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The patient had been aware of a swelling in the (left) ischiorectal region for 2 years, which altered in prominence with posture, i.e., it appeared to be less obvious when laying on his right side. On examination, a soft cystic swelling was apparent, filling the left ischiorectal fossa. Computerized tomography (CT) examination revealed the ischiorectal lesion was in continuity with a large pelvic mass, mainly left-sided with clearly defined margins. There was displacement of pelvic structures. The maximum diameter was 75mm. It did not appear to be connected with the small or large bowel. Needle biopsy was nondiagnostic.

The patient had been diagnosed with an anal fistula 8 years previously. During this period, intermittent discharge occurred in the left perianal region. He complained of a further swelling in the area, increasing in size over a period of 3 weeks. There were no bowel symptoms. There were 2 firm nodules in the left ischiorectal fossa surrounded by inflammation. Adenocarcinoma was confirmed, “erupting” through the perianal skin. There were enlarged hard lymph nodes in the left inguinal region. Sigmoidoscopy and biopsy identified an ulcerating carcinoma of the sigmoid colon at 20cm.

The patient, who suffered from severe cerebral dementia, was under supervision in a nursing home for the aged. The nursing staff noted rectal prolapse of at least 8 cm in length. An “ulcerated area” on the apex of the prolapse was biopsied and the diagnosis of adenocarcinoma confirmed. The attending gastroenterologist referred the patient. Sigmoidoscopy after reduction of the prolapse located the tumor on the posterior wall of the rectum at 10cm from the anal verge (there is no available record of a colonoscopy). Abdominal computerized tomography (CT) showed no evidence of major perirectal spread or metastatic disease.

The patient complained of symptoms for 8 years, which were: rectal discomfort (“a lump”), frequent bowel actions, diarrhea (mucus), intermittent bleeding, and rectal pain. There was evidence of a chronic anxiety state and addiction to analgesics. Sigmoidoscopy and examination under anaesthesia revealed 2 hard areas of leukoplakia, a fibrous stricture of the mid anal canal, and squamous metaplasia immediately above the dentate line. The mucosa above this area was hyperemic, redundant, and polypoid to a level of 8cm, above which the mucosa was normal. Straining revealed marked internal rectal prolapse. Biopsy of the hyperemic mucosa showed histological changes “consistent with Morson’s solitary rectal ulcer” (Figure 74.1).

The patient presented in 1985 with a long history of were not exclusive of a neoplasm. a sense of blockage in the rectum that resulted in prolonged defecation. There had been minor rectal bleeding and mucous discharge for 1 year. There was no awareness of any prolapse. Rectal examination revealed a firm stricture in the mid rectum, confirmed at 8cm by sigmoidoscopy. The lumen at this point was approximately 13mm in diameter. There were leukoplakia-like projections on the “rim” of the stenosis and 5 areas of shallow ulceration at this level. The base of the ulcers was yellow-white, firm, and surrounded by erythematous mucosa. Above this level to 15cm, the mucosa appeared normal. A barium enema demonstrated the abnormality (Figure 75.1). The radiologist stated the appearances

In June 1977, an anal fistula was treated by operation, and, although healing occurred, the rectum was “abnormal”. The radiological demonstration of a rectal stricture suggested the possibility of Crohn’s disease (Figure 76.1). The patient was referred for further management. Examination under anaesthesia revealed marked rigidity of the anorectal junction and the rectum with a long stricture of the rectum, most marked between 10cm and 13cm. An internal opening was identified on the left lateral aspect of the dentate line with an ascending track passing anteriorly. A focus of granulation tissue at 10cm in the midline anteriorly was identified as a probable secondary internal opening. The rectal mucosa was pale and edematous. Biopsies at various levels showed nonspecific inflammation.

On 5.1.90, endoscopic removal of a sessile rectal polyp (15 × 15 × 3mm) was performed. It was situated posteriorly in the lower third of the rectum. The histology report noted severe dysplasia (“;at least carcinoma in situ”) with no evidence of invasive carcinoma. Within a few days, an abscess appeared in the left ischiorectal fossa, which was drained. A fecal fistula was apparent subsequently. The patient was referred.

During the first year of her life, this patient was treated for bilateral congenital dislocation of the hips. At 26 years (1956), a caesarian section was performed, as there was “a pelvic lump present the size of a tennis ball.“ In 1975, x-rays revealed a large soft-tissue mass in the pelvis, causing a lytic lesion in the sacrum. This was thought to be a chondroma. In 1977, a transabdominal biopsy was performed and the diagnosis of desmoid tumour confirmed. On clinical examination, a firm lobulated mass filled the lower half of the abdomen to the level of the umbilicus. Rectal and vaginal examination revealed a hard pelvic mass causing marked compression of the vagina and rectum. A computerized tomography (CT) scan demonstrated considerable destruction of the sacrum. The tumor size was “12 × 12 × 15cm.” Sigmoidoscopy was not possible. A barium enema revealed sigmoid diverticulosis. At a colorectal conference (1981), the unanimous opinion was that the lesion was inoperable.

For several years, the patient had been troubled with diarrhea (6 bowel movements in 24 hours). The stools often contained small flecks of red blood and mucus. Initially on sigmoidoscopy, the patient was thought to have a polypoid carcinoma at the 20cm level. A further opinion confirmed the diagnosis of pneumatosis coli. Sigmoidoscopy revealed tense submucosal cysts between 20cm and 25cm, mostly 5mm in diameter, but also clusters of smaller lesions throughout the mucosa. Many of the cysts were “capped” with hyperemia. There were also small patches of similar hyperemia without mucosal projections. Biopsy was difficult, because the smooth surface and firm consistency of the cysts hindered closure of the forceps. The histology was consistent with the diagnosis. Colonoscopy was not performed. A barium enema revealed typical appearances of pneumatosis in the descending and sigmoid colon (Figure 79.1).

In 1987, the patient, aged 52 years, was initially investigated for rectal bleeding and a family history of colorectal cancer. Her general health status was frail, with chronic respiratory disease, severe kyphosis, osteoporosis, recurring vertebral fractures, obesity, and a Cushinoid state induced by years of steroid therapy administered for severe generalized eczema. There was a long history of constipation. Due to respiratory insufficiency and muscle weakness, the patient’s ambulatory capacity was limited to a few steps. On January 24, 1997, the patient was admitted to the hospital with severe abdominal pain and clinical signs of peritonitis.