Catálogo de publicaciones - libros

Two weeks prior to referral, the patient suffered a sudden episode of colicky abdominal pain accompanied by diarrhea that lasted 3 days. On the third day, the patient passed a small amount of dark red blood. A barium enema 1 week after the onset of symptoms showed an area of narrowing at the splenic flexure (Figure 81.1). The mucosal pattern was distorted, and small areas of “thumb printing” were just visible. A colonoscopy subsequently revealed sigmoid diverticular disease and a marked stenosis at the splenic flexure associated with ulceration. Biopsy showed nonspecific inflammatory changes. A limited contrast enema was performed 5 weeks after the onset of symptoms (Figure 81.2). The stenosis measured 10 cm in length, which the radiologist regarded as consistent with a constricting carcinoma. This diagnosis was not accepted. The patient remained asymptomatic, however a third contrast enema, now 6 months after the acute episode, showed further narrowing of the lumen, which radiologically measured 2 mm in diameter (Figure 81.3).

In 1984, the patient underwent a high anterior resection for symptomatic diverticular disease. On July 4, 1996, laparotomy was performed to exclude a sigmoid carcinoma in view of an abnormality on colonoscopy and computerized tomography (CT) examinations. No lesion was identified in the sigmoid colon, but extensive adhesions were found involving the small bowel, omentum, and the anterior abdominal wall. Due to the trauma of a difficult dissection, a small length of ileum was resected. Three weeks after the operation, a severe bout of abdominal pain occurred followed by persistent pain in the left iliac fossa (LIF). A firm mass was palpable in the LIF. A CT examination confirmed the presence of the mass anteriorly with a “fatty central component” (Figure 82.1). The pain continued and became worse in January 1997, when it was associated with a fever. The patient was treated in the hospital with intravenous antibiotics. When this acute episode subsided, the patient continued to suffer significant pain. On referral, laparotomy was advised.

In October 1996, the patient was admitted to the hospital with acute abdominal pain in the epigastrium and right iliac fossa. Investigations were nonspecific, until a barium enema demonstrated narrowing of the ascending and transverse colon. Colonoscopy was not performed. Six years previously, the patient had a lobular carcinoma of the right breast treated by mastectomy.

The patient had noticed colicky abdominal pain for 3 weeks. There had been fresh blood on the stool on 3 occasions. A barium enema demonstrated a large polypoidal mass in the mid transverse colon (Figure 84.1). Immediately proximal to the mass there was mucosal irregularity and narrowing of the lumen. Computerized tomography (CT) examination confirmed the lesion and excluded other pathology. A colonoscopy was obstructed in the mid transverse colon by what appeared to be a fungating carcinoma. No biopsy was performed.

The diagnosis of endometriosis had been confirmed some years previously and been treated by ovarian cystectomy and laparoscopic pelvic surgery. In 1987, to investigate chronic lower abdominal pain and constipation, flexible sigmoidoscopy to the splenic flexure revealed dome shaped swellings (Figure 85.1), most obvious in the sigmoid colon, covered with normal mucosa, consistent with endometriomas. A gynecologist supervised a further 5 years of medical treatment until the symptoms were sufficiently disabling to require surgery. Repeat endoscopy showed no extension of the colon lesions, which did not show on a barium enema examination.

In 1932, when the patient was a few months old, Hirschsprung’s disease was diagnosed. Details of the method of diagnosis are unknown. As a child, constipation was a significant problem, and in 1942, at age 10, bilateral lumber sympathectomy was performed with some relief of symptoms. In adult life, the constipation continued to be a significant disability despite treatment, which included regular self-administered enemas. Periods of absolute constipation for 2 weeks occurred frequently. A barium enema (Figure 86.1) showed a small-caliber rectum with marked dilatation of the sigmoid colon commencing at the recto sigmoid junction, consistent with Hirschsprung’s disease. Clinical examination and sigmoidoscopy (15 cm) were normal.

The patient was admitted to the hospital with a short history of abdominal pain, distention and absolute constipation for some days. Clinical and radiological examinations confirmed the diagnosis of acute large bowel obstruction.

For his age, the patient had been very active until he developed colicky pain in the right iliac fossa associated with loose stools and minor bleeding. These symptoms had been present for 3 weeks. He had lost weight and was found to be anemic (iron deficiency). On examination of the abdomen, there was no abnormality. Ultrasound examination revealed an abdominal mass in the mid abdomen close to the anterior abdominal wall (no description of the mass available). Colonoscopy revealed a large vascular polypoid tumor filling the lumen “in the mid transverse colon” (biopsy showed benign villous adenoma). At the time of the colonoscopy, under sedation, a mass was palpable in the right iliac fossa.

The barium was injected using a “hand pump” technique, continued despite the patient experiencing severe and increasing pain in the rectum. The patient was unable to evacuate the barium. In hospital, sigmoidoscopy revealed marked edema of the lower half of the rectum. Urgent laparotomy revealed no intraabdominal pathology. A left-sided loop colostomy was performed. Two months later, after referral, sigmoidoscopy examination under anesthetic revealed an indurated strictured rectum with intense inflammation of the mucosa and submucosal barium “blebs.” A traumatic ulcer was present immediately above the anal canal posteriorly. Plain x-rays showed persistence of a large mass of barium in the pelvis. These clinical and radiological findings showed no resolution over the next 17 months of follow up (Figure 89.1).

The patient complained of altered bowel habit and rectal bleeding for 6 weeks. He suffered from significant ischemic heart disease. Clinical examination revealed a palpable carcinoma on the left side of the rectum at 5cm, occupying 50% of the lumen. There was some loss of mobility of the tumor. Colonoscopy was performed to the cecum. The findings were sigmoid diverticulitis and small hyperplastic polyps. No specific difficulty with the examination was recorded. The patient did not complain of any abdominal symptoms subsequent to colonoscopy.