Recurrent Abdominal Distension: Colonic Ulcer is a Cause or a Consequence?

Abstract

Question: A 48-year-old woman presented with a 5-month history of recurrent abdominal distension and constipation. She had a history of pulmonary tuberculosis in childhood and breast cancer treated with surgery and chemotherapy (adriamycin/cyclophosphamide [AC] regimen) 1 year ago followed by long-term endocrine therapy with toremifene. Additionally, she took 3 months of Chinese herbs including high-dose aconite postoperatively. Physical examination revealed the distended abdomen with diffuse tenderness. Laboratory investigations indicated anemia and hypoalbuminemia. Indicators of inflammation were normal. Plain abdominal radiographs and computed tomography showed massive dilation of the small intestine and colon, and thickening of the wall of the transverse and descending colon (Figure A). Subsequently, colonoscopy was performed and revealed 2 large irregular ulcers in the transverse and descending colon (Figure B). Biopsies of lesions showed nonspecific inflammation. Based on the history of pulmonary tuberculosis, she was empirically started on antituberculosis therapy. Five months later, unfortunately, her abdominal distension was worsening (Figure C). Transverse colostomy was subsequently performed to alleviate the symptoms. Furthermore, a repeated colonoscopy showed no improvement of the ulcer lesions after a standard course of antituberculosis treatment (1 year). Thereafter, the patient received a 3-month therapy of prednisone and thalidomide. None of these therapies seemed to improve the patient’s intestinal symptoms and ulcer lesions, nor did they halt progression. What is the diagnosis? What shall we do? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Finally, segmental colon resection was performed and the pathology showed thickening of muscularis mucosae, muscularis propria atrophy and fibrosis, aberrant muscularization in serosa (Figure D), and reduction of ganglion cells accompanied by inflammatory cells infiltration, consistent with obstructive enteritidis. Additionally, histopathology demonstrated some bluish-purple crystallin-like substances engulfed by multinucleated giant cells (Figure E). Based on these findings, the patient was diagnosed with chronic intestinal pseudo-obstruction (CIPO), which may be secondary to drug-induced gut injury. Unfortunately, 1 month later, her abdominal distension recurred. Subsequently, radiopaque marker test for colonic transit was performed and revealed impaired motility of the entire colon (24 of 24 radiopaque markers diffusely distributed throughout the colon after 72 hours; Figure F). Pseudo-obstruction is characterized by signs and symptoms of a mechanical obstruction of the small or large bowel in the absence of an anatomic lesion.1De Giorgio R. Sarnelli G. Corinaldesi R. et al.Advances in our understanding of the pathology of chronic intestinal pseudo-obstruction.Gut. 2004; 53: 1549-1552Crossref PubMed Scopus (196) Google Scholar Because the symptoms of CIPO are nonspecific, it is a challenge to make precise diagnosis, especially for patients with colonic ulcers as in our case, and it may be misdiagnosed with intestinal tuberculosis and Crohn’s disease, which might be mistaken for the cause of the intestinal symptoms. Many patients undergo futile and potentially harmful surgical procedures2De Giorgio Roberto Cogliandro Rosanna F. Barbara Giovanni et al.Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy.Gastroenterol Clin North Am. 2011; 40: 787-807Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar as in our case. In fact, in our patient, CIPO, which may be secondary to drug-induced gut injury, is the cause of the colonic ulcers and intestinal symptoms. Unfortunately, the patient may need total colectomy to alleviate the symptoms.