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Persistent Left Lower Abdominal Pain
Electronic Clinical Challenges and Images in GI Persistent Left Lower Abdominal Pain
Question: A 56-year-old man presented for new onset abdominal pain. His past medical history was significant for bilateral inguinal hernia repair and appendectomy in 1997. In 2004, he was evaluated for recurrent hematochezia and a flexible sigmoidoscopy at that time revealed internal hemorrhoids. Three months before this presentation, he began to complain of colicky abdominal pain, localized to the left lower quadrant and suprapubic area. The pain was increased by food intake and was not associated with any other symptoms. The physical examination and laboratory findings were normal. Abdominal and pelvic computed tomography (CT; Figure A)
showed, in addition to the extensive sigmoid diverticulosis, mild streaking with possible air-pocket containing collection in continuity with the sigmoid colon and anterior to, and inseparable from, the bladder and anterior pelvic wall (white arrow). These findings were suggestive of sigmoid diverticulitis and the patient was started on oral ciprofloxacin and metronidazole with no pain relief. 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. MUSTAFA Z. EL HAKAM, MD ALA I. SHARARA, MD, AGAF Divisions of Gastroenterology Department of Internal Medicine American University of Beirut Medical Center (AUBMC) VICTOR CHEDID School of Medicine American University of Beirut Beirut, Lebanon
Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 0016-5085/10/$36.00 doi:10.1053/j.gastro.2009.04.064
GASTROENTEROLOGY 2010;138:e5– e6
e6
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 138, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 3: Mesh Migration Into the Sigmoid Colon The diagnosis was made by colonoscopy. The mesh was found at 30 cm from the anal verge and the scope could not be introduced further (Figure B). Pulling at the mesh with a biopsy forceps confirmed its fixed nature and laparoscopic removal with partial sigmoidectomy was subsequently performed. Retrospectively, the CT scan was reviewed and surgical sutures were present in the previously described collection (Figure C, white arrow). Mesh migration after hernia repair may be subdivided into 2 subtypes1: (1) primary migration, where the mechanical displacement happens along the least resistant paths into the adjacent anatomic spaces as a result of either inadequate fixation or external displacing forces; and (2) secondary migration owing to a foreign body reaction and subsequent erosion of surrounding tissue, with slow and gradual movement of the mesh through the transanatomic space. Clinical manifestations are therefore variable and depend on the site of migration.1 Most reported cases in the literature involve the urinary bladder. Mesh migration of the sigmoid, first reported by Lange et al,2 is a major postoperative complication, occurring mostly after laparoscopic inguinal hernia repair and causing abdominal pain and, occasionally, hematochezia. Colonoscopy is the single most effective diagnostic tool; other imaging modalities have a limited role in establishing the diagnosis.2 The mainstay of treatment is surgical removal with partial sigmoidectomy owing to the fixed and complex nature of the mesh migration. One case report, however, described successful colonoscopic removal of a splenic flexure mesh using alligator forceps.3 References 1. Agrawal A, Avill R. Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia 2006;10:79 – 82. 2. Lange B, Langer C, Markus PM, et al. Mesh penetration of the sigmoid following transabdominal preperitoneal hernia repair. Surg Endosc 2003;17:157. 3. Celik A, Kutun S, Kockar C, et al. Colonoscopic removal of inguinal hernia mesh: report of case and literature review. J Laparoendosc Adv Surg Tech A 2005;15:408 – 410. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Question: A 56-year-old man presented for new onset abdominal pain. His past medical history was significant for bilateral inguinal hernia repair and appendectomy in 1997. In 2004, he was evaluated for recurrent hematochezia and a flexible sigmoidoscopy at that time revealed internal hemorrhoids. Three months before this presentation, he began to complain of colicky abdominal pain, localized to the left lower quadrant and suprapubic area. The pain was increased by food intake and was not associated with any other symptoms. The physical examination and laboratory findings were normal. Abdominal and pelvic computed tomography (CT; Figure A)
showed, in addition to the extensive sigmoid diverticulosis, mild streaking with possible air-pocket containing collection in continuity with the sigmoid colon and anterior to, and inseparable from, the bladder and anterior pelvic wall (white arrow). These findings were suggestive of sigmoid diverticulitis and the patient was started on oral ciprofloxacin and metronidazole with no pain relief. 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. MUSTAFA Z. EL HAKAM, MD ALA I. SHARARA, MD, AGAF Divisions of Gastroenterology Department of Internal Medicine American University of Beirut Medical Center (AUBMC) VICTOR CHEDID School of Medicine American University of Beirut Beirut, Lebanon
Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 0016-5085/10/$36.00 doi:10.1053/j.gastro.2009.04.064
GASTROENTEROLOGY 2010;138:e5– e6
e6
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 138, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 3: Mesh Migration Into the Sigmoid Colon The diagnosis was made by colonoscopy. The mesh was found at 30 cm from the anal verge and the scope could not be introduced further (Figure B). Pulling at the mesh with a biopsy forceps confirmed its fixed nature and laparoscopic removal with partial sigmoidectomy was subsequently performed. Retrospectively, the CT scan was reviewed and surgical sutures were present in the previously described collection (Figure C, white arrow). Mesh migration after hernia repair may be subdivided into 2 subtypes1: (1) primary migration, where the mechanical displacement happens along the least resistant paths into the adjacent anatomic spaces as a result of either inadequate fixation or external displacing forces; and (2) secondary migration owing to a foreign body reaction and subsequent erosion of surrounding tissue, with slow and gradual movement of the mesh through the transanatomic space. Clinical manifestations are therefore variable and depend on the site of migration.1 Most reported cases in the literature involve the urinary bladder. Mesh migration of the sigmoid, first reported by Lange et al,2 is a major postoperative complication, occurring mostly after laparoscopic inguinal hernia repair and causing abdominal pain and, occasionally, hematochezia. Colonoscopy is the single most effective diagnostic tool; other imaging modalities have a limited role in establishing the diagnosis.2 The mainstay of treatment is surgical removal with partial sigmoidectomy owing to the fixed and complex nature of the mesh migration. One case report, however, described successful colonoscopic removal of a splenic flexure mesh using alligator forceps.3 References 1. Agrawal A, Avill R. Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia 2006;10:79 – 82. 2. Lange B, Langer C, Markus PM, et al. Mesh penetration of the sigmoid following transabdominal preperitoneal hernia repair. Surg Endosc 2003;17:157. 3. Celik A, Kutun S, Kockar C, et al. Colonoscopic removal of inguinal hernia mesh: report of case and literature review. J Laparoendosc Adv Surg Tech A 2005;15:408 – 410. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).