Variant Arterial Supply of the Descending Colon by the Coeliac Trunk: A Case Report.

Background and Objectives: Knowledge of arterial variations of the intestines is of great importance in visceral surgery and interventional radiology. Materials and Methods: An unusual variation in the blood supply of the descending colon was observed in a Caucasian female body donor. Results: In this case, the left colic artery that regularly derives from the inferior mesenteric artery supplying the descending colon was instead a branch of the common hepatic artery. Conclusions: Here, we describe the very rare case of an aberrant left colic artery arising from the common hepatic artery in a dissection study.

Abdominal wall actinomycotic mycetoma involving the bowel: a rare entity.

Actinomycotic mycetoma is a disease of the tropical region and usually presents as a chronic, suppurative and deforming granulomatous infection. We present an unusual case of actinomycotic mycetoma of the abdominal wall that was found to infiltrate into the bowel. A 51 year-old man presented with pain and swelling in the left flank of 2-year duration. Even after comprehensive preoperative evaluation with advanced radiological imaging, biochemistry and pathology, the diagnosis could not be arrived at. Histopathological examination of the excised specimen after the surgery guided to the diagnosis of actinomycotic mycetoma, which entirely changed the management in the postoperative period. We propose that mycetoma should be kept as a possible differential diagnosis for anterior abdominal wall swelling in the indicated clinical setting and the investigations be done keeping the same in mind. Otherwise, a lot of valuable time may be lost allowing the disease to progress further.

An unusual endoscopic finding - Acute diverticulitis / Un hallazgo endoscópico inusual - diverticulitis aguda

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Intestinal ultrasound for monitoring therapeutic response in patients with ulcerative colitis: results from the TRUST&UC study.

OBJECTIVE: Prospective evaluation of intestinal ultrasound (IUS) for disease monitoring of patients with ulcerative colitis (UC) in routine medical practice. DESIGN: TRansabdominal Ultrasonography of the bowel in Subjects with IBD To monitor disease activity with UC (TRUST&UC) was a prospective, observational study at 42 German inflammatory bowel disease-specialised centres representing different care levels. Patients with a diagnosis of a proctosigmoiditis, left-sided colitis or pancolitis currently in clinical relapse (defined as Short Clinical Colitis Activity Index ≥5) were enrolled consecutively. Disease activity and vascularisation within the affected bowel wall areas were assessed by duplex/Colour Doppler ultrasonography. RESULTS: At baseline, 88.5% (n=224) of the patients had an increased bowel wall thickness (BWT) in the descending or sigmoid colon. Even within the first 2 weeks of the study, the percentage of patients with an increased BWT in the sigmoid or descending colon decreased significantly (sigmoid colon 89.3%-38.6%; descending colon 83.0%-42.9%; p<0.001 each) and remained low at week 6 and 12 (sigmoid colon 35.4% and 32.0%; descending colon 43.4% and 37.6%; p<0.001 each). Normalisation of BWT and clinical response after 12 weeks of treatment showed a high correlation (90.5% of patients with normalised BWT had symptomatic response vs 9.5% without symptomatic response; p<0.001). CONCLUSIONS: IUS may be preferred in general practice in a point-of-care setting for monitoring the disease course and for assessing short-term treatment response. Our findings give rise to the assumption that monitoring BWT alone has the potential to predict the therapeutic response, which has to be verified in future studies.

Performance comparison between MRI and CT for local staging of sigmoid and descending colon cancer.

