A 27-year-old woman with a 9-year history of ulcerative colitis involving the entire colon was admitted to our hospital in August 1992 because of bloody stools and left lower abdominal pain. She had been treated with sulfasalazine since 1983 and the colitis had been clinically quiescent or mild for 7 years. She had also been diagnosed as having primary sclerosing cholangitis (PSC) 4 years prior to this admission, based on the clinical, laboratory, and cholangiographic findings. A barium enema and colonoscopy showed an irregular mass obstructing the bowel lumen in the distal portion of the descending colon. Biopsy specimens taken from the mass revealed moderately differentiated adenocarcinoma, and a subtotal colectomy was performed. Histologic examination of the mass lesion showed moderately differentiated adenocarcinoma invading the pericolic adipose tissue. She is currently alive 3 years after surgery. PSC has recently been reported as a risk factor for colonic neoplasia in patients with long-standing ulcerative colitis. In Japan, however, colorectal cancer associated with PSC and ulcerative colitis has rarely been reported. The present case suggests that the risk of colonic cancer is higher in patients with ulcerative colitis and PSC than in patients with ulcerative colitis alone.
A 60-year-old man who had been receiving dialysis for more than 30 years was admitted for treatment of cellulitis in his right thigh on November 7, 2003. He suffered from an ileus on December 14 and was found to have a huge, 7-cm-diameter, well-circumscribed fecalith, incarcerated at the splenic flexure of the colon. It was proving difficult to pass this naturally and surgical removal was thought to be too risky. Using a colonoscope and a water-jet probe, the fecalith was broken up; the ileus then improved and the patient was able to take oral fluids. Unfortunately, he died of cardiac failure on February 13, 2004. We conducted an autopsy, with his family's consent, and found generalized amyloidosis. Deposits of amyloid were seen in all layers of the colon. Because of this, we hypothesized that peristalsis had been poor and this had led to paralytic ileus due to stasis, which, in turn, had led to the formation of the huge fecalith. In Japan it is not rare for a patient to be on dialysis for more than 25 years and it may be that this is a cause of generalized amyloidosis. There have been no such cases of fecalith associated with gastrointestinal amyloidosis described previously, which is why we decided to report this case here.
A 64‐year‐old Japanese male was admitted to Fukuoka University Hospital to undergo further examination for an elevated γ‐glutamyltransferase (γ‐GTP) level. Endoscopic retrograde cholangiography (ERC) showed dilatation of the intrahepatic bile duct and stenosis of the proximal portion of the common bile duct. No abnormality was found in the gall‐bladder. Since the fecal occult blood test was positive, sigmoidoscopy and a barium enema were performed. Sigmoidoscopy showed a hyperemic and hemorrhagic mucosa in the rectum, but a barium enema study did not show any abnormal findings in the entire colon. We diagnosed the patient to have primary sclerosing cholangitis (PSC) and ulcerative proctitis based on these radiological and endoscopic findings. Bloody stool and fever occurred 4 months after the first admission. The patient’s colitis extended to the entire colon. Because of the failure of corticosteroid therapy, a subtotal colectomy was performed. Given that a mass was intraoperatively palpable in the gall‐bladder, a cholecystectomy was simultaneously performed. In the whole resected colon, diffuse ulcerations and mucosal islands were found. Grossly, a flat polypoid lesion, measuring 2 cm in diameter, was found in the fundus of the resected gall‐bladder. Sections of this lesion in the gall‐bladder revealed cystic atypical glands and some atypical cell clusters invading the subserosa. The present case suggests that careful observations are needed for patients with ulcerative colitis who have an elevated γ‐GTP level even if the colitis is limited to the distal colon and the serum alkaline phosphatase level is normal.
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