Actinomycosis of the Colon: A Rare Form of Presentation

Actinomycosis is an uncommon entity, caused by an anaerobic bacterium, Actinomyces israelii, which is a component of the human oral and gastrointestinal flora. The cervicofacial region is the commonest site of disease, and the abdomen is the second commonest. In this situation the disease is almost always unifocal and restricted to the right colon, especially to the cecum. We report here the case of a patient with a very rare form of this entity, characterized by multiple foci of abdominal involvement with the most severe lesions localized in the transverse and sigmoid colon. The clinical presentation resembled a picture of colon perforation by cancer or diverticulitis, and the diagnosis was made by histopathologic examination of the lesions removed at surgery. No predisposing factor was found. The infection was successfully treated with a prolonged course of penicillin, after the surgical removal of the lesions.     

Clinical experience with near-infrared ray catheter,a fluorescent ureteral catheter,on laparoscopic surgery for colon diverticulitis: A case report

Rationale:As the world''s population ages, the number of surgical cases of colovesical fistulas secondary to colon diverticulitis is also expected to increase. The key issue while performing laparoscopic surgery for these fistulas is the avoidance of iatrogenic ureteral injury. There are no reports of Near-infrared Ray Catheter being used in surgery for diverticulitis, which is one of the diseases with the highest risk of ureteral injury. We present a case of a male patient with colovesical fistulas secondary to sigmoid colon diverticulitis who underwent laparoscopic surgery with visualization of the ureter using a new surgical technique in laparoscopic surgery.Patient''s concern:An 82-year-old man presented to our urological department with general fatigue and air and fecal matter in the urine.Diagnoses:Cystography showed delineation of the sigmoid colon. Abdominal computed tomography findings revealed multiple sigmoid colon diverticula with thickened walls as well as large stones and a small amount of air in the bladder. He was diagnosed with a urinary tract infection with colovesical fistulas and bladder stones due to sigmoid diverticulitis.Interventions:After the creation of a transverse colostomy, we scheduled a laparoscopic anterior resection and cystolith removal.Outcomes:Severe inflammatory adhesions around the sigmoid colon and a high risk of ureteral injury were expected preoperatively. After induction of anesthesia, we inserted a Near-infrared Ray Catheter, a fluorescent ureteral catheter, which allowed us to easily identify and visualize the ureter in real-time. This allowed bowel dissection without concerns of ureteral injury. The operative time for the gastrointestinal part of the procedure was 150 minutes, and the patient was in a good general condition after the operation and was discharged on postoperative day 7.Lessons:The course of the ureter was easily and quickly identified by the green fluorescence from the ureteral catheter during laparoscopic surgery for fistulas associated with diverticulitis, where severe inflammation and dense fibrosis were present. Our technique is an easy and feasible approach that provides real-time urethral navigation during surgery for colovesical fistulas secondary to colon diverticulitis.     

Association between sigmoid diverticulitis and left‐sided colon cancer: a nested,population‐based,case control study

Background: An increased risk of left‐sided colon cancer in patients with diverticular disease of the sigmoid colon has been reported. The aim of this study was to investigate to what extent patients with diverticulitis of the sigmoid colon differ in long‐term risk of colon cancer compared to patients with diverticulosis of the colon without any clinical signs of diverticulitis. Methods: A total of 7159 patients (2478 M, 4681 F) discharged with a diagnosis of diverticulosis or diverticulitis in 1965–83 in the Uppsala Health Care Region were followed‐up with the Swedish Cancer Registry. Sixty‐four cases with colon cancer were identified and compared with 123 controls without cancer matched for sex, age and year of first discharge. Based on information from the patients' charts, an independent observer blinded to the outcome assigned a clinical diagnosis of diverticulitis or not diverticulitis to cases and controls. Results: In patients classified as having sigmoid diverticulitis there was an increased risk of left‐sided colon cancer compared with patients with diverticulosis without any clinical signs of diverticulitis (odds ratio?=?4.2, 95% CI 1.3–13.0) which remained after mutually adjusting for several clinical parameters in a multivariate conditional logistic regression analysis. Conclusion: The results of the study indicate a causal association between sigmoid diverticulitis and a long‐term increased risk of left‐sided colon cancer.     

