1992, The British Journal of Radiology, 65, 183-184
Case of the month Now you see it... now you don't By John S. Millar, MRCP Department of Radiology, Coventry and Warwickshire Hospital, Stoney Stanton Road, Coventry CV1 4FH, UK (Received 5 December 1990, accepted 24 April 1991)
A 52-year-old female presented with a 6 month history of left iliac fossa pain and alteration of bowel habit. She was rather overweight but examination was otherwise
Figure 1. Smoothly tapering stricture of the mid-transverse colon.
Vol. 65, No. 770
unremarkable. A blood count revealed that she was anaemic with a haemoglobin level of 10.1 g dl~'. A barium enema was requested. Two strictures in the mid-transverse colon were demonstrated (Figs 1 & 2). These appearances were unchanged by intravenous administration of Buscopan 20 mg (hyoscine butylbromide). What is your differential diagnosis?
Figure 2. Spot views of this area showing two separate strictures with an area of normal bowel in between. Normal retrograde filling of the small bowel has occurred accounting for opacification of the loop overlying the spine.
183
Case of the month
Keywords: Barium enema, Colon, Stricture, Ventral hernia
Figure 3. Film taken immediately after reduction of the patient's para-umbilical hernia. Allowing for the presence of some faecal residue and a twist in the proximal transverse colon one can see that the bowel is normally distended with a normal mucosal pattern.
Discussion
These are long strictures affecting adjacent segments of an area of distorted bowel with an abrupt cut-off between normal and abnormal bowel. In some views there appears to be shouldering (Fig. 2). The lumen is circumferentially narrowed and there is a normally distended segment of bowel between the strictures. Primary colonic neoplasm can invade an adjacent segment of bowel and produce this appearance, as can Crohn's disease. However, there was no evidence of mucosal destruction. Serosal or intramural metastases and endometriosis can produce similar patterns to this, but it would be unusual for them to involve such long segments. The very rare linitis plastica type of primary colonic neoplasm can result in long segment stricturing with relative preservation of the mucosal pattern (Thomas, 1987). Local segmental spasm could produce these appearances (Thomas, 1987), but judging by the remainder of the large bowel the Buscopan had been effective. Divertieular strictures can affect long segments of bowel with mucosal preservation. Although there are a few
184
scattered diverticula there are none in the region of the stricture; this would be a very unusual site. Local spread from an adjacent primary tumour, primary, or secondary lymphoma would be associated with an extracolonic mass and destruction of mucosa. A number of benign extrinsic processes can cause colonic strictures. These include pancreatic pseudocysts, colonic retroposition, congenital bands and adhesions (Overton et al, 1954). There was no history of previous surgery in our patient but this is not essential for the formation of adhesions. Inflammation of omentum or the appendices epiploicae, which are particularly abundant in the transverse colon, are well recognized causes (Kyaw & Koehler, 1972). The possibility of a hernia should always be considered when faced with an atypical colonic stricture. The diagnosis is usually obvious in the case of inguinal, femoral or diaphragmatic hernia. In situations where there is no external mass there may be diagnostic confusion as in the case of obturator hernia and sometimes in Spigelian hernias (Balthazar & Subramanyam, 1983). Similarly ventral hernias such as the para-umbilical variety which rarely contain colon may be easily overlooked. During air insufflation in this patient the abdomen became noticeably protuberant. On palpation an easily reducible para-umbilical hernia was found to be the cause. The aetiology of a midline "loop-type" stricture of the transverse colon in this patient was therefore obvious. The diagnosis was confirmed by a radiograph taken immediately after reduction of the hernia (Fig. 3). Considering the prevalence of ventral hernia in the adult population this complication is surprisingly rare. There is only one other report in the recent literature (Forrest & Stanley, 1978) which describes five cases. This is probably because the colon rarely enters the smaller defects while the larger ventral hernias cause little constriction of the bowel contained within them. References BALTHAZAR, E. J. & SUBRAMANYAM, B. R., 1983. Radiographic
diagnosis of Spigelian hernia. The American Journal of Gastroenterology, 78, 525-528. FORREST, J. V. & STANLEY, R. J., 1978. Transverse colon in
adult umbilical hernia. American Journal of Roentgenology, 130, 57-59. KYAW, M. M. & KOEHLER, P. R., 1972. Pseudotumours of
coion due to adhesions. Radiology, 103, 597-599. OVERTON,
R. C ,
BOLTON,
B. F. & USHER,
F. C ,
1954.
Extrinsic deformities of the colon mimicking carcinoma. Surgery, 36, 906-915. THOMAS, B. M., 1987. In A Textbook of Radiology and Imaging, ed. by D. Sutton (Churchill Livingstone, London), pp. 924-928.