PURPOSE: To compare the diagnostic performance of MRI and CT for local staging of sigmoid and descending colon cancer, with pathological results as the reference standard. METHOD: This retrospective study included 116 patients with sigmoid or descending colon cancer who underwent both MRI and CT before surgery. MRI and CT images were separately reviewed by two independent and blinded radiologists to assess the following features: T-stage, presence of extramural extension (T3-4 disease), lymph node metastases (N+), and extramural vascular invasion (EMVI+). Diagnostic performance with sensitivity and specificity for detecting positive status (T3-4, N+ or EMVI+) were assessed using receiver-operating-characteristic (ROC) curve, and compared between MRI and CT. RESULTS: MRI achieved correct T-stage in 81 of 116 patients (69.8 %) while CT in 66 (56.9 %). For detecting T3-4 disease, MRI showed better performance than CT with area under the curve (AUC) of 0.888 versus 0.712 (P =  0.002) and specificity of 81.82 % versus 54.6 % (P =  0.011). No significance was found in sensitivity between two modalities (89.2 % versus 83.1 %, P =  0.302). For detecting N+ disease, performance of MRI and CT were similar (AUC, 0.670 versus 0.650, P =  0.412). For detecting EMVI+, MRI showed better performance than CT (AUC, 0.780 versus 0.575, P =  0.012) with significantly higher sensitivity (68.6 % versus 40.0 %, P =  0.031) and similar specificity (both are 84.3 %). CONCLUSIONS: MRI may offer more superior diagnostic performance than CT for detecting T3-4 disease and EMVI, thereby supporting its alternative application to CT in local staging of colon cancer.

Primary epiploic appendagitis as an unusual cause of acute abdominal pain in a middle-aged male: A case report.

RATIONALE: Primary epiploic appendagitis (PEA) is a rare cause of acute abdomen caused by spontaneous torsion or venous thrombosis of epiploic appendices, it commonly manifests with acute lower quadrant pain, thus may mimic acute diverticulitis, appendicitis, or mesenteric infarction. PATIENT CONCERNS: In this case report, we report a 44 years old man who presented with persistent sharp pain in the left lower quadrant abdomen, Laboratory tests were mostly normal, contrast enhanced computed tomography (CECT) revealed a slightly high density shadow with fat foci in the middle was presented around the local descending colon, accompanied by the adjacent peritoneal thickening. DIAGNOSES: He was diagnosed with PEA as confirmed by an abdominal contrast enhanced computed tomography (CECT) scan. INTERVENTIONS: He was followed up in the clinic without any dietary restrictions, antibiotic or analgesic drugs use. OUTCOMES: The abdominal pain gradually subsided a week later, and there were no recurrence of the symptoms during follow-up. LESSONS: In our case, the diagnosis of PEA using CECT allows the patient to avoid surgery and other invasive treatment.

Percutaneous Antegrade Colonic Stent Insertion Using a Proximal Trans-peritoneal Colopexy Technique.

INTRODUCTION: Conventionally, colonic stents are inserted with a retrograde trans-anal approach-however, stenting of right-sided or proximal transverse colon lesions may pose a challenge due to tortuosity or long distances. We report three successful cases of percutaneous antegrade colonic stenting in patients using a proximal trans-peritoneal colopexy technique. MATERIALS AND METHODS: Three patients underwent a proximal trans-peritoneal colopexy technique for antegrade colonic stent placement. The patients included three males, ages 89, 92 and 55, who were unsuitable for conventional methods. All patients had a colopexy with the aid of three gastropexy sutures performed under CT or fluoroscopic guidance and subsequent colonic access, followed by the crossing lesion and subsequent deployment of an uncovered colonic stent. A 10-Fr pigtail catheter was exchanged for the sheath, capped and left in place along with the colopexy suture anchors. RESULTS: Percutaneous antegrade colonic stent placement was technically successful in all patients with no complications. Follow-up at 10 days, a tubogram confirmed stent patency. The pigtail drain and suture anchors were subsequently removed. CONCLUSION: Antegrade colonic stenting with the use of a three point colopexy is a straightforward well-tolerated procedure and is a useful technique in a cohort of patients in whom conventional stenting has failed/is unsuitable. Additionally, we believe we have reported the first two cases involving transverse colon access for stenting.

Left-Sided Dominance of Early-Onset Colorectal Cancers: A Rationale for Screening Flexible Sigmoidoscopy in the Young.

