Miscellaneous diseases of the colon

Miscellaneoue By

JOHN

Diseases R.

of the

HODGSON,

Colon

M.D.

A

hlYLOID is an insoluble protein substance deposited abnoLmally in various organs. The kidneys, liver, spleen, adrenal glands and gastrointestinal tract are the principal sites of involvement although, if the disease is widespread, no organ in the body is immune. The gastrointestinal tract is second to the kidneys as the most frequent site of the disease.“0 Within the gastrointestinal tract the stomach is most frequently affected and the colon is next. Mathews’:” reported that only 30 per cent of cases of amyloidosis were diagnosed prior to postmortem examination. Amyloidosis is usually classified as primary or secondary, although the two .forms are pathologically and radiologically indistinguishable. Secondary amyloidosis is associated with longstanding diseases, such as chronic osteomyelitis, tuberculosis, chronic arthritis and ulcerative colitis, or with chronic malignant neoplasms: ‘SJ~ Primary amyloidosis appears without antedating diseases. The diagnosis of amyloidosis is facilitated by use of the Congo red test, gingival or rectal biopsy, or by direct needle biopsy of an organ suspected of disease. Gastrointestinal tract involvement by amyloidosis is often asymptomatic but bleeding or even perforation may occur. In the colon, the amyloid may be deposited in the muscle layers, in the submucosal connective tissue, in the small and medium-sized blood vessels of the submucosa, or in all three. Obliteration of smaller vessels and submucosal deposition produce necrosis and ulceration. The u!cers are seen at proctoscopy as chocolate-colored craters and contain amyloid in their margins. The deposition of amyloid in the muscular layers of the colon is manifested roentgenologically as an alteration in the haustral pattern. The haustral folds become irregularly short and blunted in the areas of involvement (Fig. 1). This is best seen on postevacuation films with a moderate residue of barium. Considerable distention with barium or complete ‘evacuation of barium may obscure these characteristic haustral changes. The mucosal folds of the colon are thickened and have an irregular nodular appearance similar to that seen in lymphoma ( Figs, 2 and 3). The walls of the colon thicken. With submucosal infiltration and involvement of blood vessels; ulcers may occur, particularly in the rectum, and narrowing of the bowel with partial stenosis may result. Any segment of the colon may be involved. Differential diagnosis Includes radiation colitis, chronic ulcerative colitis and granulomatous colitis. Absence of radiation exposure and lack of the marked destructive changes of colitis should aid in establishing the diagnosis. JOHX H. HODGSON, F’oundation; Professor sity of Minnesota,).

M.D.: Consultant, Section of of C!inical Radiology, Mayo

Roent~enology, Mayo Clinic Grmhmte School of Medicine

and Mayo (Uniuer-

91 SEIIIYAR~

IY ROEYTCESOLOGY,

Vo~.3,No.

1 (JANUARY),

196s

MISCELLANEOUS

DISEASES OF THE COLON PSEUDOMEMBRASOUS

95 COLITIS

Pseudomembranous colitis occurs as a postoperative complication,“’ and as a sequel of many other diseases. Among these are colonic obstruction,lT,lS.23.24.?T,3j,37,41 renal or cardiac failure,lS overgrowth of staphylococci secondary to antibiotic therapy,13p20,3” debilitation or prematurity in infants,5 generalized overwhehning infection,“rG paralytic ileus,34 shock,35 and aganglionic meg;jcolon.2” Patients with pseudomembranous colitis are acutely ill with fever, tachycardia, nausea, vomiting, profound shock, confusion and explosive diarrhea of sudden onset. Severe infection may be present in other parts of the body. The colori becomes dilated and its mucosal surface extremely friable. Acute necrosis of the mucous membrane occurs with formation of small to large membranous plaques covering the denuded areas. These necrotic plaques may coalesce to form a pseudomembrane, a dirty-brown or yellow tissue made up of excessive mucus and fibrin together with the necrotic mucosa, erythrocytes, leukocytes and other exudates. As the disorder progresses, the entire mucosa may undergo coagulative necrosis. Peritonitis is usually present. Infection is the probable cause. Perhaps one or more of the associated conditions contribute in making the infection a rapidly progressive malignant process which is out of control almost as soon as it starts. Roentgenograms of the colon reveal moderate to severe dilatation usually involving the entire colon. The normal mucosal pattern is lost and the colon demonstrates the flat, structureless relief pattern of superficial ulceration or the ragged, ulcerating mucosal destruction of very active acute ulcerative colitis. No haustral markings are seen (Fig. 4). Abscesses may be evident and gas may be detected in the wall of the colon. Perforation is frequent, accompanied by intraperitoneal air. No contractibility of the colon is recognizable. The distribution of the diseaSe is somewhat different from that of the acute toxic megacolon of chronic ulcerative colitis, but the appearance of the bowel is similar.

