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Spontaneous perforation in collagenous colitis
Spontaneous perforation in collagenous colitis Shintaro Akamoto, MD, Masao Fujiwara, MD, Keiichi Okano, MD, and Yasuyuki Suzuki, MD, Kagawa, Japan
From the Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
A 64-YEAR-OLD WOMAN with a history of depression treated by mianserin was admitted to our hospital with acute abdominal pain. She had no history of other drug use. Abdominal tenderness with peritoneal signs was observed in the left upper quadrant. This was preceded for 2 weeks by nonbloody diarrhea and appetite loss. Laboratory tests indicated a leukocyte count of 11,930/mm3 and a C-reactive protein level of 13.69 mg/dL. Contrast-enhanced computed tomography of the abdomen indicated edema and gas within the bowel wall of the descending colon (Fig 1). Ischemic colitis and necrosis of the descending colon were suspected, and an emergency laparotomy was performed. Gas bubbles were detected in the mesentery and subserous layer of the descending colon. Wall thickening and an inflammatory change were also detected, but there were no macroscopic signs of peritonitis or necrosis in the descending colon. Left-sided colectomy and transverse colostomy were performed. Grossly, the specimen exhibited multiple longitudinal ulcers. Histopathologic examination indicated typical findings of collagenous colitis (CC) with a thick subepithelial collagenous band and an ulcerated area with mesentery penetration (Fig 2). The postoperative course was uneventful.
Fig 1. Contrast-enhanced computed tomography of the abdomen indicating edema (arrow) and gas (arrowhead) within the bowel wall of the descending colon.
DISCUSSION CC is an increasingly diagnosed clinical and pathologic variant of microscopic colitis that affects primarily middle-aged and elderly women.1 The distinct histopathologic changes consist of a mucosal inflammatory process and a characteristic subepithelial hyaline deposit in the lamina propria Accepted for publication October 22, 2012. Reprint requests: Shintaro Akamoto, MD, Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Kida-gun, Miki-cho, Kagawa 761-0793, Japan. E-mail: [email protected]. Surgery 2014;155:198-9. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2012.10.008
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Fig 2. Histopathologic examination indicating typical findings of collagenous colitis with a thick subepithelial collagenous band (A) and an ulcerated area with penetration to the mesentery (B) (hematoxylin & eosin stain).
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region. The clinical course of CC is generally benign, and serious complications are rare. Hussain et al2 reviewed 21 cases of colonic perforation in CC, that occurred mainly following colonoscopy or barium enema, and only 2 cases developed spontaneously. Of the 21 perforated cases, 14 were treated with laparotomy and colectomy, and an identifiable site of perforation was detected in only 1 case. Endoscopy in CC usually exhibits either normal mucosa or mild congestion and contact bleeding. However, another review of 12 cases demonstrated that linear ulcers were commonly detected in most of the cases of perforation.3 This case was difficult to differentiate from ischemic colon disease due to edema and
Pneumatosis coli in the findings of computed tomography. Therefore, spontaneous perforation in CC should be considered when patients present with these imaging findings and nonbloody chronic diarrhea. REFERENCES 1. Wickbom A, Lindqvist M, Bohr J, Ung KA, Bergman J, Eriksson S, et al. Colonic mucosal tears in collagenous colitis. Scand J Gastroenterol 2006;41:726-9. 2. Hussain Z, Kelly S, Clarke A, Adams S, Miller G. Colonic perforation in collagenous colitis: a systematic review of a rare complication and guidance on management. Surg Endosc 2010;24:2930-4. 3. Allende DS, Taylor SL, Bronner MP. Colonic perforation as a complication of collagenous colitis in a series of 12 patients. Am J Gastroenterol 2008;103:2598-604.
From the Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
A 64-YEAR-OLD WOMAN with a history of depression treated by mianserin was admitted to our hospital with acute abdominal pain. She had no history of other drug use. Abdominal tenderness with peritoneal signs was observed in the left upper quadrant. This was preceded for 2 weeks by nonbloody diarrhea and appetite loss. Laboratory tests indicated a leukocyte count of 11,930/mm3 and a C-reactive protein level of 13.69 mg/dL. Contrast-enhanced computed tomography of the abdomen indicated edema and gas within the bowel wall of the descending colon (Fig 1). Ischemic colitis and necrosis of the descending colon were suspected, and an emergency laparotomy was performed. Gas bubbles were detected in the mesentery and subserous layer of the descending colon. Wall thickening and an inflammatory change were also detected, but there were no macroscopic signs of peritonitis or necrosis in the descending colon. Left-sided colectomy and transverse colostomy were performed. Grossly, the specimen exhibited multiple longitudinal ulcers. Histopathologic examination indicated typical findings of collagenous colitis (CC) with a thick subepithelial collagenous band and an ulcerated area with mesentery penetration (Fig 2). The postoperative course was uneventful.
Fig 1. Contrast-enhanced computed tomography of the abdomen indicating edema (arrow) and gas (arrowhead) within the bowel wall of the descending colon.
DISCUSSION CC is an increasingly diagnosed clinical and pathologic variant of microscopic colitis that affects primarily middle-aged and elderly women.1 The distinct histopathologic changes consist of a mucosal inflammatory process and a characteristic subepithelial hyaline deposit in the lamina propria Accepted for publication October 22, 2012. Reprint requests: Shintaro Akamoto, MD, Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Kida-gun, Miki-cho, Kagawa 761-0793, Japan. E-mail: [email protected]. Surgery 2014;155:198-9. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2012.10.008
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Fig 2. Histopathologic examination indicating typical findings of collagenous colitis with a thick subepithelial collagenous band (A) and an ulcerated area with penetration to the mesentery (B) (hematoxylin & eosin stain).
Akamoto et al 199
Surgery Volume 155, Number 1
region. The clinical course of CC is generally benign, and serious complications are rare. Hussain et al2 reviewed 21 cases of colonic perforation in CC, that occurred mainly following colonoscopy or barium enema, and only 2 cases developed spontaneously. Of the 21 perforated cases, 14 were treated with laparotomy and colectomy, and an identifiable site of perforation was detected in only 1 case. Endoscopy in CC usually exhibits either normal mucosa or mild congestion and contact bleeding. However, another review of 12 cases demonstrated that linear ulcers were commonly detected in most of the cases of perforation.3 This case was difficult to differentiate from ischemic colon disease due to edema and
Pneumatosis coli in the findings of computed tomography. Therefore, spontaneous perforation in CC should be considered when patients present with these imaging findings and nonbloody chronic diarrhea. REFERENCES 1. Wickbom A, Lindqvist M, Bohr J, Ung KA, Bergman J, Eriksson S, et al. Colonic mucosal tears in collagenous colitis. Scand J Gastroenterol 2006;41:726-9. 2. Hussain Z, Kelly S, Clarke A, Adams S, Miller G. Colonic perforation in collagenous colitis: a systematic review of a rare complication and guidance on management. Surg Endosc 2010;24:2930-4. 3. Allende DS, Taylor SL, Bronner MP. Colonic perforation as a complication of collagenous colitis in a series of 12 patients. Am J Gastroenterol 2008;103:2598-604.