Case of colon gangrene
66 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?
This is a very typical case in elderly women on steroids–small vessel mesenteric disease leading to ischemic(explaining her prodromal pain) and then infarcted right colon (explainig her final presentation)–I have most often seen it in the post-op period following laparotomy for some other problem–angiography generally shows nothing, which is why I say small vessel disease–a very frustrating scenario, because all the help we can give is to take care of the final problem.
Have you ever heard of or seen it in a patient not on steroids (or did you mean non-steroidal anti-inflammatory drugs)?
Is it likely to happen to her again?
or is it characteristically in the right colon?
Follow-up and more history on the 66 year old lady with the colon ischemia:
Cecum was 7 cm on abdominal X-rays well below the 12 or 13 cm usually associated with imminent perforation of pseudo-obstruction. There was definitely not a volvulus. Pathologist states there was venous congestion of the bowel wall (but not of the mesentery) especially the cecum and mucosal hemorrhage and autolysis like that seen with volvulus, but that there were no clots in the mesenteric arteries or veins—he states this does not look like what he would expect with overdistention of the colon—-it was also a map-like pattern of ischemia and congestion not a uniform pattern.
Any other ideas what this could be?
I don’t think she is really elderly—she really doesn’t look that old and now that she is feeling well enough to look at her wrist bracelet and figure out they got her age wrong, I really wouldn’t call her elderly. If this were a small vessel disease problem due to age or steroids or non-steroidal drugs, wouldn’t you expect arterial disease (small vessel arterial disease, that is) instead of venous congestion?
I’ve seen patients in “low flow” state with mesenteric venous thrombosis. Did she have CHF or hypotension preceeding symptoms? You might want to check proteins C and S, anti-thrombin III, anti-cardiolipin antibodies, and activated protein C resistance to see if there is an underlying hypercoagulable state. Elevated homocysteine is also associated with increased thrombosis.