Lymphogranuloma venereum, caused by a filtrable virus, occurs more frequently in women in the third and fourth decades. The disease involves the rectum and adjacent pelvic sti-uctures and is often associated with chronic perineal inflammatory disease.22 The rectal involvement is usually secondary to a primary erosion on the penis or vagina.29 The virus soon invades the regional lymph nodes, producing an acute purulent lymphadenitis. In the female, the infection frequently involves the anore& lymph nodes and the rectal ~all.“~ In the male, the inguinal nodes are involved first, followed by extension to the pelvis and wall of the rectum. The virus may also be implanted directly into the mucosa as a result of abnormal sexual practices.*4 Extension of the disease to the sigmoid or other segments of the large bowel above the rectum has been described. The disease begins as an acute proctitis with a reddened, granular, friable mucous membrane. Later, mucosal ulcerations appear and, with increasing

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THE

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97

JOHN

Fig.

R.

4.-Pseudomembranous

HODGSON

col-

in a child. Dilatation of the colon, diffuse mucosal ulceration with abscess formatibn, and complete loss of normal mucosal relief pattern are apparent. (Courtesy of Dr. H. J. Williams, Children’s Hospital, St. Paul, Minnesota.)

itis

inflammatory change, the rectal wall becomes thick and rigid and the lumen greatly reduced. Rectal and perirectal fibrosis continues. The perirectal inflammatory mass may extend and involve much of the pelvis; when this happens, abscesses, fistulae and sinus tracts may form within the mass. There is pronounced connective tissue proliferation. Marked round-cell infiltration, abscess formation and ulceration characterize the histologic appearance. The roentgen features are characterized by rectal. stricture4 (Fig. 5). Sometimes two or three strictures may be present. There is marked narrowing of the lumen and the mucosa is edematous, ragged and ulcerated or replaced by fibrous tissue, depeuding on the stage of the disease (Fig. 6). Sinus or fistulous tracts, perirectal abscess, rigidity of the wall, loss of distensibility and shaggy ulceration may be seen on the roentgenogram (Fig. 7). The fistulae inay communicate with the vagina or with abscess cavities adjacent to the rectum. Late in the disease there is smooth narrowing of the rectum, replacement of mucosa by fibrous connective tissue, and marked thickening of the rectal wall (Fig. 8). The junction of normal and abnormal mucosa is seldom sharply defined and the upper margin of the diseased area tapers into normal colon. The deformity caused by radiation therapy is similar in extent, but is seldom associated with sinus tracts or as much inflammatory change; even when the mucosa becomes edematous or ulcerated, it is not to the degree seen in lymphogranuloma venereum. Chronic nonspecific ulcerative colitis does not demonstrate the marked stricturing and thickening of the bowel wall localized to the rectum, and the proctoscopic appearance is quite d&rent. Granulomatous colitis may present a similar roentgen appearance and laboratory tests or evidence of disease in the small intestine may be necessary for differential diagnosis. Schistosomiasis, described elsewhere in this issue, may also produce narrowing of the rectum and rectosigmoid c010n.~ SCLERODERhlA

Involvement

of the gastrointestinal

tract is not uncommon

in patients with

COLON

99

Fig. 5.-Lymphogranuloma venereum. Marked constriction of the lumen and mucosal ulceration with sinus tracts extending laterally are present.

Fig. 6.-Lymphogranuloma venereum involving the lower sigmoid and rectum. There is marked contraction deformity of the rectum, ulceration of mucosa and a sinus tract extending into the soft tissues adjacent to the right side of rectum. Inflammatory masses projecting into the lumen of the bowel are also present.