Subclinical peritonitis due to perforated sigmoid diverticulitis 14 years after heart-lung transplantation

Acute complicated diverticulitis, particularly with colon perforation, is a rare but serious condition in transplant recipients with high morbidity and mortality. Neither acute diverticulitis nor colon perforation has been reported in young heart-lung grafted patients. A case of subclinical peritonitis due to perforated acute sigmoid diverticulitis 14 years after heart-lung transplantation is reported. A 26-year-old woman, who received heart-lung transplantation 14 years ago, presented with vague abdominal pain. Physical examination was normal. Blood tests revealed leukocytosis. Abdominal X-ray showed air-fluid levels while CT demonstrated peritonitis due to perforated sigmoid diverticulitis. Sigmoidectomy and end-colostomy （Hartmann＇s procedure） were performed. Histopathology confirmed perforated acute sigmoid diverticulitis. The patient was discharged on the 8th postoperative day after an uneventful postoperative course. This is the first report of acute diverticulitis resulting in colon perforation in a young heart-lung transplanted patient. Clinical presentation, even in peritonitis, may be atypical due to the masking effects of immunosuppression. A high index of suspicion, urgent aggressive diagnostic investigation of even vague abdominal symptoms, adjustment of immunosuppression, broad-spectrum antibiotics, and immediate surgical treatment are critical. Moreover, strategies to reduce the risk of this complication should be implemented. Pretransplantation colon screening, prophylactic pretransplantation sigmoid resection in patients with diverticulosis, and elective surgical intervention in patients with nonoperatively treated acute diverticulitis after transplantation deserve consideration and further studies.     

Actinomycosis of the colon: a rare form of presentation

Actinomycosis is an uncommon entity, caused by an anaerobic bacterium, Actinomyces israelii, which is a component of the human oral and gastrointestinal flora. The cervicofacial region is the commonest site of disease, and the abdomen is the second commonest. In this situation the disease is almost always unifocal and restricted to the right colon, especially to the cecum. We report here the case of a patient with a very rare form of this entity, characterized by multiple foci of abdominal involvement with the most severe lesions localized in the transverse and sigmoid colon. The clinical presentation resembled a picture of colon perforation by cancer or diverticulitis, and the diagnosis was made by histopathologic examination of the lesions removed at surgery. No predisposing factor was found. The infection was successfully treated with a prolonged course of penicillin, after the surgical removal of the lesions.     

Association between sigmoid diverticulitis and left-sided colon cancer: a nested, population-based, case control study

BACKGROUND: An increased risk of left-sided colon cancer in patients with diverticular disease of the sigmoid colon has been reported. The aim of this study was to investigate to what extent patients with diverticulitis of the sigmoid colon differ in long-term risk of colon cancer compared to patients with diverticulosis of the colon without any clinical signs of diverticulitis. METHODS: A total of 7159 patients (2478 M, 4681 F) discharged with a diagnosis of diverticulosis or diverticulitis in 1965-83 in the Uppsala Health Care Region were followed-up with the Swedish Cancer Registry. Sixty-four cases with colon cancer were identified and compared with 123 controls without cancer matched for sex, age and year of first discharge. Based on information from the patients' charts, an independent observer blinded to the outcome assigned a clinical diagnosis of diverticulitis or not diverticulitis to cases and controls. RESULTS: In patients classified as having sigmoid diverticulitis there was an increased risk of left-sided colon cancer compared with patients with diverticulosis without any clinical signs of diverticulitis (odds ratio = 4.2, 95% CI 1.3-13.0) which remained after mutually adjusting for several clinical parameters in a multivariate conditional logistic regression analysis. CONCLUSION: The results of the study indicate a causal association between sigmoid diverticulitis and a long-term increased risk of left-sided colon cancer.     

Un f��calome g��ant compliqu�� d��un volvulus et d��une perforation colique bifocale

Stercoral perforation of the colon is rare and usually occurs in elderly patient suffering from chronic constipation. It can also occur in younger patient. The authors report on the case of a 42-year-old patient who presented to emergency department with acute abdomen. Initial resuscitation was performed and the patient underwent urgent laparotomy. He was found to have a massive fecal impaction which extended from the rectum to right flexure of the colon and resulted primarily in feculent peritonitis, which lead to a double perforation of the sigmoid colon and the transverse colon, and secondarily in a volvulus of the sigmoid colon. The patient underwent left hemicolectomy with Hartmann colostomy. He died two days after surgery. The size of the fecaloma together with the double perforation and the volvulus of the sigmoid colon make the interest in this case, which is never reported in the literature, at least to our knowledge.     

