Spontaneous passage of a colon ‘cast’ in a patient with ischaemic colitis

Abstract

The first recorded case of a total cast of the left hemicolon being passed spontaneously, per anus, without the development of peritonitis, is presented. Case reportA 64-year-old man presented with a 2 week history of sudden onset of central abdominal discomfort, watery diarrhoea and anorexia, with weight loss of approximately 3 kg. Examination revealed an unwell man, dehydrated, mildly icteric, with a low grade pyrexia and tachycardia. Abdominal examination was uncomfortable and revealed a slightly enlarged liver, a non-tender 6 cm abdominal aortic aneurysm and normal bowel sounds. On rectal examination, a firm ridge could be felt at 6 cm, suggestive of a carcinoma. Sigmoidoscopy, however, revealed a normal 6 cm rectal cuff, above which was blackened mucosa, with yellow watery fluid filling the lumen.An electrocardiograph showed changes consistent with a recent (asymptomatic) inferior myocardial infarction. Biochemistry revealed a raised urea (19.5mmol/l) (normal range 3.(&7.5mrnol/l) and creatinine (207pmol/l) (normal range 53-120pmol/l) and a moderate rise in bilirubin and liver enzymes. He had a normal haemoglobin, an ESR of 80 mm/h and a white cell count of 1 9 . 7~ 109/1 with neutrophilia (87 per cent). Stool culture did not grow any pathogens. A provisional diagnosis of ischaemic colitis was made and the patient was treated expectantly.He remained pain free with normal bowel sounds, his diarrhoea became less frequent and his hydration quickly improved. Biochemically his renal function became normal, and his liver function tests improved.On the seventh day after admission he suddenly and spontaneously passed 96 cm of a full thickness necrotic large bowel cast per anum.His discomfort left him and, clinically, his condition was unchanged. He had a non-tender abdomen and normal bowel sounds. Sigmoidoscopy revealed a granulation tissue lined tract, extending up from the rectal cuff, fully of watery yellow fluid. Plain supine abdominal X-ray demonstrated a normal large bowel gas pattern up to the splenic flexure, after which there was a linear gas shadow extending down deep into the pelvis ( Figure I). His white cell count was 8 . 4~ 109/1 and histology of the bowel revealed it to be a full thickness necrotic cast of the colon. Fifteen hours later and still well having passed flatus, the patient was taken to theatre and explored through a midline incision. At laparotomy, the left colon tract was found to be completely excluded from the general peritoneal cavity by omentum and small bowel adhesions. There was a 6 cm diameter infrarenal abdominal aortic aneurysm with no pulse in the inferior mesenteric artery. The left colon's track was widely laid open and drained and the transverse colon was brought out as an end colostomy. The short rectal cuff that remained was left open to drain.Postoperatively the patient's recovery was uncomplicated and he was discharged on the twelfth postoperative day. On the fiftieth postoperative day he had a straight Dacron graft replacement of the abdominal aortic aneurysm and remains...

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

“…11 Where follow-up is given, patients remained well for up to one year. 6,7,11 In this case, the descending colon and residual sigmoid appear to have infarcted from the level of the anastomosis to 21-cm proximally, whereas the distal side of the anastomosis supplied by the rectal circulation remained viable. This is likely to have occurred during the period of cardiogenic postoperative hypotension in colon in which the blood supply was compromised by previous sacrifice of the inferior mesenteric artery and possibly mesenteric tension caused by inadequate mobilization of the splenic flexure at the Hartmann's reversal.…”

“…This was caused during abdominal aortic aneurysm repair 6,9,11 or was found to be thrombosed in association with an abdominal aortic aneurysm at laparotomy for bowel ischemia. 7,8 In the two other cases, no primary cause was evident. One patient had pancreatitis, and the other had recently undergone resection of a lower rectal carcinoma with formation of a sigmoid pouch-anal anastomosis and ileostomy.…”

“…11 At surgery one patient had extensive bowel ischemia and died soon afterward 4 ; however, other patients were successfully managed with colonic resection and end colostomy or coloanal anastomosis and diverting ileostomy. [6][7][8]10,11 Retention of the granulomatous conduit in one case did not result in complications. 11 Where follow-up is given, patients remained well for up to one year.…”

“…5 On rare occasions, patients have passed infarcted segments of large bowel without such devastating symptoms. [6][7][8][9][10][11] The spontaneous passage of a full-thickness colon cast has been described seven times previously, and one case of a mucosal cast alone exists. 12 All cases have been males aged 52 to 85 years who passed 25-cm-to 96-cm-long segments of sigmoid colon, and sometimes rectum or descending colon.…”

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

“…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.…”