Distal Sigmoid Research Articles

SURGICAL REMOVAL OF UROLITH BY PRESCROTAL URETHROTOMY IN A BULL: A CASE REPORT

Urolithiasis is a major disease of domestic animals all over the world. Uroliths occur in either sex, but obstructive urolithiasis is primarily a problem of male due to anatomical conformation of their urinary tract (Larson, 1996). Various factors influences the formation of stone in the urinary tract like diet, age, sex, breed, genetic makeup, season, soil, water, hormone levels, mineral and infection (Kalim et al., 2011). Once the calculi are formed in urinary tract, they may be lodged in any part of the urinary tract, thus leading to the retention of urine causes bladder distention, abdominal pain and eventual urethral perforation or bladder rupture with death from uremia or septicemia (Gasthuys et al., 1993). Urolithiasis is seen most often during winter and during severe weather conditions with limited water intake, especially when the water has a high mineral content. In male ruminants the urethral diameter becomes progressively smaller from the ischial arch toward the tip of the penis. The calculi most commonly lodge in the urethra at the distal sigmoid flexure where there is pronounced narrowing of the urethral diameter (Wolfe and Moll, 1998).

Primary extrauterine endometrial stromal sarcoma in the sigmoid colon.

An endometrial stromal sarcoma (ESS) is an uncommon uterine neoplasm, and its primary occurrence in the intestine as an extrauterine ESS (EESS) is exceedingly rare. We hereby report a primary EESS arising in the sigmoid colon with a review of the literature. A 52-year-old woman presented with bloody stool and underwent a colon fiberscopy, which revealed a fungating mass obstructing the lumen at the distal sigmoid. A laparoscopic low anterior resection was performed, and an umbilicated polypoid mass was identified; on section, it had infiltrated the mesocolic fat and measured 3.8 cm × 2.5 cm. The tumor showed geographic sheets or nests composed of relatively monotonous stromal cells, expansion or infiltration to the proper muscle and mesocolic fat, and extensive lymphovascular invasion and metastasis to regional lymph nodes and the pelvic peritoneum. The tumor cells were strongly and diffusely immunoreactive for CD10, but negative for c-kit, CD34, and Dog1. Two months later, a hysterectomy with a bilateral salpingo-oophorectomy was performed, and no evidence of an ESS was found in the uterus.

Epinephros metastasis of colorectal cancer complicated by tumor thrombosis of inferior vena cava

Metastasis of colorectal cancer (CRC) in an adrenal gland develops in 1.8% of cases (in synchrony or in metachrony) for patients with liver metastatic lesion and aggravates for certain prognosis for long-term survival. There are no data concerning colorectal metastasis in an adrenal gland with tumor thrombosis of inferior vena cava (IVC) in world-wide literature. A patient, 57 years old, on 04.29.11 underwent palliative distal sigmoid colectomy in respect of CRC pT3N2M1 (metastatic lesion of liver right lobe). Process stabilization was noticed after 4 courses of polychemotherapy. On 07.28.11 she underwent right-sided hemihepatectomy. She underwent further 4 courses in accordance with the same scheme. On 12.06.13 case-control USI and multi-layer spiral CT of abdominal cavity detected mass lesion in the right adrenal gland, it was estimated as metastatic lesion with compression of inferior vena cava and thrombosis in its lumen at retroliver segment level. Right-sided adrenalectomy. Thrombectomy of IVC was carried out in the condition of total vascular isolation. Taking into account metastasis respectability in an adrenal gland and small extent of a tumor thrombus we suppose the described surgical practice to be justified. The problem of neoadjuvant chemotherapy prescription is still controversial.

Laparoscopic resection of lower rectal cancer with telescopic anastomosis without abdominal incisions

