Benign colonic stricture with colo-colonic fistula

Case contributed by Dr Michael P Hartung

Presentation

Abdominal pain and distension.

Patient Data

Age: 75
Gender: Female

Large, dilated loop of colon within the right and mid abdomen (likely cecum). Mildly dilated loop of colon in the left abdomen. Small bowel is nonobstructed.

Mildly dilated small bowel without discrete transition point. Dilated cecum containing a small amount stool and mostly air (pseudopneumatosis). Mild distention of the remainder of the large bowel, which transitions at a site of narrowing at the junction of the distal descending and sigmoid colon, with extensive diverticulosis of the sigmoid colon noted at this location. 

Thin colo-colonic fistula containing air along the medial and superior aspect of this narrowing which can be best seen on the coronal reformatted images.

Pathology report: 

TISSUES: Sigmoid colon - SIGMOID COLON AND DISTAL DESENDING COLON SENT UNFIXED
GROSS DESCRIPTION:
Specimen received unfixed labeled sigmoid and distal descending colon consists of a colon segment 25 x 3 cm with attached fat. The center is slightly dusky in appearance. No other surface abnormalities are seen. The specimen is opened to reveal multiple diverticula with abscess formation and thickened wall. A single small lymph node is seen in the fat. Representative sections submitted.

FINAL DIAGNOSIS:
Sigmoid and distal descending colon, resection:
- Diverticulitis with abscess formation and acute serositis.
- Single benign lymph node.

Case Discussion

When approaching colonic strictures, it is almost always to include diverticular, ischemic, inflammatory, or malignant etiologies in the differential diagnosis, while using clues in the case to favor one over the other when possible. This will help the surgeon determine their approach and properly prepare for the procedure. 

In this case, the sigmoid colon appears shortened, thickened, and with extensive diverticula. There is also a thin tract along the medial aspect which appears separate from the lumen, likely representing a thin colo-colonic fistula bypassing the scarred-down and thickened sigmoid colon. 

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Case information

rID: 59439
Published: 11th Apr 2018
Last edited: 12th Apr 2018
Inclusion in quiz mode: Included

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