Fig. ‘7.-Lymphogranuloma Contraction of the lumen and, dent, mucosal ulceration and seen in the rectum and lower

Fig. 8.-Lymphogranuloma venereum with complete destruction of rectal mucosa, severe scarring and contraction of rectum, and perirectal abscess cavity and sinus tract at the left of the rectum.

MISCELLAKEOUS

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venereum. more eviedema are sigmoid.

100

JOHN R. HODCSON

scleroderma. Unusual shaped diverticula are characteristic of large bowel in, volvement. An incidence of 53% among 19 patients with scleroderma who had barium enema studies has been reported.?l The presence of these diverticulumlike outpouchings in the colon is a complication of more advanced scleroderma and is usually associated with roentgen evidence of involvement of the esophagus and small intestine. Histologic sections of these diverticula reveal almost complete replacement of the smooth muscle layer with dense connective tissue. Between the diverticula there may be areas of smooth muscle degeneration, Weakening of the muscle layer permits the diverticular outpouching of the bowel. The diverticula are found most frequently above the level of the sigmoid, most often in the transverse (Fig. 9) and descending colon (Fig. 10). They are much larger than the usual colon diverticulum and do not have its mushroom shape but rather a boxlike or kettle-shaped appearance in which the neck is as wide as the tip. They are randomly scattered and are not paired; their number depends on the extent of involvement. In our experience, the entire colon has not been involved. These outpouchings extend beyond the limits of the margin of the bowel. The roentgen demonstration of the diverticula is best accomplished with distention of the colon by either barium or air; they are readily seen on postevacuation roentgenograms. RADIATION

INJURY OF THE COLON

Evidence of radiation injury to the colon may appear soon after exposure or after a delay of years. Aune and White” reported that symptoms may appear from 1 month to 9 years after radiation exposure. Careful examination of the skin and the eliciting of a history of radiotherapy are important for the diagnosis. Pathologically, the earliest change in the large bowel, often occurring within a few months after exposure, consists of an acute inflammatory reaction of variable severity. *v7 Edema, hyperemia and spasm may be followed by ulceration of the mucosa.loJ1 The mucosal ulcers are single or multiple, superficial or deep and punched-out with ragged bases and sharp margins.“O They may perforate to form pericolic abscesses or produce peritonitis. The mucosa is thickened and may demonstrate numerous telangiectases. The submucosa may show hyalinization. Vascular damage, including endarteritis, thrombosis, infarction and necrosis, is common. The lumen becomes narrowed with the development of scar tissue and eventually partial or complete obstruction may result~31.:~o

The roentgen changes, demonstrable with barium enema, reflect the stages of pa&olo@cal involvement. The early changes consist of spasm, edema of the mucous membrane, and loss of normal mucosal pattern. Ulceration associated with abscess formation or perforation is infrequently demonstrated (Fig. II). With cicatrization, the bowel becomes diffusely narrowed with thickened walls (Fig. 12). The mucous membrane is flat and smooth. There is usually a relatively abrupt demarcation between normal bowel and an involved segment (Fig. 13). In my experience, the stenosis does not produce complete obstruction.

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F ‘ig. 9 (top).-Scleroderma with wide-mouthed diverticula dilated small intestine is also involved colt 111, Th e! moderately Fig.

10 (bottom)-Scleroderma,

showing

the typical

scattered I3-U-OU by the dise ase.

diverticula.

lout

JOHN

F ‘ig.

11

(top).-Radiation

injury

and perirectal fistnla leading lum en s diffusely narrowed. U?U( 3os<

Fig.

12

the sigmoid

(bottom).-Radiation

colon are present.

R.

HODGSON

to rectum and sigmoid colon, showing ul Ice1-ated to small abscess cavity at right of recta Im. The

injury.

