Elderly patient with abdominal pain.
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The colon is distended from the level of the proximal rectum up to the caecum and filled with fluid and inspissated faecal matter. The caecal pole itself is not overtly distended and there is no reflux into the small bowel. No oral contrast has reached the colon. There are no discrete strictures identified. Diverticulae noted in the sigmoid colon. Segmental regions of peri-colic fluid are visible. No discrete regions of substantial wall thickening.
Reconstructions of the SMA/IMA on this portal venous imaging were normal.
A total colectomy has been performed.
Sections show large bowel with confluent coagulative necrosis of mucosa, associated with haemorrhage and a relatively sparse acute inflammatory infiltrate. There is occasional preservation of crypt bases and muscularis propria. The submucosa is oedematous and haemorrhagic. Occasionally there is transmural acute inflammatory infiltrate associated with patchy necrosis of muscularis propria. At the margins the mucosa is necrotic however the muscularis propria appears viable. The mesenteric vessels contain blood however thrombosis is not seen and there is no evidence of vasculitis.
DIAGNOSIS: Large bowel: Acute ischaemic colitis with early infarction.
This case was not prospectively called ischaemic colitis, but the patient went to theatre since she was clinically peritonitic.
TEACHING POINT: apart from obstructing lesions resulting in colonic distension, consider a vascular insult.