Acute Hemorrhage Related Colonic Injury Misdiagnosed as Signet-Ring Cell Carcinoma

Abstract

Abstract Introduction/Objective Hypovolemic shock/hypoperfusion-related gastrointestinal injury is an unusual event in the practice of oncological pathology. The histologic findings can be ambiguous, potentially masquerading other entities, especially epithelial neoplasms. One needs to pay close attention to the subtle microscopic features and the associated sudden clinical event(s). Concordant hypovolemic history will help decision-making but can be overlooked or unaware of. Methods/Case Report A 72-year-old gentleman with prostate hypertrophy, rheumatoid arthritis, and hypertension presented to the emergency room with palpitation, dizziness, and dyspnea. He was diagnosed with atrial fibrillation and started on anticoagulation. Unexpectedly, the patient returned 3 days later with sudden gastrointestinal hemorrhage and severe anemia (hemoglobin 2.7). Emergency colonoscopy identified mucosal hemorrhage, erosion, and a friable, mass-like area in the sigmoid colon; the corresponding biopsy was called signet-ring cell carcinoma. Subsequently, the patient was referred to our institution for consultation. Results (if a Case Study enter NA) The provided biopsy showed multiple clusters of signet-ring-like cells with extravasated mucin, detached or distributed within edematous colonic fragments, resembling signet-ring cell carcinoma. However, no overt cytologic or architecture atypia or mitosis was appreciated; instead, microscopic hemorrhage, capillary thrombi, withering and distorted crypts, and mucosal necrotic sloughing were present, worse on the luminal surface. Furthermore, no background dysplasia or adenoma was identified. These findings uncovered an originally misdiagnosed acute colitis due to hypoperfusion. Subsequent imaging studies detected no gastrointestinal mass/lesion. 22-months later, the patient’s clinical follow-up was unremarkable. Conclusion Severe hemorrhage/hypoperfusion-induced colitis may pose a dilemma clinically and histopathologically when the contributing event is underrecognized. Detailed history and laboratory review and astute microscopic inspection are warranted.