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Clinical Challenges and Images in GI
Clinical Challenges and Images in GI continued
Image 2
Question: A 70-year-old man was admitted to our department with lumbar pain, abdominal distention, and constipation for the last 3 days. On clinical examination, the abdomen was diffusely distended, and bowel sounds were present but reduced. An empty rectal vault was found upon digital rectal examination. Plain abdominal radiograph (Figure A) showed dilated large bowel with air–fluid levels and no air in the rectum. Colonoscopy excluded an obstructive process of the colon. Abdominal computed tomography (CT) did not detect any mechan-
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ical obstruction to account for the clinical findings. One day after admission, a characteristic dermatologic manifestation was revealed (Figure B), with a unilateral distribution and cutaneous lesions appearing simultaneously as clusters of vesicles on an erythematous base involving S2–S3 dermatome. What is the diagnosis? Look on page 715 for the answer and see the GASTROENTEROLOGY website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. GEORGIA DEDEMADI, MD, PhD GEORGE GEORGOULIS, MD Department of Surgery “A. Fleming” Hospital Athens, Greece © 2008 by the AGA Institute
0016-5085/63644/$34.00 doi:10.1053/j.gastro.2008.06.057
August 2008
CLINICAL CHALLENGES AND IMAGES IN GI
715
Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 362): Colonic Pseudo-Obstruction as a Rare Complication of Herpes Zoster Colonic pseudo-obstruction (Ogilvie’s syndrome) is described as a massive colonic dilatation associated with an underlying medical condition. Varicella-zoster virus infection affecting the innervation of the colon caused colonic pseudo-obstruction in our patient. The diagnosis was made on clinical grounds—typical clinical presentation of the cutaneous lesions—and the specific test confirmed the diagnoses. Laboratory findings revealed positive serum immunoglobulin M against varicella-zoster virus (titration 1:40). Colonoscopy and abdominal CT scan confirmed the absence of organic obstruction. The innervation of the colon consists of the extrinsic (sympathetic and parasympathetic) and the intrinsic (submucosal and myenteric plexuses) components.1,2 The visceral motor manifestations of herpes zoster include possibly direct involvement of the autonomic nervous system owing to centripetal spread from dorsal root ganglion reactivation, and direct involvement of the submucosal and myenteric plexuses, affecting the motility of left colon and rectum.3 After 7 days of intravenous therapy with acyclovir 10 mg/kg/8 hours that was administered to the patient, there was a gradual resolution of the cutaneous lesions, a rapid resolution of the abdominal dilatation, and a functional recovery from the colonic pseudo-obstruction. It is important to recognize this manifestation to institute proper management and avoid unnecessary surgery, providing complete resolution with conservative management. References 1. Holland-Cunz S, Goppl M, Rauch U, et al. Acquired intestinal agaglionosis after a lytic infection with varicella-zoster virus. J Pediatr Surg 2006;41:e29 –33. 2. Pui JC, Furth EE, Minda J, et al. Demonstration of varicella-zoster virus infection in the muscularis propria and myenteric plexi of the colon in an HIV-positive patient with herpes zoster and small bowel pseudo-obstruction (Ogilvie’s syndrome). Am J Gastroenterol 2001;96:1627–1630. 3. Debinski HS, Kamm MA, Talbot IC, et al. DNA viruses in the pathogenesis of sporadic chronic idiopathic intestinal pseudo-obstruction. Gut 1997;41:100 –106. For submission instructions, please see the GASTROENTEROLOGY website (www.gastrojournal.org).
Image 2
Question: A 70-year-old man was admitted to our department with lumbar pain, abdominal distention, and constipation for the last 3 days. On clinical examination, the abdomen was diffusely distended, and bowel sounds were present but reduced. An empty rectal vault was found upon digital rectal examination. Plain abdominal radiograph (Figure A) showed dilated large bowel with air–fluid levels and no air in the rectum. Colonoscopy excluded an obstructive process of the colon. Abdominal computed tomography (CT) did not detect any mechan-
362
ical obstruction to account for the clinical findings. One day after admission, a characteristic dermatologic manifestation was revealed (Figure B), with a unilateral distribution and cutaneous lesions appearing simultaneously as clusters of vesicles on an erythematous base involving S2–S3 dermatome. What is the diagnosis? Look on page 715 for the answer and see the GASTROENTEROLOGY website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. GEORGIA DEDEMADI, MD, PhD GEORGE GEORGOULIS, MD Department of Surgery “A. Fleming” Hospital Athens, Greece © 2008 by the AGA Institute
0016-5085/63644/$34.00 doi:10.1053/j.gastro.2008.06.057
August 2008
CLINICAL CHALLENGES AND IMAGES IN GI
715
Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 362): Colonic Pseudo-Obstruction as a Rare Complication of Herpes Zoster Colonic pseudo-obstruction (Ogilvie’s syndrome) is described as a massive colonic dilatation associated with an underlying medical condition. Varicella-zoster virus infection affecting the innervation of the colon caused colonic pseudo-obstruction in our patient. The diagnosis was made on clinical grounds—typical clinical presentation of the cutaneous lesions—and the specific test confirmed the diagnoses. Laboratory findings revealed positive serum immunoglobulin M against varicella-zoster virus (titration 1:40). Colonoscopy and abdominal CT scan confirmed the absence of organic obstruction. The innervation of the colon consists of the extrinsic (sympathetic and parasympathetic) and the intrinsic (submucosal and myenteric plexuses) components.1,2 The visceral motor manifestations of herpes zoster include possibly direct involvement of the autonomic nervous system owing to centripetal spread from dorsal root ganglion reactivation, and direct involvement of the submucosal and myenteric plexuses, affecting the motility of left colon and rectum.3 After 7 days of intravenous therapy with acyclovir 10 mg/kg/8 hours that was administered to the patient, there was a gradual resolution of the cutaneous lesions, a rapid resolution of the abdominal dilatation, and a functional recovery from the colonic pseudo-obstruction. It is important to recognize this manifestation to institute proper management and avoid unnecessary surgery, providing complete resolution with conservative management. References 1. Holland-Cunz S, Goppl M, Rauch U, et al. Acquired intestinal agaglionosis after a lytic infection with varicella-zoster virus. J Pediatr Surg 2006;41:e29 –33. 2. Pui JC, Furth EE, Minda J, et al. Demonstration of varicella-zoster virus infection in the muscularis propria and myenteric plexi of the colon in an HIV-positive patient with herpes zoster and small bowel pseudo-obstruction (Ogilvie’s syndrome). Am J Gastroenterol 2001;96:1627–1630. 3. Debinski HS, Kamm MA, Talbot IC, et al. DNA viruses in the pathogenesis of sporadic chronic idiopathic intestinal pseudo-obstruction. Gut 1997;41:100 –106. For submission instructions, please see the GASTROENTEROLOGY website (www.gastrojournal.org).