[Sigmoid colon cancer with intussusception prolapsing through the anus treated by elective laparoscopic radical surgery].

An 86-year-old man was brought in ambulance to our hospital because of sudden hematochezia and abdominal pain during defecation. Intestinal prolapse approximately 80mm from the anus and a type 1 tumor 50mm in size on the mucosal surface were detected. The intestinal prolapse was manually repositioned, and the reduction of the intussusception was confirmed by computed tomography (CT). Following colonoscopy and abdominal-enhanced CT, a sigmoid colon cancer without distant metastases was detected. Elective laparoscopic radical surgery was performed. The present study described a rare case of sigmoid colon cancer with an intussusception prolapsing through the anus and highlighted the treatment strategy by reviewing 48 previous cases. The treatment strategy employed was as follows:first, manual repositioning of the intestinal prolapse was attempted;and second, the presence of intussusception was confirmed by CT. In cases when repositioning of the intussusception was not possible, even with the use of an endoscope or contrast enema, emergency surgery was required.

Prolapsed giant sigmoid lipoma: a rare cause of adult ischaemic intussusception.

Intussusception is a rare cause of obstruction in adults and has a variable, non-specific presentation. Adult intussusception is usually associated with an underlying organic pathology, such as a benign or malignant tumour which acts as the lead point. Prolapse of the lead-point mass through the anal canal is an extremely rare presentation with very few reported cases in the literature. We describe a case of a 67-year-old man who presented with rectal prolapse of a large soft tissue mass. CT of the abdomen and barium enema revealed partial intussusception of an upper sigmoid lipomatous polyp. Examination under anaesthesia was performed and the prolapse reduced. A laparoscopic sigmoid colectomy was planned. The patient subsequently re-presented clinically unwell with a recurrent necrotic prolapsing mass. Laparotomy and sigmoid colectomy was performed and the patient recovered fully. The resected mass was a 7×4.5×4.0 cm necrotic sigmoid lipoma.

Difficulty in differentiating two cases of sigmoid stenosis by diverticulitis from cancer.

The incidence of colonic diverticulosis with or without diverticulitis has increased in the Japanese population due to the modernization of food and aging. The rate of diverticulitis in colon diverticulosis ranges from 8.1% to 9.6%. However, few cases of stenosis due to diverticulitis have been reported. These reports suggest that the differentiation between sigmoid diverticulitis and colon cancer is difficult. This report describes two cases of colon stenosis due to diverticulitis that were difficult to differentiate from colon cancer. Case 1 was a 70-year-old woman with narrowed stools for 1 month who underwent colonofiberscopy (CFS). CFS revealed a diverticulum and circumferential stenosis in the sigmoid colon. Barium enema revealed a marked, hourglass-shaped, 2-cm circumferential stenosis in the sigmoid colon. Fluorodeoxyglucose (FDG)-positron emission tomography computed tomography (CT) revealed an increased FDG uptake at the affected portion of the sigmoid colon. Sigmoid colon cancer was suspected, and laparoscopic sigmoidectomy was performed. Pathological examination demonstrated active inflammation with no evidence of malignancy. Case 2 was a 50-year-old man who presented to a nearby clinic with reduced stool output despite the urge to defecate. CFS detected severe stenosis in the sigmoid colon approximately 25 cm from the dentate line. Contrast-enhanced abdominal CT revealed multiple diverticula, wall thickening, and swelling of the lymph nodes around the peritoneal aorta and the inferior mesenteric artery. A partial sigmoidectomy was performed. Pathological examination of the resected specimen revealed no changes in the mucosal epithelial surface, but a marked infiltration of inflammatory cells was observed.

Retrospective analysis of pre- and peri-operative imaging in confirmed proximal colonic cancers--possible implications for screening flexible sigmoidoscopy.

OBJECTIVE: Faecal occult blood testing is being introduced for population screening in the United Kingdom. Flexible sigmoidoscopy may provide a viable alternative. The outcomes of the flexible sigmoidoscopy trial are awaited but the most obvious disadvantage is that only the lower third of the colon is examined and proximal pathology cannot be excluded. The relationship between proximal pathology and distal findings at flexible sigmoidoscopy is uncertain. The aim of this study was to determine the incidence of distal neoplasia in patients with confirmed proximal cancers of the colon. METHOD: All confirmed proximal colonic cancers (defined as those proximal to the splenic flexure) were identified from a database of pathology specimens at a single centre between January 1999 and August 2006. A retrospective analysis of preoperative and peri-operative mucosal imaging (contrast enema, colonoscopy and CT colonography) was conducted to identify any distal neoplasia in these patients. RESULTS: A total of 348 patients were identified. Pre- or peri-operative mucosal imaging was identified in 231 (66%) and 49 (21%) had distal neoplasia. Nineteen (8%) of these patients would have gone on to have a colonoscopy based on the UK flexible sigmoidoscopy trial protocol and 92% of the cohort would not have had a colonoscopy. CONCLUSION: Nearly 80% of confirmed proximal cancers in our series did not have any demonstrable distal neoplasia. Only 8% of our cohort would have proceeded to colonoscopy. A very significant number of proximal cancers would not have been detected.

