Ischemic colitis or melanosis coli: a case report

Melanosis Coli is described as black or brown discoloration of the mucosa of the colon. It is a benign condition, whicharises from anthraquinone laxative abuse and usually has no symptoms of its own. Though not a very rare condition,to the best of our knowledge, no case has been reported on melanosis coli in Bangladesh . Here we report a case ofmiddle aged lady presenting with passage of blood mixed stool for one year. Colonoscopy was performed whichrevealed melanosis coli and which was later confirmed by histopathology. Not thought to be a pre malignantcondition, it has been found in some patients with other diseases.Keywords: Melanosis coli; Anthraquinone; Lipofuscin; Laxative; BangladeshDOI: 10.3329/jom.v11i2.5469J MEDICINE 2010; 11 : 183-185

We report the case of a 74-year-old female with an extreme picture of melanosis coli of the whole colon after chronic use of anthraquinone laxatives for the treatment of constipation over many decades. Endoscopic work-up revealed an impressive deep black pigmentation of the whole colon mucosa which could be verified by histopathology as a widespread lipofuscin granulation. In addition, various adenomas but no colorectal carcinoma could be detected. The term melanosis coli describes a brown or black pigmentation of the colonic mucosa. Induction of melanosis coli by anthraquinone laxatives and their derivatives can be regarded as verified. The question if melanosis coli predisposes for colorectal neoplasia is discussed controversially. Based on the current literature, an association of melanosis coli between colorectal adenomas, but not colorectal carcinomas, is under discussion but the mechanisms to effect the development of colorectal neoplasia are not completely understood. Considering our case and the current scientific backround, we conclude that due to pharmaceutical side effects of anthraquinone derivatives such as electrolytic shift and water loss in addition to the risk of developing melanosis coli, anthraquinone laxatives should not be used for long-term therapy of constipation.

Melanosis coli is a condition in which the colon develops a brown to black discoloration. It is associated with chronic laxative use and frequently diagnosed incidentally during colonoscopy or histopathologic evaluation. A 74-year-old woman presented to the Emergency Department with severe abdominal pain and bilious emesis. During a cecal volvulus repair, her melanosis coli was nearly misdiagnosed as bowel ischemia. Melanosis coli is a diagnostic finding that can easily be confused with bowel ischemia, which may create a dilemma for the surgeon who is attempting to make a decision regarding the extent of a colonic resection. As such, a pathology consult is warranted in any patient with suspected ischemic colitis and concerns for concomitant melanosis coli.

Melanosis coli (MC) is a benign condition found in 1% of general population. It is associated with high intake of anthranoid laxatives [1]. We herein report two cases of elderly patients with MC in whom this condition masked underlying diseases.

Patient: Male, 6Final Diagnosis: Colonic perforation secondary to vascular Ehlers Danlos SyndromeSymptoms: Abdominal pain • constipationMedication: —Clinical Procedure: Loop colostomy followed by total colectomy and ileostomySpecialty: SurgeryObjective:Unusual clinical courseBackground:Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders with heterogeneous clinical features associated with varying genetic mutations. EDS type IV, also known as vascular EDS (vEDS), is the rarest type but has fatal complications, including rupture of major vasculature and intestinal and uterine perforation. Intestinal perforation can be spontaneous or a consequence of long-standing constipation, a common symptom among patients with EDS.Case Report:We present a case of a 6-year-old boy with the previous diagnosis of vEDS who presented with colonic perforation from a stercoral ulcer. He underwent diagnostic laparoscopy and loop colostomy, with an uneventful postoperative course. Unfortunately, he developed a second colonic perforation 14 months after the initial episode and underwent total abdominal colectomy with end ileostomy.Conclusions:Intestinal perforation is a well-documented and devastating complication of vEDS. However, spontaneous intestinal perforation is extremely rare in a young child. Therefore, the diagnosis of vEDS should be included in the differential diagnosis if a child presents with intestinal perforation. There is no clear guideline available for surgical management of colonic perforation in patients with vEDS, but total abdominal colectomy appears to provide the best chance of preventing recurrent perforation.

Adverse effects of laxatives: fact and fiction.

