892
Letters to the Editor
these polyps is largely endoscopic polypectomy, there are occasions that this may not be feasible and surgical resection is necessitated. If surgical resection is performed, subsequent surveillance and follow-up is well described by NICE guidelines. However, there remains controversy as to the surveillance regimen of malignant polyps treated by endoscopic resection. The British Society of Gastroenterology/Association of Clinical Pathologists recommends endoscopic surveillance at 3 months, and in certain cases 9 months as well after the initial polypectomy. In other countries, the surveillance regimen is rather more intense. In the USA, endoscopic surveillance is performed at 3 months and then at 1, 3 and 5 years. Several studies have also recommended more frequent endoscopic surveillance in the short term with recurrence rates of up to 20%. In a pilot study at our District General Hospital over a 5-year period, there was a 14% local recurrence rate (2/14) within 12 months. As malignant polyps represent a different clinical entity to both colorectal cancer treated with surgical resection and benign polyps with various degrees of dysplasia, there is a distinct lack of evidence for the duration and frequency of an endoscopic surveillance regimen. This poses a difficult clinical dilemma and there are considerable variations in the investigations patients receive. References 1. Bujanda L, Cosme A, Gil I, Arenas-Mirave JI. Malignant colorectal polyps. World J. Gastroenterol. 2010; 16: 3103–11. 2. Netzer P, Forster C, Biral R et al. Risk factor assessment of endoscopically removed malignant colorectal polyps. Gut 1998; 43: 669–74. 3. Volk EE, Goldblum JR, Petras RE, Carey WD, Fazio VW. Management and outcome of patients with invasive carcinoma arising in colorectal polyps. Gastroenterology 1995; 109: 1801–7. 4. Guittet L, Bouvier V, Mariotte N et al. Performance of immunochemical faecal occult blood test in colorectal cancer screening in average risk population according to positivity threshold and number of samples. Int. J. Cancer 2009; 125: 1127–33.
Roland Fernandes,* MRCS, MBBS Irshad Shaikh,† FRCS, MBBS Sameer Doughan,‡ FRCS, MBBS Henk Wegstapel,§ FRCS, MBBS Pankaj Gandhi,§ FRCS, MBBS *Department of Surgery, Royal Hampshire NHS Trust, Basingstoke, UK, †Department of Surgery, St Mark’s Hospital, Harrow, UK, ‡Department of Surgery, Queen Elizabeth The Queen Mother Hospital, Margate, UK and §Department of Surgery, Medway Maritime Hospital, Medway, UK doi: 10.1111/ans.12682
Dear Editor, B-cell lymphoma presenting as pneumatosis intestinalis: a case report A 67-year-old man, previously healthy, was referred to the surgical outpatient clinic by his general practitioner (GP) for review and
Fig. 1. CT abdomen (axial view) with arrows pointing to pneumatosis intestinalis, seen as gas in the intestinal wall.
management following an abdominal computed tomography (CT) that showed small bowel obstruction with pneumatosis intestinalis (PI) and pneumoperitoneum (Fig. 1). The CT abdomen had been organized by the GP for investigation of the patient’s 10-month history of intermittent lower abdominal pain. As a consequence of the patient’s ongoing symptoms and the CT findings, an elective laparotomy was undertaken. At operation, a nodular stricture was found in the distal jejunum with proximal small bowel dilatation. The stricture was resected and the bowel was primarily anastomosed. The histology of the stricture revealed diffuse large B-cell lymphoma (DLBCL). The patient was subsequently referred to a haematologist for chemotherapy. His abdominal symptoms resolved following the surgery. PI is an uncommon disorder where gas is seen to be present in the small or large bowel wall, either at operation or on imaging. Its reported incidence has increased with the availability of CT scanning and it is usually detected incidentally. It can be categorized as either primary/idiopathic (15% of all cases) or secondary.1 The causes of secondary PI can be further divided into benign or lifethreatening causes.2 Benign causes can be pulmonary disease, systemic diseases (such as scleroderma), intestinal pathology (such as intestinal obstruction), iatrogenic, drug induced, or following organ transplantation. Life-threatening causes include intestinal ischaemia, toxic megacolon and trauma.2 Patients with life-threatening PI usually (but not always) display signs of peritonism, unlike patients with benign PI who are typically asymptomatic.1 In our patient, it is likely that the DLBCL caused the nodular stricture, in turn causing partial bowel obstruction which led to the formation of PI. Thus, in patients presenting with PI, primary small bowel lymphoma should be considered in the differential diagnosis. References 1. Khalil PN, Huber-Wagner S, Ladurner R et al. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur. J. Med. Res. 2009; 14: 231–9.