To assess laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions. From March 2010 to June 2014, 30 patients (14 men and 16 women, aged 36-78 years, mean age 59.8 years) underwent laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through anus-preserving transanal resection. The tumors were 5-7 cm away from the anal margin in 24 cases, and 4 cm in six cases. In preoperative assessment, there were 21 cases of T1N0M0 and nine of T2N0M0. Through the middle approach, the sigmoid mesentery was freed at the root with an ultrasonic scalpel and the roots of the inferior mesenteric artery and vein were dissected, clamped and cut. Following the total mesorectal excision principle, the rectum was separated until the anorectal ring reached 3-5 cm from the distal end of the tumor. For perineal surgery, a ring incision was made 2 cm above the dentate line, and sharp dissection was performed submucosally towards the superior direction, until the plane of the levator ani muscle, to transect the rectum. The rectum and distal sigmoid colon were removed together from the anus, followed by a telescopic anastomosis between the full thickness of the proximal colon and the mucosa and submucosal tissue of the rectum. For the present cohort of 30 cases, the mean operative time was 178 min, with an average of 13 positive lymph nodes detected. One case of postoperative anastomotic leak was observed, requiring temporary colostomy, which was closed and recovered 3 mo later. The postoperative pathology showed T1-T2N0M0 in 19 cases and T2N1M0 in 11 cases. Twelve months after surgery, 94.4% patients achieved anal function Kirwan grade 1, indicating that their anal function returned to normal. The patients were followed up for 1-36 mo, with an average of 23 mo. There was no local recurrence, and 17 patients survived for > 3 years (with a survival rate of 100%). Laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions is safe and feasible.

Acute Bowel Obstruction Due to Endometriosis Treated With Colonic Stent

Introduction: Endometriosis is defined as the presence of extrauterine endometrium. It affects up to 8% of premenopausal women. Intestinal involvement is the most common extrapelvic site, affecting 5.4% of women with endometriosis, and out of which rectosigmoid endometriosis comprises 90%. Endometriosis is an extremely rare cause of large bowel obstruction. Urgent surgical intervention carries high morbidity and mortality, and operative intervention can be more difficult in extensive pelvic endometriosis. Less invasive alternatives can be considered in this situation. Case Report: A 35-year-old female presented with 2 weeks of progressive abdominal pain, nausea, and constipation. She denied hematochezia and reported no other gastrointestinal problem. She was afebrile, hemodynamically stable, and in moderate distress due to abdominal pain. Abdomen was diffusely tender, distended, and bowel sounds were present. Rectal exam revealed no abnormality. WBC count was 15 K. CT abdomen showed distended large bowel and colonic obstruction due to distal sigmoid colon stricture. A discrete mass was not seen. Colonoscopy showed tight colonic stricture with sharp angle at 18 cm above dentate line, unable to pass endoscope. The edge of the stricture was biopsied. A guide wire was advanced into the dilated colon proximal to stricture. Contrast injection revealed a 2.5-cm-long stricture. A 2.5-cm x 8-cm uncovered stent was deployed after consulting with the surgical team. Pathology showed benign edematous colonic mucosa. She did well for 2 days with scant semi-formed stools, but her symptoms got worse, and she ultimately underwent surgery. Upon initial inspection of bowel during surgery, the cecum and sigmoid colon were very dilated. The cecum was ischemic in appearance with splitting of the serosa in several areas. There was a hard, obstructing lesion in the proximal rectum, just distal to the confluence of tenia. The proximal sigmoid was resected. The initial surgical impression was diverticular disease, but pathology revealed extensive sigmoid colon endometriosis. Discussion: It is very rare to have endometriosis leading to bowel obstruction without any prior symptoms or history of endometriosis. This is the second reported case of acute bowel obstruction treated initially with colonic stent. Colonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents to treat benign conditions is controversial; however, due to associated long-term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial treatment with stent can provide time to prepare and medically optimize the patient for surgery.

Sigmoid Colon Polyp as Initial Presentation of Metastatic Papillary Renal Cell Carcinoma