Rectal prolapse as initial clinical manifestation of colon cancer.

Rectal prolapse as the initial clinical manifestation of colorectal cancer is uncommon. We describe the case of a 75-year-old woman who was diagnosed as having adenocarcinoma of the sigmoid colon after presenting with complete rectal prolapse. The tumor caused rectosigmoid intussusception and then it prolapsed out through the anus. She underwent rectosigmoidectomy and rectopexy. The postoperative course was uneventful. The relationship between colorectal cancer and rectal prolapse has not been clearly established. This case report describes an unusual presentation of colorectal cancer. It suggests that rectal prolapse can present as the initial symptom of colorectal cancer and may also be a presenting feature of the occult intra-abdominal pathology. The importance of adequate investigation such as colonoscopy should be emphasized in patients who develop a new onset of rectal prolapse.

Tumor diverticular que imita una enfermedad neoplásica en un paciente VIH-positivo / Diverticular tumor imitating neoplastic disease in an HIV positive patient

Introducción: A pesar de que en la era de la terapia antirretroviral de alta eficacia (HAART) la incidencia de los tumores malignos en la población VIH/SIDA está en creciente aumento y es actualmente su mayor causa de muerte, estos pacientes también pueden presentar lesiones tumorales de origen inflamatorio, micótico, parasitario, o bacteriano, que en algunos casos puede resultar muy difícil diferenciar de una neoplasia antes de la exéresis quirúrgica completa de la lesión. Objetivo: Comunicar el caso de un paciente VIH-positivo con un tumor inflamatorio de origen diverticular y discutir los posibles diagnósticos diferenciales. Paciente y método: Paciente masculino de 42 años, drogadependiente y VIH positivo (estadio AI), en tratamiento con HAART, con constipación y mucorrea de 4 años de evolución y proctorragia postevacuatoria y dolor abdominal a predominio de FII intermitentes desde hace un año. Examen fisico, laboratorio de rutina, CEA y perfil inmunológico normales. La videocolonoscopía y el colon por enema mostraron una estenosis sigmoidea infranqueable con mucosa conservada. La tomografia computada abdominopelviana evidenció engrosamiento parietal del colon sigmoides y múltiples ganglios no adenomegálicos. Resultados: Se indicó el tratamiento quirúrgico con el diagnóstico de un probable tumor extramucoso benigno, o de bajo grado de malignidad. Se encontró un tumor sigmoideo duro-elástico de 9 x 7 cm, con la serosa congestiva y adherencias laxas a la cara posterior de la vejiga, acompañado por varias adenopatías mesentéricas. Se realizó una resección anterior con carácter oncológico. Abierta la pieza se constató un gran engrosamiento parietal con mucosa edematosa. No tuvo complicaciones postoperatorias. La anatomia patológica informó una enfermedad diverticular del colon con peridiverticulitis y marcada fibrosis parietal. (TRUNCADO) (AU)...

Introduction: Despite the fact that in the highly active antiretroviral therapy (HAART) era the incidence of malignant tumors in HIV/AIDS population is increasing, and is currently the major cause of death, these patients can also present tumoral lesions of inflammatory, fungal, parasitic, or bacterial origin in some cases very difficult to differentiate from a neoplasia before complete surgical resection. Objective: Report on a HIV positive patient with an inflammatory diverticular tumor, and discuss the possible differential diagnosis. Patient and methods: Male, 42 years old, intravenous drug abuser, and HIV-positive (AI stage), on HAART, complaining of constipation and mucous discharge the last 4 years, and intermittent rectal bleeding and abdominal pain (predominantly in the right iliac fossae) the last year. Physical examination, blood tests, CEA, and immune status were normal. Colonoscopy and barium enema showed a not negotiable sigmoid stenosis with normal mucosa. The computed tomography of the abdomen and pelvis showed parietal thickening of the sigmoid colon and multiple not enlarged lymphoid nodes. Results: Surgical treatment, with the diagnosis of probable extramucosal benign or low-grade malignant tumor, was indicated. A 9 x 7 cm, rubber consistency sigmoid tumor was found. It had congestive serosa and smooth adhesions to the posterior aspect of the bladder, associated with several mesenteric nodes. An oncologíc anterior resection was carried out. The opened specimen showed a 4 cm thickening of the intestinal wall, with edematous, non tumoral mucosa. The postoperative course was uneventful. The histopathology report was diverticular colonic disease with peridiverticulitis, and marked parietal fibrosis. Conclusion: Currently, in the HIV-positive population the incidence of malignant tumors related or not to AIDS has increased, due to better management of opportunistic infections, and the best life expectancy... (TRUNCADO)