BACKGROUND: National databases show a recent significant increase in the incidence of colorectal cancer in people younger than 50. With current recommendations to begin average-risk screening at age 50, these patients do not have the opportunity to be screened. We hypothesized that most of the cancers among the young would be left sided, which would create an opportunity for screening the young by flexible sigmoidoscopy. OBJECTIVE: This study aims to analyze the anatomic distribution of sporadic colorectal cancers in patients under the age of 50. DESIGN: This is a retrospective review of a prospectively maintained database. SETTING: This study was conducted at a single high-volume tertiary referral center. PATIENTS: Patients under the age of 50 with colorectal cancer between the years 2000 and 2016 were included. Patients with IBD, familial adenomatous polyposis, Lynch syndrome, or hereditary nonpolyposis colorectal cancer were excluded. MAIN OUTCOME MEASURES: The primary outcomes measured were tumor location and stage, demographics, and family history. RESULTS: A total of 739 patients were included. Age range at diagnosis was 18 to 49 years; median age was 44 years. Five hundred thirty patients were between the ages of 40 and 49, 167 were between the ages of 30 and 39, 40 were between the ages of 20 and 29, and 2 were under 20. Two hundred thirty-one patients (32%) had a family history of colorectal cancer. The anatomic distribution of the cancers was: 485 rectum (65%), 107 sigmoid colon (15%), 19 descending colon (3%), and 128 right colon and transverse colon (17%). Therefore, 83% of the tumors were theoretically within the range of flexible sigmoidoscopy. LIMITATIONS: Referral bias favors rectal cancer. CONCLUSION: The combination of an increasing incidence of colorectal cancer in those under 50 years of age and the predominance of left-sided cancer suggests that screening by flexible sigmoidoscopy starting at age 40 in average-risk individuals may prevent cancer by finding asymptomatic lesions. See Video Abstract at http://links.lww.com/DCR/A579.

Empyema caused by a colopleural fistula: A case report.

RATINALE: Empyema is a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. An empyema caused by colo-pleural fistula is a rare but potentially life-threatening condition. PATIENT CONCERNS: We describe a case of 42-year-old man was brought to our Emergency Department for chest pain with dyspnea and fever. DIAGNOSES: The final diagnoses are empyema caused by colo-pleural fistula and colon cancer. INTERVENTIONS: The patient underwent laparotomy surgery, during which a tumor was found in the splenic flexure of the descending colon. The tumor penetrated the colonic serosa and invaded the left side of the diaphragm. A left hemicolectomy was performed. OUTCOMES: After the operation, the patient recovered smoothly and was discharged on postoperative day 14. It's been over 3 years now, CT and colonoscopy assessments show no recurrence or metastasis. LESSONS: This case serves as a reminder to test for pathogens in patients with an unexplained empyema. If normal intestinal bacteria are detected, the empyema may be derived from intestinal disease. In addition, an abdominal examination should be performed in patients with an empyema of unknown origin.

Sclerosing mesenteritis mimicking metachronous peritoneal metastases from descending colon adenocarcinoma.

BACKGROUND: Sclerosing mesenteritis is a non-neoplastic inflammatory disease that occurs in the bowel mesentery. Distinguishing sclerosing mesenteritis from neoplasms may be difficult because of the clinical and radiographic similarities between the two disease entities. CASE PRESENTATION: We report a case of sclerosing mesenteritis mimicking peritoneal metastases of colorectal carcinoma. A 73-year-old man with stage II descending colon adenocarcinoma with poor prognostic features was found to have developed left lower abdominal quadrant masses on computed tomography (CT) 9 months after undergoing radical surgery. These masses were diagnosed as peritoneal metastases because they grew in size and displayed fluorodeoxyglucose (FDG) uptake 3 months later; thus, a laparotomy was performed. The masses, which were localized in the jejunal mesentery, were excised completely via segmental jejunal resection. Histopathological analysis confirmed that the masses were sclerosing mesenteritis. The patient showed no signs of sclerosing mesenteritis or colorectal carcinoma recurrence during follow-up. CONCLUSIONS: In patients suspected of having localized peritoneal metastasis from malignancies, any masses must be sampled by surgical excisional biopsy and subsequently examined to rule out alternative diagnoses, such as sclerosing mesenteritis.

The length of the large intestine in children determined by computed tomography scan.

