Failure of Conservative Management After the Passage of a Distal Colonic “Cast”: Report of a Case

Abstract

When symptoms permit, it is feasible to manage patients conservatively in the short-term after this unusual event to allow recovery from the initial insult and planning of future surgery. However, definitive treatment is surgical and colonoscopic management should not delay this once the patient is fit for surgery.

Passage of “Colonic Cast” after Colorectal Surgery: Report of Four Cases and Review of the Literature

“…The occurrence in the left colon may be explained by the fact that, in most of these cases, the triggering event directly concerned the IMA or its territory, i.e., the left colon. [4][5][6][7][9][10][11] However, in spite of the insufficiency of the marginal artery in the right colon reaching nearly 50% of the population and, moreover, a recent trend of increase in the occurrence of right-sided ischemia reflecting an increased incidence of nonocclusive ischemia, the absence of reports on right-sided casts in the literature is noteworthy. 3 The preservation of the rectum, at least of its outer layer, may be explained by the knowledge that its muscular layer is supplied by the middle rectal artery derived from the internal iliac artery.…”

“…Indications for surgery are mainly intractable diarrhea 4,7,10,11 and stricture. 4,9 The initially reported cases of "colon cast" are marked by prompt interventions following the cast passage, presumably due to an enthusiastic desire to discover the pathology or to the fear of missing a lethal condition. 5,6 However, the need for urgent surgery was really arguable in two cases because of the development of generalized peritonitis and sepsis owing to free perforation of the "inflammatory tunnel" in one 11 and because of occurrence of an acute abdomen in the other.…”

“…3 This latter form universally presents with an abdominal catastrophe, but few patients have been reported to pass the infarcted colonic segment transanally, without such a devastating clinical picture, i.e., the development of peritonitis. [4][5][6][7][8][9][10][11] This particular form of acute necrotizing ischemia, first reported by Speakman 5 in 1984, presents initially in a Figure 5 Coronal maximum intensity projection multidetector CT image reveals cut-off of a vascular branch deriving from a collateral of the middle colic artery, which is indicative of thrombosis (arrow). Note ischemic colonic segment (arrowheads) in the territory of this vessel.…”

“…However, the danger of performing dilatations, even with simple colonoscopy, in such a critical ground must be emphasized. 1,4,10 Surgery, soon or late, is the rule and consists of the resection of the concerned ischemic segment. This intervention may be very atypical and cannot be qualified as a "true resection."…”

“…8 Later, this interval lengthened up to 11 months depending on the patient's symptomatology and willingness to undergo surgery. 4 Foley et al 4 recommend a limited period of conservative management during which the bowel is placed at rest and broad-spectrum antibiotics covering the fecal flora are prescribed to minimize the consequences of ischemia. [1][2][3] Colonoscopic dilatations may defer the intervention.…”