© 2014 Royal Australasian College of Surgeons
Letters to the Editor
893
2. Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am. J. Roentgenol. 2007; 188: 1604–13.
Reizal Mohd Rosli,* MBBS, BSc (Med) Devinder Raju,* FRACS, MBBS Andrew Luck,* FRACS Smita Raju,† FRANZCR, MBBS Divisions of *Surgery and †Radiology, The Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia doi: 10.1111/ans.12750
Dear Editor, Very rare cause of sepsis We review a 58-year-old woman who had an occult infective source. She initially presented to a regional hospital with fever and groin pain. There, she had a non-contrast computed tomography (CT). She was diagnosed with uncomplicated diverticulitis and discharged with antibiotics. After a week without improvement, she came to our tertiary hospital complaining of the same symptoms. Relevant background history included stepping down heavily from a ladder, ‘pulling a groin muscle’. On examination, she was febrile and tender in the right inguinal region. The abdomen was soft and minimally tender in the lower quadrants. Her white cell count was normal and the C-reactive protein was 270. When the previous non-contrast CT was reviewed, the diagnosis of diverticulitis was questioned and a contrast-enhanced CT was performed. This was reported showing thickening of sigmoid colon with adjacent inflammation. Diverticula were present but not inflamed. A flexible sigmoidoscopy followed; the mucosa was normal.
Despite broad-spectrum antibiotics she deteriorated, developing a limp and suprapubic pain. Repeated reviews of the imaging revealed an ill-defined obturator internus abscess, measuring 65 × 20 mm (Fig. 1), associated with pubic symphysis osteomyelitis. CT-guided percutaneous drainage yielded purulent fluid containing Enterococcus faecalis. The original CT was also diagnostic in retrospect, showing asymmetry of the pelvic musculature. She began to improve after the procedure and was discharged on intravenous antibiotics. Obturator internus pyomyositis (OIP) is very rare in adults, with only three recorded cases in the literature. It is more common in tropical paediatric populations; Viani et al.1 reviewed seven paediatric cases of OIP. Typical presentation was with fever, hip pain and abdominal pain following trauma or strenuous activity. Trauma in this case was the likely precipitant causing pyomyositis. The rarity of primary pyomyositis in temperate climes can lead to delayed diagnosis.2,3 Repeated reviews of imaging in occult cases are indicated. References 1. Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin. Infect. Dis. 1999; 28: 117–22. 2. Hadjipavlou M, Butt DA, McAllister J. Primary Pyomyositis: an unusual presentation in an older patient with no recognised risk factors. BMJ Case Rep. 2012; 2012: pii: bcr1220115342. 3. Bertrand SL, Lincoln ED, Prohaska MG. Primary pyomyositis of the pelvis in children: a retrospective review of 8 cases. Orthopedics 2011; 34: e832.
Kang Ler Fong,* MBBS Alistair Spiers,† MBBS Roshanak Kamyab,‡ MBBS, FRACS *JMO, †General Surgery and ‡Breast Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia doi: 10.1111/ans.12769
Dear Editor, Case report: a rare incidental finding during laparoscopic appendicectomy
Fig. 1. An axial view of computed tomography scan showing pyomyositis obturator internus.