Little information is available on the length of the normal large intestine and its component parts in children. This information would be useful for procedures such as colonoscopy. The aim of this study was to investigate the length of the large intestine and its component parts in New Zealand children. Archival deidentified pediatric supine abdominopelvic computed tomography (CT) scans were retrospectively analyzed. After exclusion criteria, a total of 112 scans (57 males and 55 females) were included in the study and divided into three age groups: 0-2 years (n = 33), 4-6 years (n = 40), and 9-11 years of age (n = 39). The length of the large bowel increased from a mean of 52 cm in children aged <2 years to 73 cm at 4-6 years and 95 cm at 9-11 years. In all age groups, the transverse colon was the longest segment, contributing ∼30% of the total length of the large bowel. In comparison to total large bowel length, the mean proportional length of the rectum (9-12%), sigmoid colon (23-27%), descending colon (19-22%), transverse colon (27-32%), and ascending colon (14-17%) varied little between the three age groups. There were no significant differences between males and females in all age groups. The cecum was located in the right upper quadrant in 27% of children aged 0-2 years but in the right lower quadrant in all 9-11 year olds. These data provide useful information on the length of the large intestine and its component parts in living children, which are particularly relevant to pediatric colonoscopy and surgery. Clin. Anat. 30:887-893, 2017. © 2017 Wiley Periodicals, Inc.

[Laparoscopic resection of a giant colon diverticulum : Case report and review of the literature]. / Laparoskopische Resektion eines Riesenkolondivertikels : Fallbericht und Literaturübersicht.

BACKGROUND: Giant diverticula are rare complications of diverticular disease. Current opinion regards operative therapy as the method of choice for the treatment of symptomatic giant diverticula; however, there is neither consensus about the technique nor about the necessary extent of resection. Based on a non-systematic review of the literature, an overview of giant diverticula in terms of epidemiology, pathology and classification is given. The current case is considered with respect to appropriate diagnostic procedures and possible therapeutic options. CASE PRESENTATION: An 80-year-old female patient presented to the emergency department with abdominal pain and dyspnea. A computed tomography scan showed a large gas-filled structure in the upper left abdomen adjacent to the left colon. A giant colonic diverticulum was suspected and laparoscopy was performed. Intraoperatively, the diagnosis of a giant colon diverticulum located at the splenic flexure was confirmed. An unremarkable diverticulosis only was found in the descending colon. The giant diverticulum was treated by an atypical colon wedge resection and the postoperative course was uneventful. DISCUSSION: This case report describes a laparoscopic atypical colon wedge resection as treatment of a giant colon diverticulum. Only four laparoscopic bowel resections in terms of sigmoid resections or hemicolectomy with primary anastomosis have been reported. Minimally invasive surgery can be a valuable alternative to open procedures. In the current case a laparoscopic atypical colon wedge resection was safely performed. This option might be considered as an alternative to extended resections of giant diverticula. Localization of the giant diverticulum and the simultaneous existence of diverticular disease are the main criteria for the decision between the different operative approaches.

Evaluating distribution of the left branch of the middle colic artery and the left colic artery by CT angiography and colonography to classify blood supply to the splenic flexure.

INTRODUCTION: CT angiography has gained widespread acceptance for preoperative evaluation of blood supply in patients with colorectal cancer. However, there have been few reports that pertain to the splenic flexure, for which surgery is technically difficult. We used preoperative CT angiography and CT colonography to evaluate blood supply to the splenic flexure. METHODS: We defined the splenic flexure as the junction of the distal third of the transverse colon and the proximal third of the descending colon. We reviewed 191 cases and considered the descending colon as divided into the proximal third and the distal two-thirds; we then determined which part of the descending colon the left colic artery (LCA) entered. We also considered the transverse colon as divided into the proximal two-thirds and the distal third, and evaluated which part of the transverse colon the left branch of the middle colic artery entered. RESULT: We classified blood supply to the splenic flexure into six types, described by the feeder vessels: type 1, the LCA (39.7%); type 2, the left branch of the middle colic artery (17.8%); type 3, the LCA and the left branch of the middle colic artery (9.9%); type 4, the accessory left colic artery (4.1%); type 5, the LCA and the accessory left colic artery (2.6%); and type 6, the marginal artery (25.6%). CONCLUSION: We classified blood supply to the splenic flexure into more complex types than previous reports had. Because we dissect the lymph nodes according to the type of blood supply, knowing the type before splenic flexure surgery is crucial.