Diffuse

narrowing

and mucosal

scarring

of

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THE

COLON

Fig. 13.-Radiation injury to colon, demonstrating a short segment of narrowing in the sigmoid with abrupt demarcation between the involved segment and the normal bowel. TUBERCULOSIS

Characteristically, tuberculosis of the gastrointestinal tract involves the ileocecal coil but may also involve other parts of the colon, the appendix, duodenum and stomach.* Intestinal tuberculosis may be primary or arise secondarily to pulmonary infection. Primary intestinal tuberculosis is rare. Autopsy studies have demonstrated that 68 to 90 per cent of persons with advanced pulmonary tuberculosis also have tuberculosis of the intestine.‘2.3’ Intestinal tuberculosis is frequently associated with nmyloidosis. Enlargement of the liver and spleen and obliteration of the right psoas shadow may be noted on roentgenograms of the abdomen. Pathologically, two types of involvement of the terminal ileum and cecum have been described, ulcerative and hyperplastic. With invasion of the lymphoid structures in this region by tubercle bacilli, chronic inflammatory change occurs and areas of necrosis develop in the mucosa. These ulcerations may be annular or longitudinal, and they undermine the mucosa. Granulomatous changes with thickening of the bowel wall occur as the disease progresses. Tubercles may be present on the serosal surface. Lymph nodes are usually involved. Ulceration or granulomatous change involving the ileocecal valve is characteristic of the disease. The importance of spasm of the terminal ileum in the early roentgen diagnosis of tuberculosis of the ileocecal coil has been emphasized by many authors,1”~1”~2z Deformity of the ileocecal valve secondary to ulceration or granulation, with irregularity of the valve and thickening of the cecal walls

JOHN R. HODGSON

104

adjacent to it, is commonly observed in tuberculosis. Gershon-Cohen and Kremens’” and Fleischner and Bernstein’; emphasized the importance of careful roentgen evaluation of the ileocecal valve in the diagnosis of tuberculosis. Normally, barium in the terminal ileum appears as a triangle with its apex toward the cecum because of the smaller orifice of the valve. If the valve orifice is gaping due to the scarring of its lips secondary to tuberculosis, the apex of the triangle may be reversed and point toward the ileum. This has beeti called an “inverted umbrella” by Fleischner and Bernstein,l” and the “Fleischner sign” by others.‘” Roentgenograms may demonstrate changes that are primarily ulcerative or hyperplastic in nature, but the usual roentgenographic picture is a combination of these (Fig. 14). Narrowing of the terminal ileum occurs, with ragged irregular margins, thickening of the wall. loss of normal mucosal pattern, and rigidity (Fig. 15). The cecum and the ileocecal valve reveal edematous or ulcerated mucous membrane or, later in the course of the disease, contraction and deformity from scarring ( Fig. 16). Granulomatous colitis and lymphoma may present problems in difierential diagnosis. When tuberculosis involves segments of colon other than the ileocecal area, roentgen differentiation from regional enteritis may be very difficult, if not impossible (Figs. 17 and 18). Rarely, tuberculosis of the intestine may spare the ileooecal area and involve another segment of the colon (Fig. 19). Such localized involvement has no roentgenologically identifiable characteristics to distinguish it from other inflammatory diseases. The presence of pulmonary tuberculosis may be helpful in differentiation. SOLITARY

U~cm

OF COLOX

Occasionally the roentgenologist encounters a solitary filling defect or constricting lesion which, on removal, is reported by the pathologist to be a solitary ulcer. The cause of these lesions is unknown. They may represent diverticulitis but, in the absence of other diverticula this is not a satisfactory explanation. The pathologic changes consist of edema, cellular infiltration, and an ulcer crater with smooth edges, which is occasionally annular. The crater may penetrate into the submucosa. Roentgenographically, when the crater fails to fill, the lesion may appear as a sessile or plaquelike mass in the wall of the colon, partially indenting the lumen (Figs. 20 and 21). The mucous membrane at the site of the lesion may be edematous but is usually intact except when the ulcer is shown. At times constriction occurs, and in these cases it may be difficult to distinguish from diverticulitis (Fig. 22). The demonstration of an ulcer crater is essential for diagnosis. When constriction occurs, the deformity has tapered ends with no abrupt demarcation between the normal and the abnormal mucosa. The bowel wall is not fixed and retains some distensibility throughout the constricted segment. ACITNOMYCOSIS

Actinomycosis may involve the colon primarily or may be secondary to an inf;ection elsewhere. In addition to the usual roentgen changes of inflammatory

