Ischemic Colitis Associated with Colonic Carcinoma" Report o f a Case*
JULIAN R . LEWIN,
M.D., H W E I - S H I E N L. H A H N , M . D .
I%v~mthe Departme~zt oJ Radiob~g_,, Met O" Hospital, Pittsburgh, Peplns~,h,ania
THE ASSOCIATION OF obstructing or potentially obstructing colorectal carcinoma and ischemic colitis in patients without an antecedent history of inflammatory bowel disease has been documented intermittently, although sparsely, since the early 1960s. The development of carcinoma of the descending colon or sigmoid is a gradual insidious process and the patient usually provides the history of gradually increasing constipation with or without hematochezia. Con> plicating ischemic colitis alters this historical sequence by interjecting an acute process associated with abdominal pain, fever, vomiting, diarrhea, and sometimes prostration. This altered historical sequence should raise suspicion in the mind of the more astute clinician of the possibility of these associated disease processes. It is more likely, however, that the diagnosis will be established at the time of barium-enema examination as in the case to be reported. Since the recognition of these associated abnormalities is important within the context of preoperative and surgical management, it is imperative that the radiologic examination be extended beyond the mere recognition of the obstructive site.
T h e following day a barium examination ctisclosed a short constrictive partiall} obstructive lesion in the mid-sigmoid colon whose configuration suggested that it represented a primary neoplasm (Fig. I). T h e r e m a i n d e r of the left colon was filled in an effort to expedite a conternplated double-contrast study, and fluoroscopically it was not appreciated that any abnormality was present in this segment until the film studies were reviewed. At that time it was noted that the configuration of" a 20 cm segment o f the left ~olou was disturbed in a characteristic pattern o f ischelnic colitis. It was also of interest to note that a short segment of normal colon separated that portion o f the cohm ilwolved by {schemic disease from the partially obstructed sigmoid neoplasm (Fig. 2). T h r e e days later left hemicolectomy was p e r f o r m e d following the surgical identification o f an obstructive neoplasm o f the sigmold. T h e d e s c e n d i n g colon was noted to be beef,~ red and thickened in appearance. T h e pathologic report included a poorly differentiated adenocarcinoma of the sigmoid colon with extension to the serosa and metastatic adenocarcinoma to three o f 29 lymph nodes. T h e remaining left colon showed changes consistent with ischemic colitis including necrosis of the nmcosa, e d e m a of the submucosa and slight inflammation o f the muscularis and serosa.
Discussion Ischemic disease o f the colon is being e n c o u n t e r e d more frequently in a hospital population with increasing n u m b e r s of older patients, but is still an uncommon disease. Colorectal carcinoma is a c o m m o n p l a c e diagnosis and, in the western world, is the most freq u e n t cause o f obstruction o f the colon. In spite o f Schwartz and Boley's ~~ e x p e r i e n c e indicating that I0 per cent o f their 90 patients with ischeniic disease o f the colon had associated neoplasnis, we believe that this association is an n n c o m m o n one and this belief is substantiated by o t h e r authors who consider the incidence to be I per cent or less. a'5,r'9 T h e recognition that the colitis proximal to obstructive colorectal carcinoma was ischemic in origin parallelled closely the identification o f the nature o f ischemic colitis itself. T h e non-neoplastic involvement o f the colon was initially variously described as "acute necrotizing colitis, ''r "acute proximal ulcerative colitis, ''~ "colitis, ''s "ulcerative disease, ''n and, if severe, " g a n g r e n e o f the colon. '''-''6 In 1966, however, Glotzer and Pihl 4 theorized that ischemia was the important initial p a t h o g e n i c factor and this e x p l a n a t i o n has come to be accepted by m o r e c o n t e m p o r a r y inves-
Report o f a Case A 54-year-old man was hospitalized on December 3, 1978, complaining o f intermittent crampy left lower q u a d r a n t pain and nausea and vomiting o f 24 hours' duration. Increasing constipation and narrowing of stools had been noted for four to five months. He had been diagnosed as having insulin-dependent adult-onset diabetes in 1968 and hypertension had been noted one year prior to the present admission. T h e patient was a well-nourished, well-developed white man having a p p a r e n t abdominal discomfort. Blood pressure was 160/90 mm Hg, pulse was 80 and regular, respirations were 18 per minute and unlabored. T e m p e r a t u r e on admission was 99.4~ At physical examination findings were negative except for abdominal distention, tympany, and r e b o u n d tenderness localized to the left lower quadrant. H e had high-pitched rushing bowel sounds. Salient laboratory data included hemoglobin 16.1 gm/dl, hematocrit 48 per cent, leukoc~,tes 15,200 with 87 per cent polymorphocytes, glucose 178 mg/dl, blood urea nitrogen I9 mg/dl, amylase 26. T h e chest r o e n t g e n o g r a m was normal. Radiologic examination o f the abdomen demonstrasted gas distention o f the colon down to the level o f its m i d - d e s c e n d i n g p o r t i o n s u g g e s t i n g an i n c o m p l e t e bowel obstruction. * Received for publication April 13, 1979. Address reprint requests to Dr. Lewin, D e p a r t m e n t o f RadiologT, Mercy Hospital, 1400 Locust Street, Pittsburgh, Pennsylvania, 15219.
