Clinical Case Summary

Isolated cecal necrosis is a rare variant of ischemic colitis, more commonly seen in elderly patients with comorbidities. It is an uncommon cause of an acute abdomen and is a differential diagnosis to consider in patients with right lower quadrant abdominal pain.
Case report: A 51-year-old man, with a history of type 1 diabetes mellitus and end-stage chronic kidney disease, on a regular hemodialysis program, attended the emergency department for abdominal pain in the lower right quadrant and bloodless diarrhea, with a 12-hour evolution. On physical examination, he had a painful abdomen on palpation of the right quadrants. The analyses showed leukocytosis 12200/ul and C-reactive protein 190 mg/L. Abdominal computed tomography (CT) scan showed diffuse parietal thickening of the ascending colon measuring approximately 10 cm in length, associated with densification of the surrounding mesenteric fat and small locoregional ganglia, favoring the hypothesis of inflammatory pathology. Given the diagnostic doubt raised by the imaging examination and its impact on the therapy to be instituted, it was decided to perform a colonoscopy, which revealed the cecum mucosa and ileocecal valve with a black color, with superficial ulceration of the proximal limit with an abrupt transition to normal colic mucosa. Biopsies of the cecum were taken and histology confirmed the diagnosis of severe ischemic colitis (necrosis). Considering that CT did not reveal complications and the patient's surgical risk, conservative therapy was decided, with fluid therapy and antibiotic, and the patient had a favorable evolution.

References

Çakar E, Ersöz F, Bag M, Bayrak S, Çolak Ş, Bektaş H, Güneş ME, Çakar E. Isolated cecal necrosis: our surgical experience and a review of the literature. Ulus Cerrahi Derg. 2014 Dec 1;30(4):214-8.

Disclosure

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Clinical Case Summary

References

Case Jr R, et al. (BMJ Case Rep 2019;12:e226355. doi:10.1136/bcr-2018-226355)
Anat Yerushalmy-Feler et al. , Diagnosis and Management of CMV Colitis doi.org/10.1007/s11908-019-0664-y

Disclosure

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Clinical Case Summary

We describe a case of an 80-year-old woman with a history of bronchiectasis, nasal polyps, and chronic sinusitis who presented to the emergency department with diarrhea(>10 bowel movements/day),abdominal pain and estimated weight loss of 6 kg over one month. She was previously treated with antiparasitics without clinical improvement. Laboratory tests showed peripheral eosinophilia(10,400/mm3 eosinophils, 51.4% of total leukocytes). Viral serologies and autoimmune study were negative. Microbiological and parasitological analyses of stool samples were negative too. Immunoglobulin E levels were elevated. Abdominal computed tomography(CT) revealed thickening of the rectal ampulla and sigmoid colon. Upper gastrointestinal endoscopy did not show any abnormalities, but rectosigmoidoscopy revealed colorectal mucosa with millimetric whitish dots, some scattered erosions, and a 20 mm ulcer in the distal rectum that was biopsied. Histological evaluation showed inflammatory changes with predominance of eosinophilic polymorphonuclear cells(>50/field). Bone marrow study showed eosinophilic myeloid hyperplasia without blasts. No cytogenetic abnormalities were identified on chromosomal analysis. During hospitalization, she developed pruritic erythematous macules on the sacral region and inner thighs that gradually improved with topical steroids. Idiopathic hypereosinophilic syndrome with gastrointestinal involvement and possible cutaneous and pulmonar, was assumed. Prednisolone 40 mg/day was started with clinical and laboratory improvement, with complete resolution of peripheral eosinophilia. The diagnosis of idiopathic hypereosinophilic syndrome is a challenge because it is a diagnosis of exclusion and manifests in various ways depending on the affected system, with gastrointestinal involvement being possible, as in the case presented here. Recognition and early initiation of appropriate treatment can improve the survival and quality of life of these patients.

