Photo Essay: Gastrointestinal Disorders

Photo Essay
A Collage of Images on a Clinical Theme  

Postoperative Intra-abdominal Abscess

VIRENDRA PARIKH, MD
Fort Wayne, Indiana

During a laparotomy for perforated sigmoid colon diverticulitis, a 75-year-old woman was found to have extensive peritonitis. She underwent sigmoid colon resection and colostomy. Postoperatively, she recovered slowly. The peritoneal fluid grew Escherichia coli, and she was given broad-spectrum intravenous antibiotic therapy.

Five days after surgery, high-grade fever and abdominal pain on the left side developed. The patient’s white blood cell count rose to 20,000/µL. There were signs of septicemia.

A CT scan of the abdomen showed a well-localized abscess in the left paracolic gutters. Percutaneous drainage of the abscess with CT guidance removed 30 mL of purulent material, which grew E coli and Klebsiella. The antibiotic regimen was changed based on the sensitivity of the organisms. The patient recovered completely.

Persistent, spiking fever accompanied by dull pain, anorexia, and weight loss are the clinical hallmarks of an intra-abdominal abscess.Abdominal CT imaging is the most efficient means of diagnosis. Exact localization of the abscess is important for management, which may involve needle aspiration and catheter drainage using CT or ultrasonography.

Indications for open surgical drainage are failure of percutaneous drainage, inability to safely drain percutaneously, an association with a bowel fistula, and the presence of multiloculated interloop abscesses. ■

Gastric Submucosal Tumor

LUCÍA C. FRY, MD, and
KLAUS E. MÖNKEMÜLLER, MD
Chandler, Arizona

A 60-year-old woman with a history of iron deficiency anemia was hospitalized because of an episode of melena. A colonoscopy performed a year earlier had shown left-sided diverticulosis but was otherwise unremarkable.

The patient underwent an esophagogastroduodenoscopy, which revealed a submucosal gastric tumor in the antrum, at a distance of 3 cm from the pylorus, in the greater curvature of the stomach. The mucosa covering the mass did not differ from the remaining antral mucosa. Probing of the submucosal tumor with the tip of the biopsy forceps revealed a solid consistency. There was no “cushion sign” suggestive of a soft lesion, such as a cyst or a lipoma.

Histologic examination of biopsy specimens revealed adenocarcinoma, which was most consistent with metastatic colon cancer. Colonoscopy showed left-sided diverticulosis and a right-sided colon cancer. 

The most common malignancy in the stomach is primary gastric cancer that arises from the glands of the mucosa.¹ The stomach can be involved in the metastasis of other cancers, such as malignant melanoma (the most frequently observed) and cancer of the breast, colon, lung, ovary, liver, and testis. Symptoms of metastatic cancer are similar to those of the primary cancer (ie, nausea, vomiting, anemia, loss of weight).

Most metastatic cancers present as ulcerated masses or nodules. The presentation of metastatic colon cancer as a submucosal gastric tumor, as in this patient, is unusual.

Histopathologic diagnosis of submucosal GI tumors is usually difficult because they are covered by normal mucosa, and routine surface biopsy is not sufficient to establish the diagnosis. In this case, biopsy specimens were obtained by using a “biopsy-on-biopsy” technique.²

A submucosal tumor of the intestinal tract also can be explored with endoscopic ultrasonography. However, endoscopic ultrasound-guided fine-needle aspiration has relatively low sensitivity for cytopathologic diagnosis.³

This patient underwent right hemicolectomy and received chemotherapy. An esophagogastroduodenoscopy performed 6 months later showed no recurrence of the gastric lesion. ■

REFERENCES:

1.Davis GR. Neoplasms of the stomach. In: Sleisenger M, Fordtran J, eds. Gastrointestinal Disease. Vol 1. 5th ed. Philadelphia: WB Saunders Co; 1993:763-789.

2.Karita M, Tada M. Endoscopic and histologic diagnosis of submucosal tumors of the gastrointestinal tract using combined strip biopsy and bite biopsy. Gastrointest Endosc. 1994;40:749-753.

3.Rösch T. Endoscopic ultrasonography in upper gastrointestinal submucosal tumors: a literature review. Gastrointest Endosc Clin N Am. 1995;5:609-614.

Paralytic Ileus

VIRENDRA PARIKH, MD
Fort Wayne, Indiana

Five days after a 70-year-old woman had undergone colon resection for cancer, she started to have abdominal bloating and pain. She was receiving a clear liquid diet. Later that day she vomited bilious material.

The physical examination showed distension of the abdomen and tympany. Bowel sounds were absent. Abdominal radiographs (A and B) confirmed generalized gaseous distension of both large and small intestines.

The patient was treated with nasogastric tube decompression, bowel rest, and intravenous fluids. She also was found to have a serum potassium level of 2.5 mEq/L. Supplemental potassium was given to correct the level. After 48 hours, bowel function returned to normal.

Paralytic ileus is a type of non-mechanical bowel obstruction that occurs when peristalsis ceases, even though the lumen is unobstructed. This can result from various conditions, but it is most frequently encountered during the postoperative period after abdominal surgery. Manipulation of the bowel during the operation as well as postoperative narcotic analgesia are the main contributory factors. Lack of physical activity after surgery and postoperative fluid and electrolyte imbalance can also play a role. Other causes are spinal injury, pneumonia, pancreatitis, metabolic disturbances, and sepsis.

The diagnosis of paralytic ileus is based on physical examination and radiologic findings. Treatment consists of bowel rest, intravenous fluid administration, and nasogastric tube decompression along with correction of underlying causes. ■

Esophageal Carcinoma With Tracheoesophageal Fistula

CHRISTOPHER C. BRODKIN, MD
John H. Stroger Jr Hospital, Cook County, Chicago

An 84-year-old woman presented with a 10-month history of dysphagia to solids and a 4-month history of dysphagia and coughing to liquids. She was severely dehydrated and cachectic; over the past 10 months, she had lost 16.2 kg (36 lb). Rhonchi and gurgling sounds were audible on auscultation of the chest.

An esophagram demonstrated a communication between the esophagus and the left main bronchus (A, black arrow). High-resolution CT revealed a mass in the mid esophagus with a communication to the left main bronchus (B, red arrow).

Esophageal carcinoma with tracheoesophageal fistula was diagnosed based on the results of esophagogastroduodenoscopy with biopsy. The cancer was classified as stage 3 because it had eroded through the esophagus, but no metastases were found. Shortly after the patient received the diagnosis, aspiration pneumonia developed, followed by respiratory failure. She was resuscitated, and mechanical ventilation was started.

When the patient regained consciousness and was extubated, she declined esophageal resection and requested a “do not resuscitate” order. For palliation, an esophageal stent was placed under endoscopic and fluoroscopic guidance. This stent occludes the fistula, allows the patient to eat and sleep, prevents cough, decreases tracheal leakage and sialorrhea, and improves quality of life. Complications of stent placement include esophageal perforation, dysphagia related to loss of peristalsis of a portion of the esophagus, aspiration caused by acid reflux, and stent migration.¹

This patient’s condition initially improved after stent placement. However, 2 days later, persistent aspiration pneumonia led to respiratory failure, and she died. ■

REFERENCE:

1.Boyce HW Jr. Palliation of dysphagia of esophageal cancer by endoscopic lumen restoration techniques. Cancer Control. 1999;6(1):73-83.