Actinomycosis of the abdominal wall after cholecystectomy: transferral theory.

Abdominal actinomycosis is a rare disease caused by Gram-positive anaerobic Actinomyces bacteria. Here, we present a patient with an intrauterine contraceptive device who developed a long lasting and unexplained recurrent, painful abdominal swelling a few months after a laparoscopic cholecystectomy.

Gastric dilatation and intestinal obstruction mimicking acute coronary syndrome with dynamic electrocardiographic changes.

BACKGROUND: ST elevation myocardial infarction is a medical emergency and the electrocardiogram is a part of the mainstay in the initial diagnosis. A variety of non-cardiac conditions have been known to mimic the electrocardiographic changes seen in acute coronary syndrome. We present a patient presenting with acute partial intestinal obstruction causing gastric distension and intestinal dilatation who also had dynamic electrocardiographic changes, mimicking anterior ST elevation myocardial infarction. Only very few cases of gastric distention and intestinal dilatation leading to acute ST segment elevation in electrocardiogram are reported so far in literature. CASE PRESENTATION: A fifty-six-year-old Sri Lankan male, without any modifiable risk factors for ischemic heart disease presented with acute onset nausea, vomiting, sweating, abdominal discomfort and fullness without any chest pain. On examination, he had a pulse rate of 50 beats per minute and his blood pressure was 110/50 mmHg. His abdomen was distended and the liver dullness was not detectable. Subsequent ECG showed > 2 mm ST elevations with T inversions in chest leads V1 to V3, J point elevation in leads L 11, L 111, aVF and T inversion in leads L 1 and aVL. Cardiac biomarkers were normal and 2D echo showed normal left ventricular function without any regional wall motion abnormalities. Abdominal X-ray showed a distended stomach, dilated ascending and descending colon with absent rectal air. Electrocardiographic changes reverted back to normal with the resolution of bowel obstruction. CONCLUSION: The mechanism of ECG changes in such a case like this is yet to be elucidated, but can be postulated to happen due to change in the position of the heart in the thoracic cavity causing change in the cardiac axis. This case emphasizes the importance of a proper history and highlights the value of auxiliary investigations such as cardiac biomarkers and echocardiogram in the diagnosis of acute coronary syndrome in a confusing situation such as this. This also illustrates the importance of early recognition of other noncardiac causes like acute gastric distention as being responsible for dynamic ECG changes. This will obviate a myriad of unnecessary investigations, interventions, costly management strategies and patient anxiety.

Perivascular epithelioid cell tumor of the descending colon mimicking a gastrointestinal stromal tumor: a case report.

BACKGROUND: We present a case of perivascular epithelioid cell tumor (PEComa), which clinically and histologically mimics a gastrointestinal stromal tumor (GIST). CASE PRESENTATION: A 42-year-old woman was found to have a mass in the left flank during her annual medical checkup. Computed tomography examination revealed a submucosal tumor of the descending colon. Surgeons and radiologists suspected that the lesion was a GIST, and left hemicolectomy was performed without biopsy. Microscopic examination showed that the lesion was composed of spindle and epithelioid cells, which were immunohistochemically negative for c-kit and positive for platelet-derived growth factor receptor (PDGFR) α. Initial diagnosis of PDGFRα-positive GIST was made. However, gene analysis did not reveal mutations in PDGFRα. Additional immunohistochemistry showed that tumor cells were positive for human melanin black 45 (HMB45), melanA, and the myogenic marker calponin. A final diagnosis of PEComa was made. CONCLUSION: PEComa should be included in the differential diagnosis of PDGFRα-positive spindle cell tumors in the wall of the gastrointestinal tract.