Introduction: Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies, with 25-30% of patients having metastatic disease upon initial presentation. Metastasis is most common to the lungs, bone, liver, brain, lymph nodes, while metastasis to the gastrointestinal tract is rare, with the large bowel being the least common site. A 75-year-old white male with a past medical history of leukemia, renal insufficiency, and internal hemorrhoids presented with abdominal pain, nausea, vomiting, diarrhea, testicular pain, and decreased appetite. Esophagogastroduodenoscopy (EGD) was performed that revealed mild gastritis, a hiatal hernia, and no active bleeding. Colonoscopy revealed diverticulosis and non-bleeding internal hemorrhoids. A semi-pedunculated 0.2-cm distal sigmoid colon polyp was removed and the histology was compatible with RCC. The immunohistochemical (IHC) analysis was positive for CAM 5.2 and AE1/AE3 (suggesting renal cell origin) and PAX-2 and PAX-8 (suggesting RCC). IHC staining also revealed positive inhibin (suggesting no adrenal cortical carcinoma origin) combined with negative primary colon malignancy markers CDX-2, CK20, and CEA and negative neuroendocrine markers synaptotrophysin, chromogranin, and CD56. Negative chromophobe RCC markers CD117 and CK7 combined with a positive vimentin and histological H&E staining suggest sigmoid colon polyp cells of papillary RCC origin. A computed tomography (CT) of abdomen with contrast showed 3 masses in right kidney, with maximum diameter of 4 cm, and a single mass in the left kidney, with a maximum diameter of 2 cm. There was no history of a nephrectomy and no other lesions were detected. These results, together with histological analysis and evidence of renal masses on CT, provide a reasonable assumption that the sole sigmoid colon polyp favors metastasis from a primary papillary RCC. To be the best of our knowledge, this is the first reported case of metastatic papillary RCC that metastasized to the colon and presented as a single polyp. RCC metastasis to the gastrointestinal tract is quite rare, with metastasis to the stomach and small bowel significantly more common than the colon. The sporadic colon metastasis case reports that do exist describe metastasis to multiple colon sites and/or colon polyps, with the majority involving clear cell RCC metastasis and not papillary RCC metastasis. Involvement of atypical RCC metastasis sites, such as the colon, usually occur in cases that have recurrence many years after kidney resection, which our patient never had. Our patient had vague abdominal symptoms likely due to gastritis and acute orchitis that led to subsequent work-up and eventual diagnosis of newonset papillary RCC and metastasis.

A Rare Case of Primary Colonic Non-Hodgkin’s Diffuse Large B-Cell Lymphoma

Introduction: Primary colonic lymphoma is a rare manifestation of colonic malignancy. We report a rare case of primary colonic non-Hodgkin’s diffuse large B-cell lymphoma (PCNHDLBL) presenting as a symptomatic rectal stricture in a patient with ulcerative colitis (UC), who was being treated with azathioprine and adalimumab. Case Report: A 66-year-old male with a 7-year history of UC treated with azathioprine for 5 years and adalimumab for 3 years presented with complaints of 4 weeks of frequent loose stools, bloody bowel movements, and lower abdominal pain while defecating. On labs, hemoglobin was 10.6 g/dL, and WBC and the metabolic panel were within normal limits. The stool was negative for Clostridium difficile. Flexible sigmoidoscopy revealed rectal polyps and a partially obstructing stricture 10 cm from the anal verge. Biopsies were taken for pathology. The colonoscope could not be advanced beyond the stricture. A CT of the abdomen and pelvis showed distal sigmoid and rectal wall thickening, as well as pericolonic fat stranding consistent with active inflammation. Pathology of the stricture was positive for PCNHDLBL. The patient declined colectomy and elected to undergo chemotherapy with rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone (R-CHOP). Discussion: PCNHDLBL is a rare extranodal type of lymphoma of the gastrointestinal (GI) tract and makes up approximately <1% of colonic tumors. Of primary GI lymphomas, most are non-Hodgkin’s, and the colon is the third most common site of these tumors after the stomach and small bowel. These tumors most commonly present with nausea, abdominal discomfort, weight loss, and GI bleeding. They are most often diagnosed by endoscopic biopsy. Azathioprine and anti-tumor necrosis factor alpha (anti-TNF) medications are associated with an increased risk of lymphoma; however, recent data has concluded that inflammatory bowel disease itself is not an independent risk factor. Azathioprine, an immunomodulator, has been reported to increase the risk of developing lymphoma in patients with inflammatory bowel disease by as much as 4 times. Anti-TNF medications such as adalimumab are also associated with an increased risk of non-Hodgkin’s lymphoma, with an estimated incidence ratio of 3 compared with the background rate in the general population. Conclusion: Azathioprine and anti-TNF medications are associated with an increased risk of lymphoma and other malignancies. It is important for the gastroenterologist to discuss the increased risk of lymphoma with the patient before initiating therapy with azathioprine and/or anti-TNF medications.