Fever of unknown origin in carcinoma of the colon.

OBJECTIVE: To report a case of fever of unknown origin in a patient with carcinoma of the colon but without gastrointestinal symptoms. CLINICAL PRESENTATION AND INTERVENTION: A 65-year-old man presented with a long-standing fever (of 38 degrees C, about two months' duration), night sweats, fatigue, malaise and anxiety. General physical examination including rectum, radiographic examinations of the chest, abdomen and bones (including ultrasonography and CT scanning) was normal. Biochemistry profile as well as other laboratory studies including blood, urine and stool cultures were normal except for erythrocyte sedimentation rate, which was 105 mm/h. A barium enema showed a rectosigmoid carcinoma. A left sigmoidal colectomy was performed. The patient recovered quickly and remained well for eight years postoperatively. CONCLUSION: This case shows that carcinoma of the colon should be included in the differential diagnosis of patients with fever of unknown origin.

A case of sigmoid lipoma presenting with intussusception.

Colonic lipomas are rare, benign tumours that rarely produce symptoms. Presented here is a case where a sigmoid lipoma acted as lead point to produce intussusception.

Adenoma velloso hipersecretante del colon sigmoides / Hypersecretive villous adenoma of the sigmoid colon

Se presenta el caso de una paciente de 41 años portadora de un adenoma velloso (AV) hipersecretante del colon sigmoides que es hospitalizada de urgencia por deshidratación y shock hipovolémico secundaria a una diarrea mucosa de un año de evolución, con falla prerrenal y acidosis metabólica, marcada hipokalemia y baja de peso de 6 kg. Luego de una vigorosa reposición hidroelectrolítica, el estudio de la diarrea reveló la presencia de un tumor velloso de 10 cm en el colon sigmoides, logrando identificarse el AV tanto al enema baritado como a la colonoscopia. Fue sometida en forma electiva a una resección anterior con buena evolución postoperatoria, cesando la diarrea en forma abrupta. El estudio histopatológico de la pieza demostró un adenoma velloso gigante sin displasia

Recurrent intussusception of the sigmoid colon caused by a transanal protruding sessile tubulo-villous malignant polyp.

We report a case of a 35 year-old woman with a large malignant sessile tubulo-villous polyp of the proximal end of a dolico-sigmoid colon causing intussusception and transanal prolapsing. The diagnosis presented some difficulties being the intussusception intermittent. The clinical feature had been initially misdiagnosed for a very large bleeding polyp (5 cm in size), protruding out of the anus with a long pedicle in the rectum. The histology of multiple bioptic samples of the lesion revealed malignancy. Conventional radiologic studies (plain x-rays, barium enema) after metal clips had been placed on the head of the polyp before it rose up the colon, led to the correct diagnosis without, nevertheless, documenting intussusception. An elective surgical resection of the dolico-sigmoid colon allowed the correct diagnosis and the curative treatment of the colonic intussusception and the malignancy.

Diffuse cavernous hemangioma of the rectosigmoid colon: imaging findings.

Diffuse cavernous hemangioma of the rectosigmoid colon (DCHR) is an uncommon disease that affects mainly young adults. As the main symptom is non-specific chronic rectal bleeding, the clinical diagnosis is difficult and often delayed. In this essay, we illustrate the imaging features of DCHR, including plain radiograph, barium enema, CT and MR study, and echoendoscopy. Pitfalls in diagnosis and the role of imaging study in the diagnosis, in the preoperative staging, and in the follow-up of the patients are defined.

[Optimizing pelvic MR diagnosis with a new gastrointestinal contrast medium]. / Optimierung pelviner MR-Diagnostik durch eine neues gastrointestinales Kontrastmittel.