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disease in the intestine, actinomycosis is characterized by sinus tracts extending from the colon to adjacent soft tissues, to other loops of intestine, or to the shin. The presence of sulfur bodies in the pus in the sinus tracts is diagnostic. Roentgen examination may reveal narrowing of a segment of the bowel, mucosal edema with ulceration, submucosal abscesses and sinus tracts. The involved segment has tapering ends without abrupt demarcation between the normal and abnormal colon (Fig. 23). The differential diagnosis includes granulomatous colitis, diverticulitis, tuberculosis, amebiasis and localized ulcerative colitis. REFERENCES 1. Aune, E. F., and White, B, V.: Gastrointestinal complications of irradiation for carcinoma of uterine cervix. J.A.M.A. 147:831-834, 1951. 2. Bacon, H. F.: Radiation proctitis: A preliminary report of 39 cases. Radiology 29:574-577, 1937. 3. Bcnedek, T. G., and Zawadzki, Z. A.: Ankylosing spondylitis with ulcerative colitis and amyloidosis: Report of a case and review of the literature. Amer. J. Med. 40:431439, 1966. 4. Bensaude, R., and Lambling, A.: Discussion on the aetiology and treatment of fibrous stricture of the rectum (including lymphograimloma inguinale). Proc. Roy. Sot. Med. 29: 1441-1456, 1936. 5. Berdon, W. E., Grossman, H., Baker, D. H., Mizrahi, A., Barlow, O., and Blanc, W. A.: Necrotizing enterocolitis in the premature infant. Radiology 83:879-887, 1964. 6. Bimbaum, D., Laufer, A., and Freund, M.: Pseudomembranous enterocolitis: A clinicopathologic study. Gastroenterology 41:345352, 1961. 7. Buie, L. A., and Malmgren, G. E.: Factitial proctitis a justifiable lesion observed in patients following irradiation. Trans. Amer. Proct. SOC. 31:80-91, 1930. 8. Camiel, M. Ft.: Ileocecal tuberculosis. Radiology 44:344-351, 1945. 9. Cbait, A.: Schistosomiasis mansoni: Roentgenologic observations in a nonendemic area. Amer. J. Roentgen. 90: 688-708, 1963. 10. Colcock, B. P., and Hume, A.: Radiation injury to the sigmoid and rectum. Surg. Gynec. Obstet. 108:306-312, 1959. Il. Craig, M. S., Jr., and Buie, L. A.: Facti-

12.

13.

14.

15.

I6.

17.

18.

I9.

20.

21.

22.

tial (irradiation) proctitis: A clinicopathologic study of 200 cases. Surgery 25472487, 1949. Crawford, P. M., and Sawyer, H. P.: tuberculosis in 1,400 Intestinal autopsies. Amer. Rev. Tuberc. 30: 568583, 1934. Cummins, A. J.: Pseudomembranous enterocolitis and the pathology of nosology. (Editorial.) Amer. J. Dig. Dis. 6:429-431, 1961. David, V. C., and Loring, M.: Extragenital lesions of lymphogranuloma inguinale. A.M.A. 106: 1875-1879, I. 1936. Fleischner, F. G., and Bernstein, C.: Roentgen-anatomical studies of the normal ileocecal valve. Radiology 54: 43-58, 1950. Gerslon-Cohen, J., and Kremens, V.: X-ray studies of the ileocecal valve in ileocecal tuberculosis. Radiology 62251-254, 1954. Glotzer, D. J., Roth, S. I., and Welch, C. E.: Colonic ulceration proximal to obstructing carcinoma. Surgery 56:950-956, 1964. Goulston, S. J. M., and McGovern, V. 1.: Pseudomembranous colitis. Gut 6:207-112, 1965. Hale, H. W., Jr., and Cosgrifl, J. H., Jr.: Pseudo-membranous enterocolitis. Amer. J. Surg. 94:716-717, 1957. Hardaway, R. M., III, and McKay. D. G.: Pseudomembranous enterocolitis: Are antibiotics wholly responsible? .4rch. Surg. 78z446-457, 1959. Heinz. E. R., Steinberg, A. J., and Sackner, M. A.: Roentgenqgiaphic and pathologic aspects of inteQina1 scleroderma. Ann. Intern. Med. 59: 822-826, 1963. and Sxilagyi, D. E.: Helper, M., Venereal lymphogranulomatous rectal

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11. IIODGSOS

Fig.