The British Journal of Radiology, February 1992
Case of the month Now you see it... now you don't By John S. Millar, MRCP Department of Radiology, Coventry and Warwickshire Hospital, Stoney Stanton Road, Coventry CV1 4FH, UK (Received 5 December 1990, accepted 24 April 1991)
A 52-year-old female presented with a 6 month history of left iliac fossa pain and alteration of bowel habit. She was rather overweight but examination was otherwise
Figure 1. Smoothly tapering stricture of the mid-transverse colon.
Vol. 65, No. 770
unremarkable. A blood count revealed that she was anaemic with a haemoglobin level of 10.1 g dl~'. A barium enema was requested. Two strictures in the mid-transverse colon were demonstrated (Figs 1 & 2). These appearances were unchanged by intravenous administration of Buscopan 20 mg (hyoscine butylbromide). What is your differential diagnosis?
Figure 2. Spot views of this area showing two separate strictures with an area of normal bowel in between. Normal retrograde filling of the small bowel has occurred accounting for opacification of the loop overlying the spine.
183
Case of the month
Keywords: Barium enema, Colon, Stricture, Ventral hernia
Figure 3. Film taken immediately after reduction of the patient's para-umbilical hernia. Allowing for the presence of some faecal residue and a twist in the proximal transverse colon one can see that the bowel is normally distended with a normal mucosal pattern.
Discussion
These are long strictures affecting adjacent segments of an area of distorted bowel with an abrupt cut-off between normal and abnormal bowel. In some views there appears to be shouldering (Fig. 2). The lumen is circumferentially narrowed and there is a normally distended segment of bowel between the strictures. Primary colonic neoplasm can invade an adjacent segment of bowel and produce this appearance, as can Crohn's disease. However, there was no evidence of mucosal destruction. Serosal or intramural metastases and endometriosis can produce similar patterns to this, but it would be unusual for them to involve such long segments. The very rare linitis plastica type of primary colonic neoplasm can result in long segment stricturing with relative preservation of the mucosal pattern (Thomas, 1987). Local segmental spasm could produce these appearances (Thomas, 1987), but judging by the remainder of the large bowel the Buscopan had been effective. Divertieular strictures can affect long segments of bowel with mucosal preservation. Although there are a few
184
scattered diverticula there are none in the region of the stricture; this would be a very unusual site. Local spread from an adjacent primary tumour, primary, or secondary lymphoma would be associated with an extracolonic mass and destruction of mucosa. A number of benign extrinsic processes can cause colonic strictures. These include pancreatic pseudocysts, colonic retroposition, congenital bands and adhesions (Overton et al, 1954). There was no history of previous surgery in our patient but this is not essential for the formation of adhesions. Inflammation of omentum or the appendices epiploicae, which are particularly abundant in the transverse colon, are well recognized causes (Kyaw & Koehler, 1972). The possibility of a hernia should always be considered when faced with an atypical colonic stricture. The diagnosis is usually obvious in the case of inguinal, femoral or diaphragmatic hernia. In situations where there is no external mass there may be diagnostic confusion as in the case of obturator hernia and sometimes in Spigelian hernias (Balthazar & Subramanyam, 1983). Similarly ventral hernias such as the para-umbilical variety which rarely contain colon may be easily overlooked. During air insufflation in this patient the abdomen became noticeably protuberant. On palpation an easily reducible para-umbilical hernia was found to be the cause. The aetiology of a midline "loop-type" stricture of the transverse colon in this patient was therefore obvious. The diagnosis was confirmed by a radiograph taken immediately after reduction of the hernia (Fig. 3). Considering the prevalence of ventral hernia in the adult population this complication is surprisingly rare. There is only one other report in the recent literature (Forrest & Stanley, 1978) which describes five cases. This is probably because the colon rarely enters the smaller defects while the larger ventral hernias cause little constriction of the bowel contained within them. References BALTHAZAR, E. J. & SUBRAMANYAM, B. R., 1983. Radiographic
diagnosis of Spigelian hernia. The American Journal of Gastroenterology, 78, 525-528. FORREST, J. V. & STANLEY, R. J., 1978. Transverse colon in
adult umbilical hernia. American Journal of Roentgenology, 130, 57-59. KYAW, M. M. & KOEHLER, P. R., 1972. Pseudotumours of
coion due to adhesions. Radiology, 103, 597-599. OVERTON,
R. C ,
BOLTON,
B. F. & USHER,
F. C ,
1954.
Extrinsic deformities of the colon mimicking carcinoma. Surgery, 36, 906-915. THOMAS, B. M., 1987. In A Textbook of Radiology and Imaging, ed. by D. Sutton (Churchill Livingstone, London), pp. 924-928.
The British Journal of Radiology, February 1992
