Presentation
Worsening abdominal pain
Patient Data
Dilated transverse colon noted. The abdomen demonstrates markedly dilated transverse colon (9 cm) with impression of slight dilatation of the descending colon with some "thumbprinting" in the wall (consistent with mucosal inflammation in the clinical circumstances). No free subphrenic gas is seen.
Case Discussion
This patient was transferred from a rural center with exacerbation of known ulcerative colitis despite steroid. Imaging to exclude toxic megacolon.
They went on to have a subtotal colectomy.
Pathology
MACROSCOPIC DESCRIPTION:
"Subtotal colectomy": A subtotal colectomy specimen consisting of 10mm terminal ileum, and 770mm of attached colon. There is severe confluent mucosal ulceration extending from the ascending colon through to a point 10mm from the distal resection margin. There are only a few residual polypoid islands of mucosa. There is patchy ulceration of the cecal mucosa. Inflammation appears largely confined to mucosa and submucosa. The wall is not significantly thickened. There is no stricturing or fat wrapping. There is no macroscopic evidence of perforation. There is no evidence of megacolon, the specimen having a maximum diameter of 70mm. No mass lesions are seen. There are multiple mesenteric nodes up to 10mm.
MICROSCOPIC DESCRIPTION:
Sections show a fulminant acute colitis extending from the cecum to approximately 15 mm. from the distal resection margin. Active chronic inflammation involves principally the the mucosa and submuscosa with broad areas of ulceration. Many of the ulcers extend to the inner layer of the muscularis propria. No granulomas are identified. The subserosa and serosa show comparatively mild chronic inflammation and vascular congestion. The intact mucosa shows no Paneth-cell metaplasia. There is no hypertrophy of the muscularis mucosae or ganglion cells. The attached terminal ileum is spared. There is no appendiceal involment. The pericolic nodes show follicular hyperplasia and congestion. The features are of active ulcerative colitis. No dysplastic features are seen and there is no evidence of tumor.
DIAGNOSIS:
Subtotal colectomy and appendectomy: Active ulcerative colitis extending from cecum to 15mm from distal resection margin; sparing of terminal ileum and appendix; reactive changes in mesenteric lymph nodes; no dysplasia or evidence of tumor seen.
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