16

5

8 g %

Fig. 15.-Tuberculosis of the right colon of a 49 year old man with bilateral pulmonary tuberculosis. At operation, the ileum and ceculn showed numerous miliary tubercules studding the serosal surface. The roentgenogram reveals a flat, structureless relief pattern with ulceration of the terminal ileum and cecum and moderate narrowing of lumen.

Fig. 16.-Tuberculosis in a 48 year old woman without pulmonary tuberculosis. Exploration of the abdomen revealed involvement of the terminal ileum, cecum and ascending colon. Note marked constriction in the cecum and ascending colon due to hyperplastic granulomatous tissue.

E p g 3 2 v) E

K Fig. 14.-Tuberculosis in a 48 year old woman with no evidence of pulmonary disease. At operation, involvement of the ileum, cecum and ascending colon and adjacent lymph nodes were found. The roentgenogram shows ulceration, mucosal destruction and marked constriction of the cecum and ascending colon. The terminal ileum is dilated and the ileocecal valve is gaping.

108

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HODGSON

Fig. 19.-Tuberculosis of the sigmoid. The patient presented with a tender mass in the left lower quadrant. Exploration of the abdomen revealed an inflammatory mass involving the sigmoid. A lymph node was removed and showed tuberculosis. At autopsy, tuberculosis involved the si‘gmoid and descending colon. The roentgenogram shows mucosal edema, ulceration and a fistulous tract extending from the s@noid into the adjacent soft tissue.

Fig. l&-Tuberculosis in a 43 year old man who had bilateral pulmonary tuberculosis with cavitation and positive sputum. The roentgenogram shows extensive ulcerative and hyperplastic disease involving the terminal ileum, ascending colon, transverse colon and splenic flexure. The extensive involvement is not characteristic of the roentgen changes in tuberculosis.

Fig. 17.-Tuberculosis in a 35 year old man with a long history of pulmonary tuberculosis with cavitation. At operation, tuberculosis involving the terminal ileum and ascending and transverse colon was conihmed. Ileosigmoidostomy was performed.’ The patient died subsequently of tuberculous peritonitis. The roentgenogram shows ulceration, constriction, mucosal destruction and submucosal inflammatory masses involving a few inches of terminal ileum, the right colon and much of the transverse colon.

$

2 8

%

110

JOHh‘

R

HODGSON

Fig. 20 (left).-Ulcer of the colon. A flat sessile filling defect is seen along the inferior margin of the transverse colon near the hepatic flexure in a 25 year old woman with a history of bleeding from the colon. At operation, three ulcers were found in the transverse colon, 4 by 5 cm. Fig. 21 (right).-Ulcer inferior margin of the ulcerated.

of the colon. Note the flat, sessile defect (arrow) transverse colon. The mucosa appears irregular

along the but not

Fig. 22.-Ulcer of the colon in a 56 year old woman. A. Postevacuation film shows a narrowed segment at the junction of the descending colon and sigmoid. A. Spot film of the distended colon showing the narrowed segment to better advantage. The mucosa appears intact except for some enlargement of folds, probably edema. A crater is seen in the proximal portion of the defect. No diverticula were noted in this area or elsewhere in the bowel. Surgical exploration revealed a solitary ulcer, 4 by 3.5 cm. in diameter. which had penetrated into the submucosa.

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Fig. 23.-Actfnomycosis. The barium enema is that of a 67 year old man who had an abdominal mass. Note edema and slight ulceration of mucosa with narrowing in the transverse colon to the left of the midline. At operation, this segment of bowel was involved in an inflammatory mass apparently originating in the colon. Colostomy was performed. Subsequent exploration revealed multiple sinus tracts extending from the transverse colon to the sigmoid. Pus in the sinus tracts contained sulfur granules and resection revealed actinomycosis primary in transverse colon with marked pericolitis. The roentgen changes are those of inflammatory disease and are nonspecific.

