Case of colon gangrene

colon gangrene66 year old white female looks much younger than stated age, does not drink or smoke (although her husband was heavy smoker until recently).

Long term history of brief abdominal pain blamed on apparently documented peptic ulcer disease and relieved by ranitidine.

Severe pain 2 weeks ago, went away.

On non-steroidal anti-inflammatory drugs for arthritis type pain.

Yesterday at 2 pm got sudden severe abdominal pain and marked distention (according to family simultaneously)–looked 9 months pregnant.

Earlier yesterday am had normal bowel movement.

Pain was severe constant knife like with cramping exacerbations.

Family agreed that patient had not been distended until this episode started yesterday.

Previous total abdominal hysterectomy (but on exploration no adhesions from this surgery).

Patient had large explosive bowel movement after arriving at hospital but this did not relieve her pain–nurses commented that this bowel movement looked and smelled like the thick yellow stuff coming out her nasogastric tube (which looked and smelled feculent to the nurses but not to me, just like ordinary thick sour gastric contents to me).

When I saw her 5 hours later, she was distended, her abdomen was tender and got progressively more tender (it was rigid by the time we got to the OR about 9 pm) and she had obstructed sounding bowel sounds.

X-rays taken in ER earlier showed air throughout colon and rectum with dilation of the colon but cecum was not dilated enough for imminent rupture, no air in small bowel or stomach on X-rays.

Saw another surgeon first who recommended surgery for small bowel obstruction, but they requested me which explains the slight delay from ER arrival to OR.

At operation, has early gangrene of entire right colon. Flex sig though showed hemorrhagic necrotic changes of mucosa all the way to upper descending colon (I guided the scope while assistant passed it from below so was easily able to get the flex sig to the mid-transverse colon).

There was no obvious volvulus (although transverse and sigmoid colons were both redundant), no adhesions, no cancers, no strictures, no signs of mesenteric vascular insufficiency.

Any ideas about the etiology?

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