Dina Halegoua-De Marzio, MD, is an attending gastroenterologist and transplant hepatologist in practice at Thomas Jefferson University Hospital in Philadelphia, PA. Halegoua-DeMarzio will oversee the Case Conference blog, working with the fellows at Thomas Jefferson for the most interesting and engaging cases of the month.

Disclosure: Halegoua-DeMarzio reports she was an consultant for Intercept Pharma.

BLOG: 93-year-old male with abdominal pain and distention

Colin Smith, MD, is currently a third year gastroenterology and hepatology fellow at Thomas Jefferson University Hospital. He received a BA from Kenyon College in Gambier, Ohio. He then attended medical school at Jefferson Medical College in Philadelphia, and completed his residency in internal medicine at Thomas Jefferson University Hospital. He looks forward to practicing gastroenterology in the Philadelphia area.

Case

The patient is a 93-year-old with a history of adenocarcinoma of the colon status-post sigmoidectomy ten years prior who presents to the Thomas Jefferson University Hospital emergency department (ED) with abdominal pain and distention. A week prior he was evaluated at another ED and was treated for a fecal impaction with manual disimpaction. In our ED he noted increased abdominal girth without passage of stool or flatus since discharge from the outside ED. He denied fevers, chills, SOB, or chest pain, and had not noticed any recent weight loss, melena, or hematochezia. A rectal tube was placed, resulting in significant output of stool and gas and decreased distention and pain.

Colin Smith

His past medical history included coronary artery disease, H. pylori-associated peptic ulcer disease treated with triple-therapy, untreated prostate cancer, and colon adenocarcinoma (Stage IIA [T3N0M0]) diagnosed 10 years ago. His past surgical history included a two-vessel coronary artery bypass graft, as well as a sigmoidectomy with coloproctostomy for the colon cancer 10 years prior to presentation. His family history and social history were unremarkable.

The patient last underwent colonoscopy five years ago. The preparation was poor. Oozing ulcerations were noted at 40 cm from the anal verge, and biopsies revealed focal ulceration and granulation tissue without evidence of neoplasia.

On exam, his vital signs were normal. His abdomen was moderately distended and tympanic without tenderness. His bowel sounds were active and “tinkling.” There were no palpable masses or organomegaly. The remainder of the exam was unremarkable.

Laboratory Data and Imaging

His complete blood count, metabolic panel, electrolytes, and liver function tests were all normal.

Computed tomography scan of the abdomen and pelvis (CT A/P) revealed marked dilation of the colon distal to the coloproctostomy, measuring up to 17 cm. The remainder of the colon was air filled and mildly dilated, with colonic wall thickening extending from the hepatic flexure to the anastomosis. The anastomotic sutures were intact. The prostate was markedly enlarged to 8.6 cm.

CT IMAGES

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Figure 1: CT A/P showing 8.6 cm prostate.

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Figure 2: CT A/P showing marked distal colonic distention.

Colonoscopy revealed a patent anastomosis at 20 cm from the anal verge. A nodular, ulcerated, circumferential, obstructing lesion was noted at 40 cm. Multiple biopsies were taken

COLONOSCOPY IMAGES

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Figure 3: Patent anastomosis at 20 cm.

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Figure 4: Nodular, obstructing lesion at 40 cm.