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Dark red rectal bleeding and melena occurred over several days, 4 weeks prior to the patient’s referral. Chest pain occurred during this period diagnosed as angina. Colonoscopy revealed diverticular disease of the sigmoid colon and a lobulated polyp protruding through the ileocecal valve. The polyp intermittently retracted from view, and examination beyond the ileocecal valve confirmed its attachment to the terminal ileum by a broad pedicle. Biopsy showed nonspecific inflammatory changes. A small bowel series confirmed the polyp in the terminal ileum and suggested this was a solitary lesion.

The patient was examined by colonoscopy as a routine follow up procedure in view of a past history of three small benign polyps in the ascending colon. There were no gastrointestinal symptoms. Three hyperplastic polyps (3mm) were removed from the sigmoid (1) ascending colon (2). A polypoid lesion was noted in the partially open ileocecal valve, which was red and smooth. Attempts to biopsy this were unsuccessful. Endoscopy of 10–12cm of terminal ileum proximal to the polypoid lesion showed no abnormality of the mucosa.

The patient presented with a family history of colorectal cancer (mother) and recent increase in rectal bleeding. At colonoscopy, seven polyps in the descending and sigmoid colon were removed by diathermy snare. Six polyps were ≤5mm in size (benign). The largest polyp was situated in the distal sigmoid colon on a short broad pedicle and measured 18mm. This polyp was a villous adenoma containing infiltrating, moderately differentiated carcinoma. After a detailed discussion with the patient, colon resection was recommended.

For a few months, the patient had noticed intermittent pain in the right iliac fossa. There were no gastrointestinal symptoms. On referral to a gynecologist, a mobile firm swelling was palpable in the abdomen. The diagnosis of an ovarian tumor was made and operation advised.

The patient was referred for investigation of an iron deficiency anemia which bone marrow studies suggested was due to chronic blood loss. Over a period of 6 months the patient had suffered episodic abdominal pain of a colicky type and noticed the onset of fatigue and exertional dyspnea. Panendoscopy and colonoscopy soon after the onset of symptoms revealed no abnormality. These endoscopies were repeated 6 months later and again failed to find a cause for bleeding. A small bowel enema x-ray revealed a stricture of the upper jejunum (Figure 5.1).

At the age of 10 years, appendectomy was performed for intermittent abdominal pain. At 33 years of age, laparotomy was performed for acute bowel obstruction that had been preceded by some years of colicky abdominal pain, and during this period he was found to be anemic. At operation, a fibrous stricture, at the base of a Meckel’s diverticulum, was found to be causing the obstruction. This was resected with a side-to-side anastomosis, as the proximal bowel was grossly distended. In 1992, at the age of 55 years, the patient presented with a 9-month history of colicky central abdominal pain and distention. Hematological investigation revealed an iron deficiency anemia. Clinical examination, panendoscopy, and colonoscopy did not reveal significant pathology. A small bowel barium series demonstrated an area of narrowing and dilatation in the lower ileum.

Between 1959 and 1974, the patient had suffered 4 episodes of profuse rectal bleeding requiring transfusion. Barium enema examination (1974) revealed diverticulosis throughout the colon. The patient resided some distance from sophisticated surgical services and this influenced the decision to operate.

The patient suffered recent acute pain in the right iliac fossa. Admission to hospital was necessary, and a plain x-ray of the abdomen revealed loops of dilated small bowel. A gastrograffin enema indicated deformity of the ileocecal region. The patient’s condition settled and he was discharged from hospital and transferred for further investigations.

The patient was examined by colonoscopy in view of a family history of colorectal cancer (mother). There were no previous or current gastrointestinal symptoms. In the base of the cecum there was a smooth hemispherical swelling covered by normal mucosa (Figure 9.1). This was diagnosed as a mucocele of the appendix by the colonoscopist. A computerized tomography (CT) examination demonstrated that the lesion was continuous with the appendix, which was dilated (Figure 9.2).

Following an “influenza type illness,” the patient complained of pain in the right sacral region. A white cell count of 19,000 returned to normal after antibiotics. A computerized tomography (CT) examination of the pelvis revealed a 4.0 × 6.5cm cystic mass, thick walled and partly calcified. The mass was intimately related to the right side of the sigmoid colon and contained multiple septations (Figure 10.1). A calculus was demonstrated in the right ureter. Examination under anesthetic revealed a mobile soft mass in the pelvis. Three small hyperplastic polyps at 20cm were the only abnormalities seen on colonoscopy. The indirect hemagglutination test (IHA) for hydatid disease was negative.