© 2014 Royal Australasian College of Surgeons
A 37-year-old gentleman presented with severe abdominal pain to Canterbury Hospital, Sydney, NSW, Australia. He was referred into hospital by his general practitioner with a computed tomography (CT) scan and was reviewed by the on-call surgical registrar. Otherwise, he is a fit and healthy individual with no concurrent co-morbidities. Past medical history included that at the age of 18, he was involved in a motor vehicle accident (MVA) that resulted in head trauma, fractured left orbit, comminuted nasal bones and a ruptured spleen. He subsequently underwent a laparotomy splenectomy with nil complications in Lebanon. Diagnosis of acute appendicitis was made and he was urgently consented, and theatre was arranged for emergency laparoscopic appendicectomy, fearing sepsis in this splenectomized patient. The
Letters to the Editor
these polyps is largely endoscopic polypectomy, there are occasions that this may not be feasible and surgical resection is necessitated. If surgical resection is performed, subsequent surveillance and follow-up is well described by NICE guidelines. However, there remains controversy as to the surveillance regimen of malignant polyps treated by endoscopic resection. The British Society of Gastroenterology/Association of Clinical Pathologists recommends endoscopic surveillance at 3 months, and in certain cases 9 months as well after the initial polypectomy. In other countries, the surveillance regimen is rather more intense. In the USA, endoscopic surveillance is performed at 3 months and then at 1, 3 and 5 years. Several studies have also recommended more frequent endoscopic surveillance in the short term with recurrence rates of up to 20%. In a pilot study at our District General Hospital over a 5-year period, there was a 14% local recurrence rate (2/14) within 12 months. As malignant polyps represent a different clinical entity to both colorectal cancer treated with surgical resection and benign polyps with various degrees of dysplasia, there is a distinct lack of evidence for the duration and frequency of an endoscopic surveillance regimen. This poses a difficult clinical dilemma and there are considerable variations in the investigations patients receive. References 1. Bujanda L, Cosme A, Gil I, Arenas-Mirave JI. Malignant colorectal polyps. World J. Gastroenterol. 2010; 16: 3103–11. 2. Netzer P, Forster C, Biral R et al. Risk factor assessment of endoscopically removed malignant colorectal polyps. Gut 1998; 43: 669–74. 3. Volk EE, Goldblum JR, Petras RE, Carey WD, Fazio VW. Management and outcome of patients with invasive carcinoma arising in colorectal polyps. Gastroenterology 1995; 109: 1801–7. 4. Guittet L, Bouvier V, Mariotte N et al. Performance of immunochemical faecal occult blood test in colorectal cancer screening in average risk population according to positivity threshold and number of samples. Int. J. Cancer 2009; 125: 1127–33.
Roland Fernandes,* MRCS, MBBS Irshad Shaikh,† FRCS, MBBS Sameer Doughan,‡ FRCS, MBBS Henk Wegstapel,§ FRCS, MBBS Pankaj Gandhi,§ FRCS, MBBS *Department of Surgery, Royal Hampshire NHS Trust, Basingstoke, UK, †Department of Surgery, St Mark’s Hospital, Harrow, UK, ‡Department of Surgery, Queen Elizabeth The Queen Mother Hospital, Margate, UK and §Department of Surgery, Medway Maritime Hospital, Medway, UK doi: 10.1111/ans.12682
Dear Editor, B-cell lymphoma presenting as pneumatosis intestinalis: a case report A 67-year-old man, previously healthy, was referred to the surgical outpatient clinic by his general practitioner (GP) for review and
Fig. 1. CT abdomen (axial view) with arrows pointing to pneumatosis intestinalis, seen as gas in the intestinal wall.
management following an abdominal computed tomography (CT) that showed small bowel obstruction with pneumatosis intestinalis (PI) and pneumoperitoneum (Fig. 1). The CT abdomen had been organized by the GP for investigation of the patient’s 10-month history of intermittent lower abdominal pain. As a consequence of the patient’s ongoing symptoms and the CT findings, an elective laparotomy was undertaken. At operation, a nodular stricture was found in the distal jejunum with proximal small bowel dilatation. The stricture was resected and the bowel was primarily anastomosed. The histology of the stricture revealed diffuse large B-cell lymphoma (DLBCL). The patient was subsequently referred to a haematologist for chemotherapy. His abdominal symptoms resolved following the surgery. PI is an uncommon disorder where gas is seen to be present in the small or large bowel wall, either at operation or on imaging. Its reported incidence has increased with the availability of CT scanning and it is usually detected incidentally. It can be categorized as either primary/idiopathic (15% of all cases) or secondary.1 The causes of secondary PI can be further divided into benign or lifethreatening causes.2 Benign causes can be pulmonary disease, systemic diseases (such as scleroderma), intestinal pathology (such as intestinal obstruction), iatrogenic, drug induced, or following organ transplantation. Life-threatening causes include intestinal ischaemia, toxic megacolon and trauma.2 Patients with life-threatening PI usually (but not always) display signs of peritonism, unlike patients with benign PI who are typically asymptomatic.1 In our patient, it is likely that the DLBCL caused the nodular stricture, in turn causing partial bowel obstruction which led to the formation of PI. Thus, in patients presenting with PI, primary small bowel lymphoma should be considered in the differential diagnosis. References 1. Khalil PN, Huber-Wagner S, Ladurner R et al. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur. J. Med. Res. 2009; 14: 231–9.