0012-3706/79/0700i0328/$00.60 9 American Society of Colon and Rectal Surgeons 328
Volume 22
Xumbe~ 5
329
ISCHEMIC COLITIS WITH CARCINOMA
Fro. 1. Right posterior view of constrictive carcinoma of sigmoid colon. t i g a t o r s , a'9,t~ T h i s i s c h e m i a is a p p a r e n t l y r e l a t e d to i n c r e a s e d i n t r a l u m i n a l p r e s s u r e a n d has its m o s t p r o f o u n d e f f e c t u p o n t h e m u c o s a a n d t h e least u p o n t h e serosa. Other types of colorectal obstruction other t h a n s t e n o s i n g c a r c i n o m a likely to c a u s e g a n g r e n o u s o r n o n g a n g r e n o u s d i s t e n t i o n i s c h e m i c colitis ( i n c l u d i n g s t e n o t i c d i v e r t i c u l i t i s , v o l v u l u s , fecal i m p a c t i o n , etc.) have been described by Saegesser and S a n d b l o m ? T h e n e c r o t i z i n g i n f l a m m a t o r y p r o c e s s res u i t i n g D o m i s c h e m i a p r o x i m a l to t h e c o l o n i c car-
cinoma produces the familiar radiologic pattern of irregular narrowing, absence of normal mucosal pattern, "thumb-printing," and isolated discrete ulcerations. T h e t r a n s i t i o n b e t w e e n n o r m a l a n d d i s e a s e d b o w e l is a b r u p t a n d m o s t f r e q u e n t l y a s h o r t s e g m e n t o f n o r m a l b o w e l is p r e s e n t b e t w e e n t h e o b s t r u c t i v e lesion a n d t h e a r e a o f i s c h e m i c colitis. S e v e r e i s c h e m i c d a m a g e m a y b e d i f f i c u l t to i d e n t i f y at l a p a r o t o m y since t h e s e r o s a a n d m u s c u l a r wall, bett e r a b l e to r e s i s t p e r f u s i o n d i m i n u t i o n , m a y a p p e a r f a M y n o r m a l . It is t h e r e f o r e i m p e r a t i v e t h a t t h e d i a g nosis be e s t a b l i s h e d p r e o p e r a t i v e l y since s i g n i f i c a n t m o r b i d i t y a n d m o r t a l i t y o c c u r f r o m s u t u r e - l i n e disr u p t i o n s h o u l d t h e s u r g e o n u n k n o w i n g l y fail to inc l u d e b o t h t h e t u m o r a n d t h e i s c h e m i c s e g m e n t in t h e resection. It would appear that the diagnostic r a d i o l o g i s t m u s t b e a l e r t to t h e p o s s i b i l i t y o f t h e serio u s c o m p l i c a t i o n o f p r o x i m a l i s c h e m i c s e g m e n t s in studying obstructive colorectal disease since the b a r i u m - e n e m a e x a m i n a t i o n m a y a f f o r d t h e first d e finitive i n d i c a t i o n o f this c o m p l i c a t i o n . F r e q u e n t l y , t h e r a d i o l o g i s t is c o n t e n t to t e r m i n a t e t h e e x a m i n a tion following recognition of the location and nature o f t h e o b s t r u c t i v e c a r c i n o m a . T h e c o m p l i c a t i o n o f isc h e m i c colitis a s s o c i a t e d w i t h this a b n o r m a l i t y o c c u r s with s u f f i c i e n t i n c i d e n c e to w a r r a n t f u r t h e r c a r e f u l r a d i o l o g i c e x a m i n a t i o n o f t h e c o l o n in its e n t i r e t y .