Tu1477 Near Real Time Characterisation of Colorectal Cancer and Adenomatous Polyps Using Rapid Evaporative Ionisation Mass Spectrometry (Reims)

localization of the colonoscope tip may not be reliable. We aimed to assess accuracy of colonoscopist localization of polyps at the time of colonoscopy and determine if patient, procedure or colonoscopist variables influence the accuracy of localization. Methods: We conducted a prospective observational study in consecutive patients presenting for elective, outpatient colonoscopy at an academic center. All procedures were performed by board-certified colonoscopists. Polyps found during colonoscope withdrawal were included. The endoscopic location of each polyp was reported by the colonoscopist at the time of resection and prospectively recorded. Magnetic endoscope imaging (ScopeGuide, Olympus, Japan) was used to generate a reference standard for polyp location. For each procedure, a ScopeGuide image of the instrument location on insertion, caecal intubation and during polypectomy was prospectively obtained. Colonoscopists were blinded to the ScopeGuide image. Three separate expert colonoscopists, blinded to the endoscopist’s assessment of polyp location, independently reviewed the ScopeGuide images to obtain a reference standard for polyp location (Cronbach alpha 0.98). We assessed the accuracy of colonoscopist polyp localisation using the ScopeGuide-derived reference standard. We assessed extent of deviation between colonoscopist location and ScopeGuide location, by dividing the colon in 18 segments from caecum to distal rectum. Results: A total of 282 polyps were resected in 155 patients by 16 colonoscopists. Overall accuracy of polyp localization was 85%. Accuracy varied significantly (p!0.001) by colonic segment: caecum 100%, ascending 77%, transverse 82%, descending 56%, sigmoid 90%, rectum 95%. There was no significant deviation between ScopeGuide location and colonoscopist location for polyps located in the distal sigmoid and rectum (mean deviation 0.3 segments, range 0-3 segments, pZ0.32). There was significant deviation between ScopeGuide location and colonoscopist location from caecum to mid-sigmoid colon (mean deviation 0.8, range 0-6 segments, p!0.001). Extent of deviation between actual and predicted location was not influenced by patient sex, age, body mass index, surgical history, bowel preparation or years of colonoscopy experience. Conclusion: Accuracy of localization of polyps is imprecise, and affected by position within the colon. Methods to improve lesion localization at colonoscopy should be studied.

Sigmoid Vaginoplasty with a Modified Single Monti Tube: A Pediatric Case Series

No consensus exists regarding the most effective procedure for neovagina formation. We describe our experience with modified single Monti tube colovaginoplasty in pediatric patients with disorders of sexual differentiation. Six patients were retrospectively identified who underwent primary sigmoid vaginoplasty with a modified single Monti tube between 2009 and 2012. Data were collected from patient charts. The procedure is performed by isolating an 8 to 10 cm segment of distal sigmoid colon or proximal rectum, which is detubularized along the anterior mesentery, folded and retubularized longitudinally, leaving the mesentery in a cephalad position. A channel is dissected in the pelvis to accommodate the neovagina. Mean patient age was 12.7 years (range 6 to 17). The primary diagnosis was androgen insensitivity in 3 cases (50%), and Mayer-Rokitansky syndrome, partial androgen insensitivity and persistent cloaca in 1 each (16.7%). Chromosomal analysis revealed 46XY in 4 patients (66.7%). Median followup was 7.9 months (range 3 to 41). One patient who engages in vaginal intercourse reported satisfactory vaginal length without discomfort. In 1 patient an anastomotic stricture developed, which was managed by buccal mucosal grafting. Modified single Monti tube sigmoid vaginoplasty is a safe, effective technique for neovagina formation in pediatric patients with disorders of sexual differentiation. Compared to other existing methods, our technique allows for the use of shorter bowel segments with decreased tension of the vascular pedicle.

Arterial and venous thrombosis of the cerebral vasculature in GAPO syndrome

A 37-year-old male, previously diagnosed with GAPO syndrome, was admitted to our hospital complaining of recurrent episodes of transient weakness and numbness in his left arm for 3 months, and severe headache with progressive dysphagia for 15 days. His cranial magnetic resonance (MR) images showed multiple ischemic foci in the bilateral periventricular and supraventricular white matter. Cerebral MR-angiography showed total occlusion of the right internal carotid artery and moderate stenosis in the left internal carotid. We also detected chronic thrombotic changes in the distal left sigmoid sinus, proximal right sigmoid sinus, and bilateral jugular veins on cerebral MR-venography. He was diagnosed with dilated cardiomyopathy at age 31 years, which was reported as a novel association; and later he had a myocardial infarction at age 34 years. To the best of our knowledge, this is the first patient with GAPO syndrome and arterial atherosclerosis in cerebral-as well as coronary-arteries and intracranial venous thrombosis. We report the evolution of the disease in this patient, who died at age 38 years due to respiratory failure secondary to lower respiratory tract infection.