Clinical Case Summary

A 65-year-old female with recurrent episodes of rectal bleeding consulted the emergency department. A digital rectal examination showed bright red blood on admission, and a complicated mass was palpated. Routine blood tests and other clinical studies were unremarkable. Colonoscopy revealed a 7 cm blackish, friable rectal tumor protruding from the anal canal (Figure 1).
According to the histopathology report, intraepithelial melanocytes abnormally proliferated, with positive Melan-A and HMB45, indicating malignant anorectal melanoma. Chest, abdominal, and pelvic CT scans were negative for metastatic disease. However, a pelvic MRI revealed an anal canal tumor directly invading the internal sphincter and extending to the lower rectum, involving two regional lymph nodes and no obstruction signs.
A positron emission tomography scan confirmed an intensely hypermetabolic lesion centered on the anorectal region (standardized uptake value = 28), with no distant metastases. According to the diagnostic workup findings, the multidisciplinary oncology board proceeded with abdominoperineal resection (APR) without neoadjuvant immunotherapy (Figure 2).
Anorectal melanoma accounts for 1%–1.9% of rectal cancers and<2% of all melanomas (1). In the United States, it occurs in 0.27 cases per 1 million population annually in an upward trend (1). Primary lesion sites include below the dentate line (42.7%), around the dentate line (33.3), and above the dentate line (23.9%) (2). Typical clinical manifestations are fresh rectal bleeding, anal mass sensation, and tenesmus (3). Surgery, which includes APR or wide local excision, remains the cornerstone of treatment for early-stage anorectal melanoma (3).

References

1. Coté TR, Sobin LH. Primary melanomas of the esophagus and anorectum: epidemiologic comparison with melanoma of the skin. Melanoma Res 2009;19:58-60.
2. Bello DM, Smyth E, Perez D, et al. Anal versus rectal melanoma: does site of origin predict outcome? Dis Colon Rectum 2013;56:150-7.
3. Meguerditchian AN, Meterissian SH, Dunn KB. Anorectal melanoma: diagnosis and treatment. Dis Colon Rectum 2011;54:638-44.

Clinical Case Summary

A 55-year-old woman was referred to the Gastroenterology outpatient clinic due to a positive fecal occult blood test, in colorectal cancer screening context.
Patient’s history included asthma and hysterectomy. She was nulliparous, had no history of infertility, started menopause 6 years earlier and had never reported dyschezia, macroscopic hematochezia, dysmenorrhea nor changes in bowel habits. Physical examination was unremarkable.
Colonoscopy that followed revealed a vinous, sessile, polypoid, ulcerated and friable lesion measuring 30-40mm, at the anterior rectal wall (12 cm of anal margin). Histopathologic examination showed endometriosis foci invading rectal mucosa, without dysplasia or malignancy resembling signs. The lesion was also characterized by endoscopic ultrasound (EUS) which describes a 40x38x27mm, hemicircumferential, hypoechoic lesion, originating from the rectovaginal septum and invading muscularis propria and all rectal layers at certain locations, partially occluding rectal lumen.
Since the patient was asymptomatic and postmenopausal, risk of complications was considered low, and she was discharged.
When endometrial-like tissue invades beyond 5mm of depth into visceral peritoneum, it’s considered a deep infiltration of the endometriosis¹.
Colorectal involvement occurs in 5-12,3% of cases² and while most lesions invade the serosa and muscularis propria, only 5-6% invade the mucosa³ which is why rectal mucosal biopsies are rarely diagnostic. In rectum, implants are usually associated with dyschezia, cyclic hematoquezia and tenesmus.
What makes this case paradigmatic is the asymptomatic presentation with a large and ulcerative polypoid rectal lesion in a postmenopausal woman, which rose malignancy suspicion. The lack of correlation between symptom severity and endometrial implants’ size, has been previously described.⁴
Despite the low risk of progression during menopause, colonoscopy is helpful to rule out malignancy at presentation.

