed with trichotillomania and started on fluoxetine, with improvement in her behavioral symptoms. In young female patients with nonspecific chronic abdomen pain and a palpable mass, trichobezoar should be considered in the differential diagnosis. Contrast-enhanced abdomen CT is the preferred imaging modality and removal of the trichobezoar with an appropriate endoscopic or surgical procedure is the treatment of choice. It is essential to diagnose and treat the underlying behavioral condition to prevent recurrent episodes.