5. Diverticular disease, complications Re-Visited

Introduction Filiform polyposis of the colon is an uncommon entity occasionally encountered in patients with inflammatory bowel disease, characterised by multiple worm-like mucosal projections consisting of sub-mucosal cores lined by normal mucosa. Case study A 60-year-old man presented with signs and symptoms of large bowel obstruction for 7 days. The patient had a CT scan of the abdomen that showed thickening of the sigmoid wall with suspicion of malignancy. Subsequent colonoscopy showed an exophytictumour extending over 5 cm of the distal sigmoid. The biopsy showed only mucosal ulceration with no evidence of malignancy. The patient then underwent anterior resection of the sigmoid colon. The sigmoid colon was carpeted by numerous finger like projections. On histology this showed mucosal prolapse as a result of extensive diverticular disease. Discussion We discuss the unusual clinical presentation and gross findings of colonic polyposis related to diverticular disease. Only three similar cases have been reported in the English literature since 2010.

Impact of proximal resection margins on oncologic outcomes for patients with sigmoid colon cancer

Purpose: The purpose of this study was to evaluate the association between proximal resection margin (PRM) length and oncologic outcomes in sigmoid colon cancer. Methods: This was a retrospective cohort study on patients with sigmoid colon cancer between 1996 and 2009 and treated by curative primary resection. Tumor location was classified into two groups: SDPS, which was located in the proximal sigmoid colon or the sigmoid-descending junction; and MDS, which was located in the mid and distal sigmoid colon. Results: The mean PRM length was 8 cm (range, 6 to 11.5 cm). A total of 132 patients (11.7%) had a PRM Conclusion: PRM length was associated with tumor location within the sigmoid colon but not with the oncologic outcome.

Primary Intestinal Lymphangiectasia Isolated to the Colon: A Rare Cause of Chylous Ascites

Purpose: Recognize primary intestinal lymphangiectasia as a rare cause of chylous ascites. Case: A 20-year-old male with twp years of watery diarrhea and protein-losing enteropathy of uncertain etiology presented to our hospital with abdominal distention and pain. He denied trauma, travel, abdominal surgery, alcohol use, or family history of gastrointesintal disorders. Prior work-up including esophagogastroduodenoscopy (EGD), colonoscopy, capsule endoscopy, stool studies, and HIV test was unremarkable, except for an elevated fecal alpha-1-antitrypsin level. Physical exam was notable for a tensely distended, non-tender abdomen without hepatosplenomegaly, lymphadenopathy, or edema. Labs revealed hypoalbuminemia, hypoprotienemia, lymphopenia, and low IgG. Paracentesis yielded 5 L of milky white fluid with triglycerides of 1656 mg/dL, consistent with chylous ascites. Fluid culture and cytology were negative. CT abdomen showed extensive lymphadenopathy, but image-guided biopsy was not possible due to the small size of the lymph nodes. CT chest and neck, PET/CT, echocardiogram, PPD, LDH, germ cell tumor markers, and urine 5-HIAA were unremarkable. Lymphoscintigraphy revealed abdominal chylous leak of unknown origin without evidence of obstruction. Exploratory laparoscopy confirmed innumerable peritoneal lymphangiectasias between 5 mm and 2 cm limited to the distal transverse, descending, sigmoid colon, and proximal rectum. Intraoperative Argon beam coagulation was unsuccessful at reducing lymphangitic leakage. Despite a high protein, low-fat diet, the patient continues to require weekly paracentesis. Discussion: Primary intestinal lymphangiectasia (PIL) is a rare congenital malformation of the intestinal lymphatic system, characterized by protein losing enteropathy, hypoproteinemia, lymphopenia, and hypogammoglobulinemia. Lesions typically affect the small bowel and present at an early age with symptoms such as lower extremity edema, chronic diarrhea, steatorrhea, chylous ascites, and lymphedema. EGD or capsule endoscopy may show a characteristic appearance of edematous small bowel mucosa with engorged white villi. Lymphangiography may be a useful diagnostic study when endoscopic visualization and biopsy fail to confirm a diagnosis. The mainstay of treatment remains dietary reduction of long-chain triglycerides (LCT) and a high-protein diet. Several features about this case of PIL are unique, including lesions isolated to the left side of the colon, sparing the small bowel and the relatively late age of symptom onset. Given the isolated colonic involvement, it is perhaps not surprising that dietary elimination of LCT did not improve this patient's symptoms, but may make a left hemicolectomy a future treatment option.

