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Silver Stools Revisited
Electronic Clinical Challenges and Images in GI Silver Stools Revisited Jonathan Wyse1 and Laura Drudi2 1Department
of Medicine, Division of Gastroenterology, SMBD - Jewish General Hospital, and 2McGill University Faculty of Medicine, Montreal, Quebec, Canada
Question: A 76-year-old man presented with fever and right upper quadrant pain and was diagnosed with cecal adenocarcinoma, infected coloduodenal fistula, and hepatic abscess with cultures revealing streptococcus viridans bacteremia. He underwent right hemicolectomy, fistula repair, and abscess drainage with antibiotics. He subsequently made a full recovery. After being lost to follow-up, he was referred back to hospital 3 years later for worsening fatigue, a 70-pound weight loss, and abdominal pain. He had severe iron deficiency anemia (hemoglobin, 4.6 g/dL). His stools were observed to be distinctly silver in color (Figure A), and abdominal computed tomography (CT) was performed (Figure B). What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.01.062
GASTROENTEROLOGY 2013;144:e9 – e10
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 5: Ampullary Neoplasm From Metastatic Colon Cancer CT revealed contrast remaining in lumen of second stage of duodenum (long arrow), and a mass adjacent to and invading the second stage of the duodenum obstructing the distal common bile duct (CBD) at the ampulla of Vater (Figure B, arrowhead). Metastatic cecal adenocarcinoma to the ampulla of Vater was diagnosed. This recurrence of adenocarcinoma likely resulted from the previous coloduodenal fistula. The patient received palliative care and passed away 5 weeks after admission. In 1955, Ogilvie credited Thomas in the British Medical Journal with describing silver stools in patients with cancer of the ampulla of Vater, as “motions having the colour of oxidized silver or aluminum paint.”1 This came to be known as Thomas’ sign. Acholic (pale) stools secondary to CBD obstruction combined with the black-tarry color of melena is believed to produce the characteristic silver color of ampullary neoplasms. Reference 1. Ogilvie H. Thomas’s sign, or the silver stool in cancer of the ampulla of Vater. Br Med J 1955;1:208.
e10
of Medicine, Division of Gastroenterology, SMBD - Jewish General Hospital, and 2McGill University Faculty of Medicine, Montreal, Quebec, Canada
Question: A 76-year-old man presented with fever and right upper quadrant pain and was diagnosed with cecal adenocarcinoma, infected coloduodenal fistula, and hepatic abscess with cultures revealing streptococcus viridans bacteremia. He underwent right hemicolectomy, fistula repair, and abscess drainage with antibiotics. He subsequently made a full recovery. After being lost to follow-up, he was referred back to hospital 3 years later for worsening fatigue, a 70-pound weight loss, and abdominal pain. He had severe iron deficiency anemia (hemoglobin, 4.6 g/dL). His stools were observed to be distinctly silver in color (Figure A), and abdominal computed tomography (CT) was performed (Figure B). What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.01.062
GASTROENTEROLOGY 2013;144:e9 – e10
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 5: Ampullary Neoplasm From Metastatic Colon Cancer CT revealed contrast remaining in lumen of second stage of duodenum (long arrow), and a mass adjacent to and invading the second stage of the duodenum obstructing the distal common bile duct (CBD) at the ampulla of Vater (Figure B, arrowhead). Metastatic cecal adenocarcinoma to the ampulla of Vater was diagnosed. This recurrence of adenocarcinoma likely resulted from the previous coloduodenal fistula. The patient received palliative care and passed away 5 weeks after admission. In 1955, Ogilvie credited Thomas in the British Medical Journal with describing silver stools in patients with cancer of the ampulla of Vater, as “motions having the colour of oxidized silver or aluminum paint.”1 This came to be known as Thomas’ sign. Acholic (pale) stools secondary to CBD obstruction combined with the black-tarry color of melena is believed to produce the characteristic silver color of ampullary neoplasms. Reference 1. Ogilvie H. Thomas’s sign, or the silver stool in cancer of the ampulla of Vater. Br Med J 1955;1:208.
e10