Umbilical Region Pain, Diarrhea, and Bloody Stools

Abstract

Question: A 75-year-old man was admitted to the hospital because of umbilical region pain, diarrhea, and bloody stools. The pain was continuous and occasionally associated with nausea, vomiting, or food intake. On examination, he was noted to have slight tenderness over right lumbar region and no organomegaly. His hemoglobin level was 91 g/L (normal range, 119–157) and the serum levels of alpha-fetoprotein and carcinoembryonic antigen were normal. Abdominal ultrasound delineated a 7-cm, mixed echo mass in right upper abdominal. Abdominal plain computed tomography (CT) revealed diffuse colonic wall thickening with an ellipse-shaped, low-density mass shadow in hepatic flexure of the colon. The tumor with fiber septation growing in the enteric cavity blocked excretion of food. Contrast-enhanced CT scan showed the low-density mass without reinforcement and the thickened colonic wall was obvious reinforcement as concentric luminal stenosis (Figures A–D). He was failed to complete colonoscopy because of bloody stools. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The diagnosis was established after laparotomy by resecting part of ascending colon. The bulge was approximate 6 × 5 cm along with intussusception of the proximate intestinal canal and an 0.5-cm diameter ulcer in the tumor, which were the cause of the worsening anemia. His hemoglobin level decreased to a low of 74 g/L before surgery. Histologically, the tumor was an encapsulated nodule, consisting of mature adipose tissue, clearly different from lipomas because of the intralesional proliferation of vascular tissue (Figures E and F). Angiolipomas of gastrointestinal tract are rare. Occasional colonic angiolipomas have been reported in the literature.1Chen Y.Y. Soon M.S. Preoperative diagnosis of colonic angiolipoma: a case report.World J Gastroenterol. 2005; 11: 5087-5089PubMed Google Scholar, 2Kato K. Matsuda M. Onodera K. et al.Angiolipoma of the colon with right lower quadrant abdominal pain.Dig Surg. 1999; 16: 441-444Crossref PubMed Scopus (19) Google Scholar There was no case of colon angiolipoma intussusception like our patient's, especially in the free ascending colon. The level of urgency was an important factor when choosing the most optimal treatment. In the case of intussusception, acute bleeding, or obstruction, emergency surgery was generally suggested instead of the further auxiliary examination.3Kacar S. Kuran S. Temucin T. et al.Rectal angiolipoma: a case report and review of literature.World J Gastroenterol. 2007; 13: 1460-1465PubMed Google Scholar Angiolipomas in gastrointestinal tract are benign tumors. The resection tumor, stained by anti-smooth muscle antibody and HMB45, showed negative results for muscle fibers, which was different from malignant angioliposarcoma. During follow-up, this angiolipoma tract was noninfiltrating and showed no recurrence.