AIM: Optimization of pelvic MRI by a new concept of water-equivalent bowel contrast agent. METHODS: We performed contrast enhancement of the bowel by oral application of 1000 ml of an aqueous mannitol solution one hour before pelvic MRI. In addition we performed an enema by 250 ml of water in one patient. RESULTS: Oral and rectal contrast enhancement of the bowel was tolerated without complications by our patients. Pelvic MRI was improved by a better delineation of the bowel. CONCLUSION: The concept of water-equivalent bowel enhancement is promising. It must be assessed by further studies; in particular, it must be compared with the available concepts of positive and negative bowel contrast enhancement.

The yield of flexible sigmoidoscopy and double-contrast barium enema in the diagnosis of neoplasms in the large bowel in patients with a positive Hemoccult test.

BACKGROUND AND STUDY AIMS: In an ongoing screening study of 68,306 patients for early detection of colorectal cancer, those with a positive Hemoccult II test (H2) were examined with a flexible sigmoidoscope (60 cm) (FS) and double-contrast barium enema (DCE). The aim of this study was to compare the results of FS and DCE examinations in the rectum and the sigmoid colon, and to evaluate the benefit of DCEs. PATIENTS AND METHODS: 1831 FS and DCE examinations were performed on the basis of positive H2 tests (90% acceptance rate for positive Hemoccult tests). The radiologists were unaware of the endoscopic findings. One hundred and thirty-five patients underwent total colonoscopy due to abnormalities found on FS or DCE, or both. All patients were followed-up through various Swedish cancer registers (range: 50-145 months). RESULTS: The sigmoidoscope was fully introduced in 71% of cases, and the mean time for the examination was 5 minutes. The combination of FS and DCE detected 235 adenomas of 1 cm and more, and 81 cancers which were in Dukes stages A (n = 29), B (n = 22), and C (n = 23). Twenty-one cancers (26%) and 24 adenomas (10%) identified on DCE were above the rectosigmoid area. The rate of overlooked adenomas (> or = 1.0 cm) and cancers was 22 and five for FS in the rectosigmoid area, and 55 and 15, respectively, for DCE. Adenomas found in the rectosigmoid area were only rarely associated with more proximal adenomas of 1 cm and more (1%). CONCLUSIONS: This approach-screening by FS and DCE, and selective use of colonoscopy in case of abnormalities-leads to the diagnosis of significant colonic tumors (larger adenomas and cancers) in 17.7% of cases; only two of eighty-three cancers (2.4%) were overlooked with this method.

Fibrovascular polyp of the sigmoid colon.

A case of a fibrovascular polyp of the sigmoid colon is reported. The patient tested positively for fecal occult blood on a mass survey for colorectal cancer, and underwent colonoscopic examination which revealed a pedunculated submucosal tumor in the sigmoid colon. The tumor, about 10 mm in diameter, had a short thin stalk and was removed endoscopically; the histological diagnosis was fibrovascular polyp. This extremely rare polyp is discussed, and particular attention is focused on the unusual endoscopic features and on the appropriate management.

Endoscopic localization of colon cancers.

In order to determine the accuracy of endoscopic localization of colon cancers, the endoscopic location was compared to the actual location at the time of operation in 320 patients who underwent resection of intraabdominal colon cancer between 1983 and 1988. The endoscopic location was correct in 86% of the cases. There were 44 endoscopic errors, including seven missed cancers. One-third of all endoscopic errors occurred when the tumor was in the cecum. We conclude that endoscopy is an accurate method of localizing colon cancers. However, with the advent of laparoscopic surgery and the loss of the ability to palpate the colon, the 14% of endoscopic errors take on a greater importance and additional means for localizing tumors should be pursued in selected cases.

Accuracy of double contrast barium enema and sigmoideoscopy in the detection of polyps in patients with diverticulosis.

The sensitivity between double contrast barium enema (DCBE) and sigmoideoscopy in diagnosing neoplastic lesions in the sigmoid colon was compared in patients with diverticulosis. In 52 patients with severe diverticulosis (> or = 15 diverticulas) the DCBE detected one out of 4 polyps found by sigmoideoscopy. In the remaining 54 patients with mild diverticulosis (< 15 diverticulas) DCBE detected 7 out of 10 polyps found by sigmoideoscopy. Successful bowel preparation did not influence the outcome of the DCBE. Sigmoideoscopy was incomplete in 17 (16%) of the patients; females were more difficult to examine than males (p = 0.012), as were those with a previous pelvic operation (p = 0.032). We conclude that neither DCBE nor sigmoideoscopy alone is sufficient to detect all neoplastic lesions in the sigmoid colon in patients with sigmoid diverticulosis of the colon.