Recurrent Clostridium difficile Colitis in a Patient with Concurrent Diverticulitis

Background:Clostridium difficile infection (CDI) and diverticulitis both cause inflammation of the colon and mimic each other radiographically. Distinguishing between the two entities is essential, as the treatment for diverticulitis (fluoroquinolone or cephalosporin, in addition to an antibiotic with anaerobic activity) can be a harbinger for CDI. Although rare, both diseases can present simultaneously, making diagnosis and treatment difficult. Case Presentation: A 76-year-old man with a history of recurrent diverticulitis subsequently developed CDI and was referred to us with recurrent symptomatic colitis. In May and November, 2011, he developed left lower quadrant abdominal pain and was treated with ciprofloxacin and metronidazole for 10 days with resolution of symptoms each time. Another episode occurred in December, 2011, but he now developed bloody, watery diarrhea. His stool C. difficile toxin assay was positive, and he was treated with metronidazole for two weeks with resolution of his diarrhea. Three months later, he again developed watery diarrhea, and his stool was positive for C. difficile. He responded to treatment with oral vancomycin followed by a prolonged taper, but within a week of discontinuing the taper, his diarrhea returned and he became dehydrated, requiring hospitalization. His WBC was 15.6 x 10ˆ3/μl. CT scan (June 4, 2012) showed thickening of the distal transverse, descending, and sigmoid colon. Given these findings, he was treated for recurrent sigmoid diverticulitis (ciprofloxacin and metronidazole) and CDI (fidaxomicin followed by a vancomycin taper). Review of his follow-up abdominal CT (June 29, 2012) showed resolution of colitis in the transverse and descending colon, but residual abnormalities in the sigmoid colon. As his symptoms resolved, he continued only a suppressive dose of vancomycin (125 mg once daily). He again became symptomatic (July, 2012) with bloody stools, abdominal cramps, and fever, and was treated for both entities. Although his vancomycin regimen was empirically increased to 250 mg QID, his stool C. difficile assay was negative, and this episode likely represented simple diverticulitis. The patient successfully underwent resection of the sigmoid colon two months later and has had no further symptoms. Conclusion: Management of recurrent CDI and diverticulitis becomes difficult as the antibiotics used to treat the latter are often the culprit in the development of the former. Prior studies suggest that patients with diverticulosis who develop CDI are more prone to CDI, as the diverticula themselves serve as a reservoir for C. difficile spores. In patients with recurrent CDI and concurrent diverticulitis, surgical resection of the latter should be considered.