Purpose: Melanosis is abnormal dark coloration of skin/mucosa. Although melanosis coli is common, it rarely involves the upper GI tract mucosa. Melanosis duodeni is a rare, benign clinical entity characterized by dark pigmentation of duodenal mucosa of uncertain etiology. We report a case with clinical, endoscopic and pathologic correlation of duodenal melanosis. Methods: A 69-year-old female with PMH of chronic GERD, HTN (treated with hydralazine and carvedilol), CHF, chronic renal disease on hemodialysis and anemia was referred by otorhinolaryngologist for endoscopic evaluation after laryngoscopy showed edema of posterior commissure consistent with GERD. She was seen by ENT for a chronic cough and dysphagia. Prior endoscopic findings five years ago were significant for reflux esophagitis, gastritis and PUD. She denied any symptoms of hematemesis, melena, diarrhea or constipation. Physical examination was unremarkable, including rectal exam and occult bleeding. Results: Laboratory findings were significant for anemia and renal failure. Panendoscopy was done where EGD revealed pigmented duodenal mucosa, erosive esophagitis and antral gastritis without active bleeding. Upon biopsy, microscopic histopathologic findings of chronic inflammatory cell infiltrates and foci of brown-black pigment in lamina propria were consistent with melanosis. H.pylori was negative. Colonoscopy was unremarkable except for diverticulosis and AV malformation without any pigmentation. Conclusions: Melanosis duodeni: endoscopically seen as discrete, flat, small, brown-black dark pigmented spots in the duodenal mucosa, and is generally considered to be local deposition of iron from oral iron intake. There is no known association with pigmentation elsewhere in the GI tract, or with the use of laxatives. On literature review, the exact mechanism is unknown; it is found to be associated with history of oral iron intake, upper GI bleeding, co-morbid conditions like HTN, ESRD, CHF, DM and certain medications like hydralazine or diuretics, most of which were present in our case. Although it is a benign condition of unclear clinical importance that does not require any specific therapy, endoscopists and pathologists must be aware of this rare entity.Figure: Chronic inflammatory cell infiltrates and foci of brown-black pigment in lamina propria consistent with melanosis in duodenum.

BackgroundMelanosis coli is a benign condition characterized by deposition of lipofuscin in colonic mucosa due to long-term laxative use.Case presentationHere I am reporting a case of an 85-year-old man who presented with constipation, with a history of long-term herbal medication intake as laxatives, and upon evaluation, he was found to have melanosis coli.ConclusionMelanosis coli is a common adverse effect of chronic laxative use which is more common in elderly population with constipation.

Anthranoid laxatives are widely used laxatives of natural origin. Because of their chemical structure they are carried unabsorbed to the large bowel, where metabolism to the active aglycones takes place. These aglycones exert their laxative effect by damaging epithelial cells, which leads directly and indirectly to changes in absorption, secretion and motility. Damaged epithelial cells can be found as apoptotic bodies in the pigmented colonic mucosa, characteristic for pseudomelanosis coli. Pseudomelanosis coli is a condition caused by chronic (ab)use of anthranoid laxatives and has recently been associated with an increased risk of colorectal carcinoma. In vitro and animal studies have shown a potential role of anthranoid laxatives in both the initiation and promotion of tumorigenesis. Studies in humans have also suggested tumour promoting activities for these laxatives. Although the short-term use of these substances is generally safe, long-term use cannot be recommended.

Cronkhite-Canada syndrome (CCS), first described by Cronkhite and Canada in 1955, is characterized by gastrointestinal polyposis, cutaneous hyperpigmentation, onychodystrophy and alopecia. As compared with complete form of full expression, the incomplete form may lack one or some of the clinical cutaneous manifestations. A 60-year-old Taiwanese man had chronic diarrhea and poor appetite with gradual weight loss over the past one year. Numerous discrete freckle-like macules were scattered over palms and soles, as well as the flexural sides of upper extremities. All the twenty digits, toenails in particular, were slightly clubbing in shape with dystrophic nails. Male-pattern baldness rather than diffuse hair loss was observed. Endoscopy and small bowel series disclosed numerous polyps of varying sizes from the stomach to descending colon; histopathology revealed juvenile polyps with focal adenomatous change. After subtotal colectomy, fingernails have regrown but toenails remained dystrophic. Freckle-like macules over palms, soles, and flexural sides of upper extremities faded and decreased in number, while hair loss was stable. We present this case of incomplete form of CCS, and discuss the differential diagnoses in dermatological aspect.