References

1. Vercellini P, Sergenti G, Buggio L, et al. Advances in the medical management of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2021;71:78-99. doi: 10.1016/j.bpobgyn.2020.06.004 [published Online First: 2020/07/19]
2. Wills HJ, Reid GD, Cooper MJ, et al. Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review. Aust N Z J Obstet Gynaecol 2008;48(3):292-5. doi: 10.1111/j.1479-828X.2008.00871.x [published Online First: 2008/06/06]
3. Meuleman C, Tomassetti C, D'Hoore A, et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011;17(3):311-26. doi: 10.1093/humupd/dmq057 [published Online First: 2011/01/15]
4. Working group of Esge E, Wes. Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis daggerdouble dagger paragraph sign. Facts Views Vis Obgyn 2020;11(4):269-97. [published Online First: 2020/04/24]

Clinical Case Summary

75 years old female reporting vomiting, chronic diarrhea, epigastric pain and weight loss since 2021. She was initially investigated with Esophagogastroduodenoscopy and biochemical exams (both negative). Computed Tomography (CT) showed enlarged mesenteric lymph nodes in right iliac fossa, mesenterial fibrous distortion, venous vessels stenosis, wall thickening in distal ileal tract and mucosal hyperemia. Several differential diagnoses were proposed: ileal Neuroendocrine Tumor (NET) with mesenteric metastases, small bowel neoplasia/ileal lymphoma, inflammatory bowel disease, vascular disruption/ischemia, infections (i.e. tuberculosis). NET markers were negative, as well as Positron Emission Tomogaphy (PET) with Gallium. Total body FDG PET showed hypermetabolism in terminal ileum. Ileocolonoscopy showed sub stenosis, with a serpiginous ulcer of 8 mm located 15 cm from the ileocecal valve and mucosal edema. Histology was nonspecific. The patient underwent ileal resection and right hemicolectomy. Surgical specimen histopatology with immunohistochemical staining (for S100, CD117, Bcl-2 and Calretinin) diagnosed sporadic diffuse ganglioneuromatosis. Post-operative follow up was regular. The differential diagnosis was indeed challenging. The symptoms were confusing, i.e. the presence of diarrhea and the absence of anemia, and the endoscopic appearence was nonspecific. The lesion was hard to sample endoscopically, so surgical specimen evaluation was needed. Video capsule or device-assisted enteroscopy could have been attempted, but with caveats related to luminal stenosis. Multiple neuroendocrine neoplasia (MEN) IIB had to be ruled out since the patient had multiple thyroid nodules, to exclude medullary carcinoma. Subsequent follow up has yet to be established.

References

1. Endoscopic image showing ileal ulcer and stenosis
2. CT scan with mesenterial distortion and lymph nodes enlargment
3. CT scan showing ileal wall thickening and corresponding FDG PET uptake

Introduction

Chronic anal fissure is a frequent cause of referral to the proctology clinic and is associated with significant morbidity. In cases refractory to conservative measures, botulinum toxin (BT) is an alternative to a surgical approach, without the risk of permanent damage to the internal anal sphincter.

Aims & Methods

The aim of this study was to assess the efficacy of BT in anal fissure healing and to identify predictors of non-response. This was a retrospective, single-centre, observational study. Patients with chronic anal fissure who underwent TB between 2019 and 2023. Patients with a follow-up of less than 3 months or inflammatory bowel disease were excluded. On clinical reassessment, patients were categorised as complete, partial or refractory.

Results

Of the 118 patients selected, 80 were included. The average age was 49.1 ± 14.9 years, with 73.8% (n=59) of the patients female. The overall TB response rate was 62.0%. More than one TB session was carried out on 40.0% (n=32) of the patients, with an average of 1.5±0.6 per patient, with an interval between sessions of 3.4 ± 5.8 months. On reassessment after the first application, 30.0% (n=24) showed a complete response, 56.3% (n=45) a partial response and 13.8% (n=11) were refractory. Of the partial or refractory responders, after completing the treatment cycle, 56.5% (n=13) showed a complete response, 26.1 (n=6) a partial response and 17.4% (n=4) were refractory. During a median follow-up of 10.0 [3-48] months, 7 patients became asymptomatic and 2 patients had a recurrence of the cleft. 21 patients (26.3%) were referred for surgery. The duration of symptoms was an independent predictor of TB treatment failure and the need for surgery (OR 4.895; p=0.049).

Conclusion

TB has a satisfactory response rate in the treatment of patients with chronic anal fissure, making it possible to avoid surgery in patients, specially with a short duration of symptoms.