Recently, the incidence and severity of Clostridium difficile infection (CDI) has increased. In cases of fulminant infection, surgery is a viable therapeutic option but associated with high mortality. We sought to examine factors associated with mortality in a large sample of patients with severe CDI that underwent surgery. A retrospective study was conducted in patients with severe CDI undergoing colectomy. Demographics, risk factors, comorbidities, clinical and laboratory data, and time between admission/diagnosis of CDI and colectomy were collected. Conventional markers of severity were evaluated as predictors of mortality. Sixty-four cases were included for analysis. The overall observed mortality rate was 45.3 per cent. Few conventional markers of severity were significantly associated with mortality. Risk factors that correlated with postsurgical mortality were vasopressor use (odds ratio, 3.08; 95% confidence interval, 1.00 to 9.92) and shorter time between diagnosis and surgery (median time, 2 vs 3 days, P = 0.009). This study suggests that a delay in surgery after diagnosis of severe CDI may improve overall outcomes. The finding regarding timing of surgery is contrary to traditional teaching and may be the result of improved medical treatment and stabilization before surgery. Consideration should be given to the importance of timing of colectomy in fulminant CDI, whereas prospective studies should be conducted to elucidate causal relationships.
An 86-year-old man with chronic acid reflux, cryptogenic cirrhosis complicated by hepatic encephalopathy, ascites, and nonbleeding esophageal varices presented to the emergency department with progressive epigastric pain. A portable chest radiograph revealed a 20-mm, disc-like radiopaque foreign body within the middle one-third of the esophagus, which was seen migrating into the gastric fundus 1 hour later on sequential noncontrast abdominal computed tomography imaging (Figure 1). The patient denied foreign-body ingestion, including button battery or coin. Given the history of hepatic encephalopathy and the resemblance of a button battery on imaging, the patient underwent an emergent push upper endoscopy in adherence with guidelines from the American Society for Gastrointestinal Endoscopy on prompt removal of suspicious ingested foreign bodies. 1 The foreign body was not found on endoscopy to the proximal jejunum. After procedure, follow-up radiographs no longer demonstrated the foreign body, and it seemed to have vanished.
INTRODUCTION: Diffuse Large B Cell Lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma accounting for 25% of cases. Of those, only one third are found to have a primary extranodal source. While this is known to arise from the stomach, a colorectal primary site is exceedingly unique. We present the case of primary colonic DLBCL diagnosed in a patient admitted for hematochezia. CASE DESCRIPTION/METHODS: An 85-year-old female with coronary artery disease on aspirin and diverticulosis presented to the emergency room with acute hematochezia and left lower quadrant (LLQ) abdominal pain. She was hemodynamically stable with reproducible LLQ tenderness and rectal exam confirming bright red blood. Labs were pertinent for leukocytosis and hemoglobin of 12.1 g/dL down from a baseline of 14.4 g/dL. Contrasted abdominal CT revealed a 4.1 cm soft tissue mass in the ascending colon with extravasation of contrast consistent with active bleeding. Due to concern for a malignant bleeding etiology, interventional radiology performed CT angiography, but were unable to identify an active arterial source. The patient continued with hematochezia and was taken for urgent colonoscopy. Within the ascending colon, a 5cm non-obstructing, fibrous mass with central ulceration was identified and biopsied. Colorectal surgery was consulted; due to concern for recurrent bleeding a right hemicolectomy was performed the following day. Final pathologic diagnosis revealed primary colonic DLBCL with local lymph node involvement. PET/CT showed complete resection of disease and, through multidisciplinary shared decision making, further treatment or surveillance was not pursued. At follow up the patient is doing well without recurrent symptoms. DISCUSSION: Primary colorectal DLBCL accounts for less than 0.3% of all cancers involving the large intestine. While data is limited, the majority of patients are male between the 5th and 7th decades of life. Symptoms are nonspecific with few cases discovered due to overt bleeding. Endoscopic appearance is variable including mucosal nodularity, ulceration or a mass with or without ulceration, which can mimic adenocarcinoma. Due to the abundance of lymphoid tissue, most lesions involve the cecum and ileocecal valve. Diagnosis of primary colonic DLBCL can include local lymph node involvement, but distant nodal disease must be excluded. The mainstay of treatment is surgical resection with adjuvant chemotherapy, however, due to patient age and preference a conservative strategy was pursued.
INTRODUCTION: We present a case of primary endometrioid adenocarcinoma with invasion of the rectosigmoid colon, highlighting the importance of colonoscopy, biopsy, cross-sectional imaging, and a multidisciplinary approach to the management of extraluminal lesions. CASE DESCRIPTION/METHODS: A 47-year-old female with a history of lymphangioleiomyomatosis (LAM) was admitted for abdominal pain, hematochezia, tenesmus, and proctalgia following 7 months of abnormal bowel habits and 20 pounds of unintentional weight loss. Review of symptoms was negative for abnormal uterine bleeding. Examination revealed tenderness on palpation of the lower abdominal quadrants, and grossly bloody stool with digital rectal exam. Computed tomography (CT) of the abdomen and pelvis with contrast demonstrated circumferential rectal wall thickening with enhancement. Colonoscopy revealed an ulcerated extraluminal rectosigmoid mass, and biopsies were obtained. Magnetic resonance imaging (MRI) demonstrated a large heterogeneous mass involving the uterus and rectum with no discernable fascial plane. Initial pathology reported invasive adenocarcinoma without a primary origin delineated. A multidisciplinary conference prompted additional immunostaining of the sample, confirming endometrioid adenocarcinoma. The patient was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IVa endometrioid adenocarcinoma and underwent surgical management with adjuvant chemoradiation. Genetic testing demonstrated heterozygosity with a pathologic variant in the MutL homolog 1 (MLH1) gene consistent with Lynch Syndrome. Surveillance positron emission tomography scanning 6 months later revealed no evidence of disease recurrence. DISCUSSION: Extraluminal lesions are notoriously difficult to diagnose with endoscopy alone. In this case, cross-sectional imaging with CT and MRI was unable to differentiate the origin of the lesion, and pathologic examination without the clinical context of the extraluminal nature of the tissue obtained on colonoscopy delayed the definitive diagnosis. This case highlights the importance of a multidisciplinary approach to cases of suspected extracolonic malignancies with colonic invasion in order to expedite definitive diagnosis and treatment. There are no reports of concomitant Lynch Syndrome and LAM in the literature and the clinical significance is unclear. Further study may be helpful in elucidating potential links between these two uncommon conditions.
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