Brown Tubular-Shaped Object Rectally Expelled in a Patient With Persistent Diarrhea

Abstract

GAST Question: A 72-year-old man presented to the emergency room of our hospital. The patient was diagnosed with cerebral infarction by computed tomography. Laboratory investigation revealed dehydration, renal failure (serum blood urea nitrogen, 38 mg/dL; serum creatinine, 7.8 mg/dL), inflammatory reaction (white blood cell count, 18,700/mL; serum Creactive protein, 39 mg/dL), and disseminated intravascular coagulation (DIC). We began continuous infusion therapy with heparin for the cerebral infarction, continuous hemodiafiltration for renal failure, gabexate mesylate for DIC, and antibiotics. Bloody, watery, and mushy diarrhea, as well as persistent fever, were also present. The duration of the diarrhea was approximately 3 weeks, although the patient’s stool was negative for Clostridium difficile toxin. At day 23, the patient spontaneously passed a 66-cm, tubular-shaped, brown object from the rectum (Figure A, B). On physical examination and palpation, he frowned but did not show tenderness, rebound tenderness, or muscular defense. Laboratory investigation revealed that the white blood cell count and serum C-reactive protein had decreased. Contrast computed tomography revealed that the entire colon was thin-walled except for the ascending colon and inferior end of the rectum, with no vascular thrombosis. Additionally, the wall of the ascending colon and inferior end of the rectum were edematous and there was no free air, ascites, pneumatosis, or portal venous gas (Figure C, D). What is the brown tubular-shaped object? What is the appropriate management? Look on page 1500 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.