Inadvertent transmural India ink tattooing simulating intestinal infarction

Abstract

An 80-year-old man with a history of colon carcinoma, which was resected for cure in 1985, presented with guaiac positive stools. A colonoscopy was performed and showed a new colonic primary in the distal sigmoid colon. At the time of endoscopy, biopsies were done and the tumor was marked with India ink to facilitate locating the lesion at laparotomy. Metastatic workup was unremarkable. The patient was otherwise asymptomatic. He was brought to the operating room subsequently. At laparotomy, a small segment of small bowel was found within a nest of abdominal adhesions and appeared necrotic (Fig. 1). After adhesiolysis, this segment was delivered through the incision and upon examination it was believed that there may have been an adhesive band that caused this (Fig. 2). On closer inspection the area in question was noted to have good peristalsis, and on palpating the adjacent mesentery palpable pulses were present. The serosa appeared healthy and not friable. Apart from dark discoloration, all other parameters of intestinal viability were normal. Further exploratory laparotomy did not reveal any further adhesive bands or any internal hernia defects. The colonic tumor was easily identified because there were a few scattered areas of India ink tattoos from the endoscopic markings on the serosa of the large bowel. The tumor location was verified with the colonoscope. It then became apparent that the infarcted-appearing bowel was a result of the injection of India ink traversing the large bowel and infiltrating layers of the small bowel. A resection of the large bowel tumor with primary anastomosis was carried out, and the discolored small bowel was left intact. Postoperatively the patient made an uneventful recovery.