Intractable Hiccups: A Rare Presentation of Invasive Colon Adenocarcinoma

Introduction: Hiccups are caused by a sudden onset of diaphragmatic and intercostal muscle contraction followed by laryngeal closure. Patients with GI malignancies get hiccups from many causes, such as chemotherapy agents, steroids, or metastases invading the hiccup reflex. However, hiccups as the presenting symptom of advanced cancer is uncommon, and is rarely found in the literature. We present a case of intractable hiccups as the presenting symptom of invasive colon adenocarcinoma. Case: A 67-year-old male with a history of diabetes and hypertension presented to the hospital with persistent hiccups for two months. Chlorpromazine moderately controlled the hiccups, however, they were sometimes severe enough to induce dyspnea. He denied any abdominal pain, nausea, or vomiting, but did report a 20-lb weight loss, decreased appetite, and increasing lower back pain over a two-week period. A CT scan of the abdomen/pelvis showed a 7-cm heterogeneous, ill-defined mass arising from the rectosigmoid colon with necrotic regions. Pelvic MRI localized the mass to the distal sigmoid with a left psoas muscle abscess. Colonoscopy showed a circumferential polypoid friable mass 20 cm from the anal verge, with a narrowed lumen. Subsequent biopsies revealed invasive adenocarcinoma. The patient had an ex-lap where a rectosigmoid mass adherent to the bladder and small bowel was resected, and a final diagnosis was moderately to poorly differentiated adenocarcinoma, stage III T4BN2A. The patient's hiccups decreased in intensity after his surgery. Discussion: Hiccups can be classified into three categories; self-limiting (due to gastric distention from overeating or aerophagia), that last for <48 hours, persistent, lasting for >48 hours, or, rarely, intractable, lasting for >1 month (due to CNS lesions, mediastinal disease, MI, TB, medications, or GI disorders). GI disorders including GERD, achalasia, gastric distention, SBO, and GI malignancies such as esophageal, pancreatic, and biliary cancers may cause intractable hiccups due to visceral afferent fiber stimulation of the vagus nerve in the hiccup reflex arc. GI malignancies may lead to intractable hiccups from cancer drugs such as cisplatin, which releases 5-HT from vagal afferents starting the hiccup reflex, and steroids, which have receptors within the efferent limb of the hiccup reflex. It is very rare for hiccups to develop in a patient with untreated colon adenocarcinoma. To our knowledge, this is the first case in the literature where invasive colon adenocarcinoma presented as intractable hiccups.

Metastatic Infiltrating Ductal Carcinoma of the Breast to the Colon

Purpose: A 76-year-old female presented with a 1-day history of dyspnea and chest tightness. She endorsed a history of estrogen receptors (ER)-positive breast cancer with known metastases involving the bones 4 years prior to presentation. Physical examination showed afebrile patient with stable vital signs. She appeared pale. Cardiopulmonary and abdominal examination was unremarkable. Fecal occult blood was positive. Laboratory studies showed hemoglobin of 8.2 g/dL. Computed tomography (CT) scan of the abdomen and pelvis showed irregular wall thickening of the cecum. The patient subsequently underwent colonoscopy and developed bleeding from the sigmoid colon. Following colonoscopy, the patient began to report generalized abdominal pain. Abdominal X-ray subsequently demonstrated intraabdominal free air. The patient was emergently taken to the operation room where she was found to have a perforation in the distal sigmoid colon and a 2 x 3-cm mass at the ileocecal valve, with peritoneal studding. Limited resection was performed via ileocecectomy with closure of the perforation. Histopathologic examination was consistent with an invasive poorly differentiated ER-positive carcinoma involving the cecum, appendix, and the intra-abdominal adipose tissue, consistent with a breast cancer primary. Adjuvant chemotherapy with cyclophosphamide and doxorubicin was administered post-operatively, following surgical recovery. Colorectal involvement is particularly rare in the setting of metastatic diseases. Breast cancer is the most common tumor to metastasize to the colon, followed by melanoma. Infiltrating lobular breast carcinoma tends to metastasize to the gastrointestinal (GI) tract and that has been linked to a particular tropism of the metastatic cells of lobular ductal carcinoma.Figure: CT abdomen and pelvis. A (coronal view), B&C (axial views) show an area of irregular wall thickening and a fungating mass in the cecum.

Chronic Radiation Proctopathy and Colopathy

Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage, and chronic radiation proctopathy generally manifests with anorectal pain, diarrhea, rectal bleeding, and/or anemia. Endoscopic findings include loss of mucosal vasculature, patchy erythema, and angioectasia, which correlate with ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia on histopathological examination. Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation exposure, they can present up to 30 years after treatment. Radiation proctopathy, found incidentally during endoscopy, does not warrant any therapy. Argon plasma coagulation (APC) is the mainstay of endoscopic therapy for chronic radiation proctopathy. Laser therapy and dilute formalin (2–10%) application are associated with higher complications and are not commonly utilized. In this video presentation, endoscopic findings are described in chronic radiation proctopathy and colopathy as well as APC therapy. This article is part of an expert video encyclopedia.