Acknowledgment The authors thank Dr. D.J. Dillon for his permission to include data from his patient in this report.
References
Fro. 2. Double-contrast study demonstrating long segment of ischemic colitis in descending colon.
1. Addleman W: Obstructing carcinoma with acute proximal ulcerative colitis. Am J Gastroenterol 40: 174, 1963 2. Dencker H, Lingardh G, Muth T, et al: Massive gangrene of the colon secondary to carcinoma of the rectum: Case report. Acta Chir Scand 135: 357, 1969 3. Ganchrow MI, Clark JF, Benjamin HG: lschemic colitis proximal to obstructing carcinoma of the colon: Report of a case. Dis Colon Rectum 14: 38, 1971 4. Glotzer DJ, Pihl BG: Experimental obstructive colitis. Arch Surg 92: 1, 1966 5. Glotzer DJ, Roth SI, Welch CE: Colonic ulceration proximal to obstructing carcinoma. Surgery 56: 950, 1964 6. Herrmann JW, Paine JR, Stubbe NJ: Acute obstruction with gangrene of the colon secondary to carcinoma of the sigmoid. Surgery 57: 647, 1965 7. Hurwitz A, Khafif RA: Acute necrotizing colitis proximal to obstructing neoplasms of the colon. Surg Gynecol Obstet 111: 749, 1960 8. Millar DM: Colitis and antecedent carcinoma. Dis Colon Rectum 8: 243, 1965 9. Saegesser F, Sandblom P: Ischemic lesions of the distended colon: A complication of obstructive colorectal cancer. Am J Surg 129: 309, 1975 10. Schwartz SS, Boley SJ: Ischemic origin of ulcerative colitis associated with potentially obstructing lesions of the colon. Radiology 102: 249, 1972 1 I. Senturia HR, Wald SM: Ulcerative disease of the intestinal tract proximal to partially obstructing lesions: Roentgen appearance. Am J Roentgenol Radium Ther Nucl Med 99: 45, 1967
JULIAN R . LEWIN,
M.D., H W E I - S H I E N L. H A H N , M . D .
I%v~mthe Departme~zt oJ Radiob~g_,, Met O" Hospital, Pittsburgh, Peplns~,h,ania
THE ASSOCIATION OF obstructing or potentially obstructing colorectal carcinoma and ischemic colitis in patients without an antecedent history of inflammatory bowel disease has been documented intermittently, although sparsely, since the early 1960s. The development of carcinoma of the descending colon or sigmoid is a gradual insidious process and the patient usually provides the history of gradually increasing constipation with or without hematochezia. Con> plicating ischemic colitis alters this historical sequence by interjecting an acute process associated with abdominal pain, fever, vomiting, diarrhea, and sometimes prostration. This altered historical sequence should raise suspicion in the mind of the more astute clinician of the possibility of these associated disease processes. It is more likely, however, that the diagnosis will be established at the time of barium-enema examination as in the case to be reported. Since the recognition of these associated abnormalities is important within the context of preoperative and surgical management, it is imperative that the radiologic examination be extended beyond the mere recognition of the obstructive site.
T h e following day a barium examination ctisclosed a short constrictive partiall} obstructive lesion in the mid-sigmoid colon whose configuration suggested that it represented a primary neoplasm (Fig. I). T h e r e m a i n d e r of the left colon was filled in an effort to expedite a conternplated double-contrast study, and fluoroscopically it was not appreciated that any abnormality was present in this segment until the film studies were reviewed. At that time it was noted that the configuration of" a 20 cm segment o f the left ~olou was disturbed in a characteristic pattern o f ischelnic colitis. It was also of interest to note that a short segment of normal colon separated that portion o f the cohm ilwolved by {schemic disease from the partially obstructed sigmoid neoplasm (Fig. 2). T h r e e days later left hemicolectomy was p e r f o r m e d following the surgical identification o f an obstructive neoplasm o f the sigmold. T h e d e s c e n d i n g colon was noted to be beef,~ red and thickened in appearance. T h e pathologic report included a poorly differentiated adenocarcinoma of the sigmoid colon with extension to the serosa and metastatic adenocarcinoma to three o f 29 lymph nodes. T h e remaining left colon showed changes consistent with ischemic colitis including necrosis of the nmcosa, e d e m a of the submucosa and slight inflammation o f the muscularis and serosa.