© 2014 Royal Australasian College of Surgeons
Letters to the Editor
893
2. Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am. J. Roentgenol. 2007; 188: 1604–13.
Reizal Mohd Rosli,* MBBS, BSc (Med) Devinder Raju,* FRACS, MBBS Andrew Luck,* FRACS Smita Raju,† FRANZCR, MBBS Divisions of *Surgery and †Radiology, The Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia doi: 10.1111/ans.12750
Dear Editor, Very rare cause of sepsis We review a 58-year-old woman who had an occult infective source. She initially presented to a regional hospital with fever and groin pain. There, she had a non-contrast computed tomography (CT). She was diagnosed with uncomplicated diverticulitis and discharged with antibiotics. After a week without improvement, she came to our tertiary hospital complaining of the same symptoms. Relevant background history included stepping down heavily from a ladder, ‘pulling a groin muscle’. On examination, she was febrile and tender in the right inguinal region. The abdomen was soft and minimally tender in the lower quadrants. Her white cell count was normal and the C-reactive protein was 270. When the previous non-contrast CT was reviewed, the diagnosis of diverticulitis was questioned and a contrast-enhanced CT was performed. This was reported showing thickening of sigmoid colon with adjacent inflammation. Diverticula were present but not inflamed. A flexible sigmoidoscopy followed; the mucosa was normal.
Despite broad-spectrum antibiotics she deteriorated, developing a limp and suprapubic pain. Repeated reviews of the imaging revealed an ill-defined obturator internus abscess, measuring 65 × 20 mm (Fig. 1), associated with pubic symphysis osteomyelitis. CT-guided percutaneous drainage yielded purulent fluid containing Enterococcus faecalis. The original CT was also diagnostic in retrospect, showing asymmetry of the pelvic musculature. She began to improve after the procedure and was discharged on intravenous antibiotics. Obturator internus pyomyositis (OIP) is very rare in adults, with only three recorded cases in the literature. It is more common in tropical paediatric populations; Viani et al.1 reviewed seven paediatric cases of OIP. Typical presentation was with fever, hip pain and abdominal pain following trauma or strenuous activity. Trauma in this case was the likely precipitant causing pyomyositis. The rarity of primary pyomyositis in temperate climes can lead to delayed diagnosis.2,3 Repeated reviews of imaging in occult cases are indicated. References 1. Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin. Infect. Dis. 1999; 28: 117–22. 2. Hadjipavlou M, Butt DA, McAllister J. Primary Pyomyositis: an unusual presentation in an older patient with no recognised risk factors. BMJ Case Rep. 2012; 2012: pii: bcr1220115342. 3. Bertrand SL, Lincoln ED, Prohaska MG. Primary pyomyositis of the pelvis in children: a retrospective review of 8 cases. Orthopedics 2011; 34: e832.
Kang Ler Fong,* MBBS Alistair Spiers,† MBBS Roshanak Kamyab,‡ MBBS, FRACS *JMO, †General Surgery and ‡Breast Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia doi: 10.1111/ans.12769
Dear Editor, Case report: a rare incidental finding during laparoscopic appendicectomy
Fig. 1. An axial view of computed tomography scan showing pyomyositis obturator internus.
© 2014 Royal Australasian College of Surgeons
A 37-year-old gentleman presented with severe abdominal pain to Canterbury Hospital, Sydney, NSW, Australia. He was referred into hospital by his general practitioner with a computed tomography (CT) scan and was reviewed by the on-call surgical registrar. Otherwise, he is a fit and healthy individual with no concurrent co-morbidities. Past medical history included that at the age of 18, he was involved in a motor vehicle accident (MVA) that resulted in head trauma, fractured left orbit, comminuted nasal bones and a ruptured spleen. He subsequently underwent a laparotomy splenectomy with nil complications in Lebanon. Diagnosis of acute appendicitis was made and he was urgently consented, and theatre was arranged for emergency laparoscopic appendicectomy, fearing sepsis in this splenectomized patient. The