Strangulation of the Colon Complicating Acute Pancreatitis

We report a patient with alcohol-induced necrotizing pancreatitis who developed a severe ileus followed by incarceration of a portion of the transverse colon within a ventral hernia. Laparotomy 9 days after the onset of symptoms revealed infarction of the transverse colon and infection of the pancreas. This is the first report of a case of acute pancreatitis that led to a strangulated ventral hernia of the colon. We believe that the enteric organisms that infected the pancreas originated in the incarcerated transverse colon.     

Perforated diverticulitis of the transverse colon

A case of localized, perforated diverticulitis of the transverse colon in a 45-year-old woman is presented. Preoperatively, this rare disease is indistinguishable from other acute surgical conditions, and often is mistaken for carcinoma at laparotomy. This report increases awareness of this unusual condition, and emphasizes the clinical, diagnostic, and therapeutic implications. Case reports described in the literature are reviewed.     

Acute solitary diverticulitis of the transverse colon in a child

Solitary colonic diverticula are rare. Most have been described in the cecum or ascending colon. Solitary diverticula of the transverse colon are extremely rare, and there are only a few reports in the English medical literature, all occurring in adulthood. This paper reports the case of a 13-year-old girl with a solitary, true diverticulum of the transverse colon, presenting as acute diverticulitis.     

Role of CT in diagnosis and management of complications of diverticular disease

The clinical complications of diverticular disease may be unclear. Seven patients with complicated diverticulitis of the transverse, descending, and sigmoid colon were examined with computed tomography. Exact knowledge of the anatomical relationships of the transverse, descending, and sigmoid colon and neighboring structures are a prerequisite for understanding and interpreting the extensions of peridiverticular disease. Computed tomography proved to be useful in evaluating the presence and extent of sequelae of perforations, and, as a consequence, influenced the planning and timing of treatment.     

Filiform polyposis associated with sigmoid diverticulitis in a patient without inflammatory bowel disease

Filiform polyposis (FP) of the colon is an uncommon entity that is occasionally encountered in patients with inflammatory bowel disease (IBD). FP is morphologically characterized by multiple slender worm-like projections consisting of submucosal cores lined with normal mucosa. To date, only two cases of FP have been reported in patients with inflammatory conditions of the gastrointestinal tract other than ulcerative colitis or Crohn's disease. We report an additional case of FP occurring in an 83-year-old man with no history of IBD. The patient underwent anterior resection of the sigmoid colon for perforated diverticulitis. Around the diverticular orifice, localized FP involving a 13-cm colonic segment was observed. The filiform polyps consisted of submucosal fibrovascular cores lined with normal mucosa without epithelial dysplasia. To our knowledge, this is the first reported case of FP associated with colonic diverticulitis in a patient without IBD.     

Chilaiditi's syndrome. Successful surgical correction by colopexy

We describe the case of a patient affected by the Chilaiditi's syndrome, the interposition of the small or large bowel between the inferior face of the diaphragm and the liver, a rare anomaly, often asymptomatic. A 50-year-old man came to our outpatients clinic because of persistent pain in the right abdominal region. Two attempts to perform colonoscopy failed because of the impossibility of passing through the transverse colon. A double contrast enema indicated only sigmoid diverticulitis. Only after abdominal radiography was the abnormal position of the right colon noted. At surgery the right colon was totally intraperitoneal and positioned between the diaphragm and liver, which was smaller than normal. The right colon was repositioned and fixed to the anterior abdominal wall. The postoperative course was uneventful and the right abdominal pain disappeared completely. In conclusion, surgical treatment of Chilaiditi's syndrome may be required in cases of persistent abdominal pain. Received: 10 August 2001 / Accepted in revised form: 29 September 2001     

Colonic Vascular Anomalies and Colon Cancer in Neurofibromatosis: Report of a Case

We report a case of neurofibromatosis with synchronous adenocarcinomas in the sigmoid and transverse colon. There was widespread intimal proliferation in arteries in the region of the tumors and also in the cecum. Such vascular lesions are associated with von Recklinghausen’s disease. The cecal lesion produced mural thickening visible on computed tomography. This case supports a possible genetic link between neurofibromatosis and adenocarcinoma of the colon.     