Tactoid body features in a Schwann cell hamartoma of colonic mucosa

Mesenchymal colorectal polyps are uncommon lesions, particularly those of neurogenic origin. We describe a mucosal Schwann cell hamartoma of the colon with tactoid features, so far reported in peripheral nerve sheath tumours, and address its differential diagnosis and clinical implications. A 72-year-old man underwent screening colonoscopy that presented a 5-mm polyp on distal sigmoid. Histologically, it displayed a lesion in the lamina propria comprising oval structures with tactoid features and bland spindle cells, entrapping adjacent crypts. No ganglion cells were seen. Spindle cells expressed only S-100 protein and vimentin. Mucosal Schwann cell hamartoma was recently recognized as distinct from common (submucosal) colorectal Schwannomas and so far not associated to inherited syndromes. Thus, it should be considered in the differential diagnosis of look-alike lesions (eg, ganglioneuroma, neuroma, and neurofibroma) that may occur in the setting of inherited syndromes such as Cowden syndrome, multiple endocrine neoplasia-2B, and type 1 neurofibromatosis.

Primary intestinal Hodgkin's lymphoma associated with Crohn's disease

The authors present the case of a 37-years-old man with pancolic Crohn’s disease (CD) diagnosed 20 years ago, characterized by a penetrating behavior with need for surgery (segmental colon resection) for a colovesical fistula. Due to a corticodependent evolution, the patient has been in treatment with azathioprine for 8 years, with only partial clinical response, reason why he started infliximab (treatment continued for 3 years). An acute exacerbation prompted a colonoscopy that revealed severe inflammatory activity within the distal sigmoid and rectum with no changes in the remaining colonic and ileal mucosa (Fig. 1). Biopsies revealed infiltration of the mucosa by classic Hodgkin’s lymphoma (Fig. 2), with positivity for Epstein-Barr virus (Fig. 3) and severe inflammatory activity. Computed tomography (Fig. 4) and bone marrow aspirate excluded extra intestinal lymphoproliferative disease (LD). After multidisciplinary consultation, the patient underwent total colectomy plus abdominoperineal resection of rectum (Fig. 5) with permanent ileostomy, the main indication was based on the lack of response to the medical therapy for CD. Since the resected specimen had no evidence of involvement of the isolated lymph nodes, it was decided not to start any adjunctive therapy. Primary intestinal Hodgkin’s lymphoma is very rare presenting an incidence of less than 0.5 % (1). Its association with CD is even rarer, with only sporadic cases described in literature (2). There are still doubts whether the pathogenesis of the increased risk of LD in patients with CD correlates with the inflammatory disease activity or with the immunosuppressive treatment (3,4). The identification of Epstein-Barr virus infection in patients with Hodgkin’s lymphoma is often reported in the described cases, suggesting that this agent might be implicated in the pathogenesis of the LD (5). Primary intestinal Hodgkin’s lymphoma associated with Crohn's disease

VARIATIONS IN MAGNETIC RESONANCE VENOGRAPHIC ANATOMY OF THE DORSAL DURAL VENOUS SINUS SYSTEM IN 51 DOGS

Variations in intracranial dural venous sinus anatomy have been widely reported in humans, but there have been no studies reporting this in dogs. The purpose of this retrospective study was to describe variations in magnetic resonance (MR) venographic anatomy of the dorsal dural venous sinus system in a sample population of dogs with structurally normal brains. Medical records were searched for dogs with complete phase contrast, intracranial MR venograms and a diagnosis of idiopathic epilepsy. Magnetic resonance venograms were retrieved for each dog and characteristics of the dorsal dural sinuses, symmetry of the transverse sinuses and other anatomic variations were recorded. A total of 51 dogs were included. Transverse sinus asymmetry was present in 58.8% of the dogs, with transverse sinus hypoplasia seen in 39.2%, and aplasia in 23.5% of dogs. For 70.6% of dogs, at least one anatomic variation in the dorsal sagittal sinus was observed, including deviation from the midline (33.3%) and collateral branches from either the dorsal sagittal sinus or dorsal cerebral veins (54.9%). In 5 dogs (9.8%) a vessel was also identified running from the proximal transverse sinus to the distal sigmoid sinus, in a similar location to the occipital sinus previously reported in children. Findings from this study indicated that, as in humans, anatomic variations are common in the intracranial dural venous sinus system of dogs. These anatomic variations should be taken into consideration for surgical planning or diagnosis of cerebrovascular disease.