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.

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.

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.

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.

Prevalence and distribution of colonic diverticula assessed with CT colonography (CTC).

OBJECTIVES: This study aimed to evaluate the prevalence of colonic diverticula according to age, gender, distribution, disease extension and symptoms with CT colonography (CTC). METHODS: The study population included 1091 consecutive patients who underwent CTC. Patients with diverticula were retrospectively stratified according to age, gender, clinical symptoms and colonic segment involvement. Extension of colonic diverticula was evaluated using a three-point quantitative scale. Using this data, a multivariate regression analysis was applied to investigate the existence of any correlation among variables. RESULTS: Colonic diverticula were observed in 561 patients (240 men, mean age 68 ± 12 years). Symptomatic uncomplicated diverticular disease (SUDD) was present in 47.4% of cases. In 25.6% of patients ≤40 years, at least one diverticulum in the colon was observed. Prevalence of right-sided diverticula in patients >60 years was 14.2% in caecum and 18.5% in ascending colon. No significant difference was found between symptomatic and asymptomatic patients regarding diverticula prevalence and extension. No correlation was present between diverticula extension and symptoms. CONCLUSION: The incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding, with their prevalence increasing with patient age. SUDD does not seem to be related to diverticula distribution and extension. KEY POINTS: Incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding. SUDD does not seem to be related to diverticula distribution and extension.

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.

A novel animal model of gastrointestinal obstruction for the development of stent.

BACKGROUND: The need for newer gastrointestinal (GI) stents has been continuously raised. Newly developed stents are generally tested for physical properties in vitro and directly introduced to clinical practice because there is no reliable animal model of GI obstruction. The aim of this study was to establish an animal model both that can represent obstruction of the GI tract and be used to develop new stents. MATERIAL AND METHODS: Surgical obstruction of the descending colon by wrapping with a nonabsorbable synthetic mesh and rubber bands was made in 17 healthy mongrel dogs. Four days later, a covered self-expanding metallic stent was placed for the obstructed segment in each dog under fluoroscopic guidance. Patency and migration of the inserted stents were evaluated clinically on a daily basis and fluoroscopically on a weekly basis. After sacrifice of the dogs, the degree and extent of residual colonic obstruction were assessed fluoroscopically. The specimen of the colonic obstructed segment was examined microscopically. RESULTS: In all 17 mongrel dogs, segmental obstruction in the descending colon was successfully created and confirmed with fluoroscopic examination using a contrast medium. The percentage of luminal narrowing ranged from 99%-100%. Stent placement was technically successful in all 17 dogs. During the follow-up period, stent migration occurred in 12 dogs and indwelling time of a stent ranged from 0-95 d (mean 29.2 ± 38.8 d). On postmortem pathologic examination, it was found that fibrosis had newly formed outside the colonic longitudinal muscle layer in all dogs. CONCLUSIONS: Our canine colonic obstruction model is the first animal model that can be feasible for developing a new design of stent and provide in vivo data on complications, particularly stent migration.

Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded?

BACKGROUND: It is routine practice to perform colonoscopy as a follow-up after an attack of diverticulitis, with the main aim to exclude any underlying malignancy. PURPOSE: This study aimed to determine whether colonoscopy is necessary and what additional information is gained from this procedure. DESIGN: This is a study of a retrospective cohort. SETTINGS AND PATIENTS: From January 2003 to June 2009, patients in whom left-sided diverticulitis was diagnosed on CT scan were matched with colonoscopy reports within 1 year from the date of CT by the use of radiology and endoscopy databases. Patients who had colonoscopy within 1 year before the CT scan were excluded. The Western Australian Cancer Registry was cross-referenced to identify patients who subsequently received diagnoses of cancers for whom colonoscopy reports were unavailable. MAIN OUTCOME MEASURES: The main outcome measures were the number of patients in whom colorectal cancers were diagnosed and other incidental findings, eg, polyps, colitis, and stricture. RESULTS: Left-sided diverticulitis was diagnosed in 1088 patients on CT scan, whereas follow-up colonoscopy reports were available for 319 patients. Eighty-two (26%) patients had incidental findings of polyps (9 polyps >1 cm), and 9 patients (2.8%) received diagnoses of colorectal cancers on colonoscopy. After cross-referencing with the cancer registry, the overall prevalence of colorectal cancer among the cohort within 1 year of CT scan was 2.1% (23 cases). The odds of a diagnosis of colorectal cancer were 6.7 times (95% CI 2.4-18.7) in patients with an abscess reported on CT, 4 times (95% CI 1.1-14.9) in patients with local perforation, and 18 times (95% CI 5.1-63.7) in patients with fistula compared with patients with uncomplicated diverticulitis. LIMITATIONS: This study was limited by the unavailability of data for private/interstate hospitals, and the relatively small number of cancer cases reduced the statistical power of the study. CONCLUSIONS: We recommend routine colonoscopy after an attack of presumed left-sided diverticulitis in patients who have not had recent colonic luminal evaluation. The rate of occult carcinoma is substantial in this patient population, in particular, when abscess, local perforation, and fistula are observed.

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.

Point-of-care sonographic detection of intestinal ascaris lumbricoides in the pediatric emergency department.

Point-of-care ultrasound use is rapidly growing in acute-care settings such as pediatric emergency departments, and new applications are continually being explored. This is especially true in the developing world where the World Health Organization estimates that 75% of people have no access to any imaging or availability of more costly imaging technology may be limited (Essential Health Technologies Strategy 2004-2007). We report a case of intestinal roundworm infection in a 3-year-old boy and describe the ultrasound findings of Ascaris lumbricoides.

[Mesenteric cyst in the descending colon: a case report]. / Chist al mezocolonului descendent.

Mesenteric cysts are rare abdominal findings. The majority are asymptomatic and if found are discovered incidentally during ultrasonography and/or CT scanning. The optimal surgical treatment requires complete excision of the cyst. We report a case of 36-year-old woman with mesenteric cyst in the descending colon. Laboratory tests indicated no abnormality. Abdominal CT revealed a cystic mass in the retropreritneal space measuring 14.0 x 8.3 x 9.4 cm, density 26-29 HU. We found a cystic mass at the mesentery of the descending colon that was removed in toto. The authors discuss the symptoms and complications, classification, and treatment of mesenteric cysts with review of literature.

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.

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.

[Frequency and epidemiology of primary epiploic appendagitis on CT in adults with abdominal pain]. / Fréquence et épidémiologie descriptive de l'appendicite épiploïque primitive par l'exploration tomodensitométrique des douleurs abdominales de l'adulte.

PURPOSE: Advances in medical imaging have improved the presurgical diagnosis of isolated epiploic appendagitis. The authors assess its relative frequency and define its main epidemiological criteria. PATIENTS AND METHODS: Study of an adult population presenting with abdominal pain and evaluated by CT over a 3 year period. Evaluation for the presence of an isolated fat density paracolic mass with hyperdense periphery. A review of the literature was performed as well. RESULTS: The frequency of epiploic appendagitis is estimated at 1.3% and its incidence at 8.8 cases/million/year. The typical patient profile is a young to middle aged male presenting with left flank and lower quadrant pain. Obesity, GI symptoms, fever, and leukocytosis are characteristically absent while elevation of the CRP is typical. CT shows the lesion along the anterolateral margin of the descending or sigmoid colon. Spontaneous resolution usually occurs within 8 days. CONCLUSION: Our results confirm epidemiological data from the literature. Knowledge of the imaging features of epiploic appendagitis will ensure conservative patients management and avoid unnecessary surgery.