23.

24.

25.

26.

27.

stricture. Amer. J. Roentgen. 48: 179190, 1942. Hobin, F. P.: Pseudomembranous enterocolitis: A fatal complication of congenital aganglionic megacolon. Amer. J. Dis. Child. 111:661-663, 1966. Hurwitz, A., and Khafif, R. A.: Acute necrotizing colitis proximal to ohstrutting neoplasms of the colon. Surg. Gynec. Obstet. 111:749-752, 1960. Jackson, C: C., Bacon, H. E., and Trimpi, H. D.: Pathogenesis of tuberculous ulceration of colon and rectum: A preliminary report. Lancet 73:464-466, 1953. Jensen, E. J,, Bargen, J. A., and Baggenstoss, A. H.: Amyloidosis associated with chronic ulcerative colitis. Gastroenterology lZ75-83, 1950. Kleclmer, M. S., Bargen, J. A., and Baggenstoss, A. H.: Pseudomembranous enterocolitis: clinicopatholo-

28.

29.

30. 31. 32.

gic study of fourteen cases in which the disease was not preceded by an operation. Gastroenterology 21:212222, 1952. Klein, I.: Roentgen study of lympliogranuloma venereum: Report of 24 cases. Amer. J. Roentgen. X:70-75, 1944. Kornhlith, B. A.: Lymphogranuloma venereum: Treatment of 300 cases with special reference to use of Frei antigen intravenously. Amer. J. Med. Sci. 198:231-246, 1939. hlathews, W. H.: Primary systemic amyloidosis. Amer. J. Med. Sci. 228: 317333, 1954. May, J., and Loewenthal, J.: Irradiation injury to the colon. Gut 6:444447, 1965. hiitchell, R. S., and Bristol, L. 1.: Intestinal tuberculosis: .4n analysis of 346 cases diagnosed by routine intestinal radiography on 5,529 admissions for pulmonary tuberculosis ( 1924-1949).

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Amer. J. Med. Sci. 227:241-249, 1954. Pearce, C., and Dineen, P.: A study of pseudomembranous enterocolitis. Amer. J. Surg. 99:292-300, 1960. Pettet, J. D., Baggenstoss, A. H., Dearing, W. H., and Judd, E. S., Jr.: Postoperative pseudomembranous enterocolitis. Surg. Gynec. Obstet. 98: 546-552, 1954. Reiner. L., Schlesinger, M. J., and Miller, G. M.: Pseudomembranous colitis following Aureomycin and Chloramphenicol. Arch. Path. 54: 39-67, 1952. Rityo, M., and Litner, C.: Roentgen manifestations of primary amyloidosis of the colon: Case report. Amer. J. Roentgen. 89:760-765, 1963. Senturia, H. R., and Wald, S. M.:

38.

39. 40.

41.

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Ulcerative disease of the intestinal tract proximal to partially obstructing lesions: Roentgen appearance. Amer. J. Roentgen. 99:45-51, 1967. Warren, I. 4., Strygler, I., and Kobernick, S. D.: Amyloidosh secondary to chronic ulcerative colitis. Ann. Intern. Med. 51:795-801, 1959. Wenzel, J. F.: Factitial proctitis: The role of lymphatic destruction. Amer. J. Surg. 92:678-682, 1956. Wigby, P. E.: Post-irradiation stricture of rectum and sigmoid following treatment for cervical cancer. Amer. J. Roentgen. 49:307-320, 1943. Williams, E.: Staphylococcal pseudomembranous enterocolitis complicatwith Aureomycin. ing treatment Lancet 2:999-1000, 1954.

THE SPANISH ROENTGEN When a stamp honoring a famous person is issued in another country, it is not unusual to find that the artist has introduced a few traits which bring that face closer to the nationality of the country where the stamp originated. On the occasion of the 7th Congress of Radiologists of Latin Culture, which convened in Barcelona in April 1967, Spain issued a special stamp. Thereon, lined up with a rotating anode tube and the so-called atomic orbits, Wilhelm Conrad Roentgen (1845-1923), the German, displays the dignified, bronzelike profile of a Spanish grand*.-E. R. N. Grigg, M.D.