Discussion Ischemic disease o f the colon is being e n c o u n t e r e d more frequently in a hospital population with increasing n u m b e r s of older patients, but is still an uncommon disease. Colorectal carcinoma is a c o m m o n p l a c e diagnosis and, in the western world, is the most freq u e n t cause o f obstruction o f the colon. In spite o f Schwartz and Boley's ~~ e x p e r i e n c e indicating that I0 per cent o f their 90 patients with ischeniic disease o f the colon had associated neoplasnis, we believe that this association is an n n c o m m o n one and this belief is substantiated by o t h e r authors who consider the incidence to be I per cent or less. a'5,r'9 T h e recognition that the colitis proximal to obstructive colorectal carcinoma was ischemic in origin parallelled closely the identification o f the nature o f ischemic colitis itself. T h e non-neoplastic involvement o f the colon was initially variously described as "acute necrotizing colitis, ''r "acute proximal ulcerative colitis, ''~ "colitis, ''s "ulcerative disease, ''n and, if severe, " g a n g r e n e o f the colon. '''-''6 In 1966, however, Glotzer and Pihl 4 theorized that ischemia was the important initial p a t h o g e n i c factor and this e x p l a n a t i o n has come to be accepted by m o r e c o n t e m p o r a r y inves-
Report o f a Case A 54-year-old man was hospitalized on December 3, 1978, complaining o f intermittent crampy left lower q u a d r a n t pain and nausea and vomiting o f 24 hours' duration. Increasing constipation and narrowing of stools had been noted for four to five months. He had been diagnosed as having insulin-dependent adult-onset diabetes in 1968 and hypertension had been noted one year prior to the present admission. T h e patient was a well-nourished, well-developed white man having a p p a r e n t abdominal discomfort. Blood pressure was 160/90 mm Hg, pulse was 80 and regular, respirations were 18 per minute and unlabored. T e m p e r a t u r e on admission was 99.4~ At physical examination findings were negative except for abdominal distention, tympany, and r e b o u n d tenderness localized to the left lower quadrant. H e had high-pitched rushing bowel sounds. Salient laboratory data included hemoglobin 16.1 gm/dl, hematocrit 48 per cent, leukoc~,tes 15,200 with 87 per cent polymorphocytes, glucose 178 mg/dl, blood urea nitrogen I9 mg/dl, amylase 26. T h e chest r o e n t g e n o g r a m was normal. Radiologic examination o f the abdomen demonstrasted gas distention o f the colon down to the level o f its m i d - d e s c e n d i n g p o r t i o n s u g g e s t i n g an i n c o m p l e t e bowel obstruction. * Received for publication April 13, 1979. Address reprint requests to Dr. Lewin, D e p a r t m e n t o f RadiologT, Mercy Hospital, 1400 Locust Street, Pittsburgh, Pennsylvania, 15219.