Segmental Tuberculosis of the Colon Diagnosed By Colonoscopy

Segmental tuberculosis of the colon is a rare clinical entity. In the absence of pulmonary or ileocecal involvement, colonic tuberculosis may be difficult to differentiate from neoplasm or Crohn's disease by symptomatic and radiological means. Colonoscopy and biopsy can, however, establish the diagnosis and prevent operative intervention, as indicated in the present report. A patient with a radiologically demonstrated strictured lesion of the sigmoid colon was found at colonoscopy to have several hemorrhagic transverse ulcers ranging in diameter between 1–4.5 cm. Multiple target colonoscopic biopsies, specifically from the ulcer beds, revealed necrotizing granulomas and acid-fast bacilli. Antituberculous chemotherapy produced remarkable symptomatic, radiographic and endoscopic improvements and averted exploratory laparotomy for the establishment of the diagnosis. This case report points out the importance of colonoscopic biopsy as a useful diagnostic modality in this disease.     

ENDOSCOPIC TREATMENT OF A BENIGN COLOCUTANEOUS AND ENTEROCOLIC FISTULA BY INSERTION OF OVERLAPPING SELF‐EXPANDABLE METAL STENTS

We report the successful closure of fistulae at the site of a benign colocolonic anastomotic stricture using self‐expandable metal stents (SEMS). The stricture and fistulae developed after sigmoid colon resection for diverticulitis. After closure of the fistulae with a covered stent and resolution of inflammation, 10 months later the patient elected to undergo one‐stage resection of the diseased colon and stent. Although there have been previously reported cases of SEMS for closure of malignant colonic fistula, there are limited reports of SEMS for closure of benign colonic fistulae and none demonstrate long‐term success. We conclude that this patient exemplifies the potential applications of SEMS as definitive therapy for benign colorectal disease.     

A Case of Crohn's Disease which Initially Presented with Diffuse Inflammation in the Rectum and Sigmoid Colon

Abstract: This case report describes a female patient with Crohn 's disease who had diffuse proctosigmoiditis without a longitudinal ulcer or cobblestone appearance at the initial attack. She was treated with sulfasalazine on the presumptive diagnosis of ulcerative colitis. Two and a half months later, painful ulcers in the oral cavity and a deep longitudinal ulcer in the sigmoid colon were found, and a non-caseous granuloma was revealed in the biopsy specimens taken from the sigmoid colon. A definitive diagnosis of Crohn's disease was established from these findings and treatment with a corticosteroid was effective.     

SUCCESSFUL PLACEMENT OF SELF‐EXPANDABLE METALLIC STENTS FOR DOUBLE COLORECTAL CANCERS

Stent placement for the palliation of unresectable colon cancer is an alternative to surgical treatment that has recently become popular. A dedicated stent for colorectal cancer is not available in Japan. We report a patient with two colonic obstructions who underwent a successful palliative treatment using two stents. He was admitted to Toho University Ohashi Medical Center because of ileus. A colonoscopy revealed two advanced lesions with stenosis in the sigmoid and transverse colon. Because he had multiple liver metastases and severe Alzheimer dementia, we selected palliative stent placement for the treatment of both strictures. We placed a covered stent in the sigmoid colon stricture and subsequently attempted to place a second stent in the transverse colon stricture. However, the second stent could not be placed in the transverse colon because the modified delivery system could not pass through the first stent in the sigmoid colon. This probably led to a twisting of the stent in the sigmoid colon. We next used the 24 F introducer sheath that is included in Keller‐Timmermans Introducer Sets. This strategy allowed the modified delivery system to be easily passed through the initial stent in the sigmoid colon and then advanced into the transverse colon stricture, enabling both stents to be positioned properly.     

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.     

A CASE OF PYOGENIC GRANULOMA IN THE SIGMOID COLON TREATED WITH ARGON PLASMA COAGULATION

Pyogenic granuloma (PG) with hemorrhagic tendency, is often recognized in the oral mucosa and skin, but rare in the gastrointestinal tract. Only 20 cases have been reported in the gastric mucosa. There have been no reports of gastrointestinal PG treated by argon plasma coagulation (APC). We report here the first case of PG in the sigmoid colon treated by APC. The patient was a 64‐year‐old woman complaining of constipation who was referred to a university hospital of Kochi Medical School. She presented with easily bleeding mucosa, as revealed by a total colonoscopic study in the sigmoid colon. Magnifying colonoscopic examination showed two sessile small polyps in the sigmoid colon. Pathological examination of the biopsy specimens revealed pyogenic granuloma. We treated this lesion by endoscopic APC. No recurrence has been found as of 9 months after APC therapy.