Kimura Jiro, Lefor Alan Kawarai, Kubota Tadao
Department of Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
Department of Surgery, Jichi Medical University, Tochigi, Japan.
Int J Surg Case Rep. 2018;46:38-40. doi: 10.1016/j.ijscr.2018.04.008. Epub 2018 Apr 16.
Colonic ischemia is challenging to diagnose preoperatively. We present a patient with colonic ischemia, initially considered to have colonic obstruction. We review the history, physical findings, imaging, operative documents and postoperative diagnosis of this patient with an atypical presentation of colonic ischemia.
A 74-year old female presented with dyspnea on exertion and melena. A tumor in the sigmoid colon was identified by colonoscopy and biopsy showed adenocarcinoma. After admission, she developed abdominal pain. Computed tomography scan revealed the mass in the sigmoid colon and dilation of the proximal colon. She was diagnosed with colonic obstruction due to the sigmoid cancer and emergent transverse loop colostomy was performed. Postoperatively she developed hypotension and the colostomy appeared ischemic. Emergent reoperation showed ischemia from the ileum to the sigmoid colon. Despite resection, the patient died postoperatively of multiple organ system failure.
The resulting delay in diagnosis of colonic ischemia likely contributed to the poor outcome. Imaging studies play a key role in the management of acute abdominal emergencies. However, imaging can be misleading because it is only a "radiological diagnosis". A radiological diagnosis makes sense when it is the same as the "clinical diagnosis". An emphasis must be placed on history taking and physical examinations.
It is difficult to diagnose colonic ischemia in patients with suspected colonic obstruction due to colon cancer. The imaging studies in these patients may be misleading, resulting in adverse outcomes.