0012-3706/79/0700i0328/$00.60 9 American Society of Colon and Rectal Surgeons 328
Volume 22
Xumbe~ 5
329
ISCHEMIC COLITIS WITH CARCINOMA
Fro. 1. Right posterior view of constrictive carcinoma of sigmoid colon. t i g a t o r s , a'9,t~ T h i s i s c h e m i a is a p p a r e n t l y r e l a t e d to i n c r e a s e d i n t r a l u m i n a l p r e s s u r e a n d has its m o s t p r o f o u n d e f f e c t u p o n t h e m u c o s a a n d t h e least u p o n t h e serosa. Other types of colorectal obstruction other t h a n s t e n o s i n g c a r c i n o m a likely to c a u s e g a n g r e n o u s o r n o n g a n g r e n o u s d i s t e n t i o n i s c h e m i c colitis ( i n c l u d i n g s t e n o t i c d i v e r t i c u l i t i s , v o l v u l u s , fecal i m p a c t i o n , etc.) have been described by Saegesser and S a n d b l o m ? T h e n e c r o t i z i n g i n f l a m m a t o r y p r o c e s s res u i t i n g D o m i s c h e m i a p r o x i m a l to t h e c o l o n i c car-
cinoma produces the familiar radiologic pattern of irregular narrowing, absence of normal mucosal pattern, "thumb-printing," and isolated discrete ulcerations. T h e t r a n s i t i o n b e t w e e n n o r m a l a n d d i s e a s e d b o w e l is a b r u p t a n d m o s t f r e q u e n t l y a s h o r t s e g m e n t o f n o r m a l b o w e l is p r e s e n t b e t w e e n t h e o b s t r u c t i v e lesion a n d t h e a r e a o f i s c h e m i c colitis. S e v e r e i s c h e m i c d a m a g e m a y b e d i f f i c u l t to i d e n t i f y at l a p a r o t o m y since t h e s e r o s a a n d m u s c u l a r wall, bett e r a b l e to r e s i s t p e r f u s i o n d i m i n u t i o n , m a y a p p e a r f a M y n o r m a l . It is t h e r e f o r e i m p e r a t i v e t h a t t h e d i a g nosis be e s t a b l i s h e d p r e o p e r a t i v e l y since s i g n i f i c a n t m o r b i d i t y a n d m o r t a l i t y o c c u r f r o m s u t u r e - l i n e disr u p t i o n s h o u l d t h e s u r g e o n u n k n o w i n g l y fail to inc l u d e b o t h t h e t u m o r a n d t h e i s c h e m i c s e g m e n t in t h e resection. It would appear that the diagnostic r a d i o l o g i s t m u s t b e a l e r t to t h e p o s s i b i l i t y o f t h e serio u s c o m p l i c a t i o n o f p r o x i m a l i s c h e m i c s e g m e n t s in studying obstructive colorectal disease since the b a r i u m - e n e m a e x a m i n a t i o n m a y a f f o r d t h e first d e finitive i n d i c a t i o n o f this c o m p l i c a t i o n . F r e q u e n t l y , t h e r a d i o l o g i s t is c o n t e n t to t e r m i n a t e t h e e x a m i n a tion following recognition of the location and nature o f t h e o b s t r u c t i v e c a r c i n o m a . T h e c o m p l i c a t i o n o f isc h e m i c colitis a s s o c i a t e d w i t h this a b n o r m a l i t y o c c u r s with s u f f i c i e n t i n c i d e n c e to w a r r a n t f u r t h e r c a r e f u l r a d i o l o g i c e x a m i n a t i o n o f t h e c o l o n in its e n t i r e t y .
Acknowledgment The authors thank Dr. D.J. Dillon for his permission to include data from his patient in this report.
References
Fro. 2. Double-contrast study demonstrating long segment of ischemic colitis in descending colon.
1. Addleman W: Obstructing carcinoma with acute proximal ulcerative colitis. Am J Gastroenterol 40: 174, 1963 2. Dencker H, Lingardh G, Muth T, et al: Massive gangrene of the colon secondary to carcinoma of the rectum: Case report. Acta Chir Scand 135: 357, 1969 3. Ganchrow MI, Clark JF, Benjamin HG: lschemic colitis proximal to obstructing carcinoma of the colon: Report of a case. Dis Colon Rectum 14: 38, 1971 4. Glotzer DJ, Pihl BG: Experimental obstructive colitis. Arch Surg 92: 1, 1966 5. Glotzer DJ, Roth SI, Welch CE: Colonic ulceration proximal to obstructing carcinoma. Surgery 56: 950, 1964 6. Herrmann JW, Paine JR, Stubbe NJ: Acute obstruction with gangrene of the colon secondary to carcinoma of the sigmoid. Surgery 57: 647, 1965 7. Hurwitz A, Khafif RA: Acute necrotizing colitis proximal to obstructing neoplasms of the colon. Surg Gynecol Obstet 111: 749, 1960 8. Millar DM: Colitis and antecedent carcinoma. Dis Colon Rectum 8: 243, 1965 9. Saegesser F, Sandblom P: Ischemic lesions of the distended colon: A complication of obstructive colorectal cancer. Am J Surg 129: 309, 1975 10. Schwartz SS, Boley SJ: Ischemic origin of ulcerative colitis associated with potentially obstructing lesions of the colon. Radiology 102: 249, 1972 1 I. Senturia HR, Wald SM: Ulcerative disease of the intestinal tract proximal to partially obstructing lesions: Roentgen appearance. Am J Roentgenol Radium Ther Nucl Med 99: 45, 1967