Introduction: Ulcerative colitis (UC) is a debilitating disorder of colon. The incidence of UC peaks in the age group of 15 to 25, and only 1% are infantile. Despite initial medical treatment, in refractory cases, colectomy is needed. There are few studies regarding surgical results of treatment of UC in infancy. Material & Methods: In our descriptive retrospective study we reviewed medical files of infants with ulcerative colitis that consulted with us for surgery between 2009 and 2014. Age at onset, family history of inflammatory bowel disease, symptoms of onset, colonoscopic findings, duration of Medical treatment, Indication of surgery, Type of operation, surgical complications and their Management and mortality was recorded. Results: We found five patients with the diagnosis of UC in their first year of life; 4 boys and 1girl. The mean age of onset of the disease was 35 days (range 3-60). The mean age of patients at the time of surgical consult was 7 months. The disease began in 3 patients with watery diarrhea. Family history was positive in only one of our cases. He had sever FTT with no response to medical treatment which was an indication for surgery and he underwent total proctocoletomy, ileoanal anastomosis and loop ileostomy which failed and 3 days after the first operation we performed an end ileostomy. Two cases had colon perforation following their colonoscopy and one of them (a 4 month girl) expired before laparotomy and the other (a 12 month boy) underwent colostomy creation while he was in septic shock. The fourth patient was a 2 day old neonate with abdominal distention and intestinal obstruction. Rectal biopsy showed agangliosis so he underwent a transanal pull through procedure with a diagnosis of hirschsprung’s disease. After surgery he experienced recurrent watery diarrhea and further diagnostic investigations brought about the diagnosis of UC. Our last patient was a 3 day old neonate that underwent ileostomy in the initial surgery with suspicion of total colonic agangliosis and underwent subtotal colectomy when he was 2 months old. At 1.5 years he developed toxic mega-colon in the remnant of colon when he was old and thus was referred to us and underwent colostomy. After 3 month the final surgery was carried out. Conclusions: If a child presents with recurrent bloody or watery diarrhea even in infancy, UC should be considered as a differential diagnosis. The pattern of the disease in infancy appears more rigorous. Evidence-based management of UC presenting in infancy is incomplete but early surgical attempt can reduce catastrophic results.

Hyperreactio luteinalis (HL) is a rare entity in which both ovaries are multicystic and enlarged under the action of human chorionic gonadotropin (hCG), mostly seen in the third trimester of pregnancy. This benign condition is usually asymptomatic and doesn’t need any specific treatment, as the ovaries spontaneously reduce in size after birth. This is a case report of a 33-year-old woman diagnosed with hyperreactio luteinalis during the second trimester of her induced pregnancy. An ultrasound scan at 22 weeks of gestation revealed bilateral multicystic enlarged ovaries along with multiple fetal malformations and hydropsfetalis. Usually, HL is most commonly seen in situations in which there are high levels of hCG, but our patient had normal levels of hCG during all her pregnancy, which makes our case even rarer. In conclusion, the most important challenge when faced with HL is to differentiate between it and other differential diagnosis especially malignant tumors, because unlike them, this benign condition doesn’t need surgical treatment.

Anisocoria (unequal pupil size) occurring acutely can be indicative of serious neurological pathology. However, in healthcare professionals who handle nebulised medicines, acute anisocoria is often caused by benign conditions such as mydriasis (abnormal pupil dilation) triggered by exposure to certain drugs and occurring unilaterally. This article reports on the case of an emergency nurse who developed acute anisocoria while on shift. It describes the initial assessment and further investigations, outlines the differential diagnosis, and discusses the implications for emergency nursing practice. Drug-induced mydriasis should be considered in healthcare professionals presenting with acute anisocoria, especially in the absence of red-flag symptoms. Increased awareness of this benign and self-limited condition could promote the safer handling of nebulised medicines and a more nuanced application of 'gloves off' recommendations.

Background: Laparoscopic colectomy is a safe and effective alternative to open colectomy for colorectal cancer. It is not widely adopted because of its complex procedures and estimated higher morbidity and mortality in the early period of the learning curve. In this paper, we report on the short-term results of our first 14 consecutive laparoscopic colectomies performed in 2006. Methods: Laparoscopic colectomy was offered as an alternative to elective open colectomy for colorectal cancer, except for T4 tumors. Fourteen patients underwent laparoscopic resection of colorectal cancer in 2006. In this paper the characteristics of patients and tumors are reported as well as the short-term outcomes, including the length of operation time, conversion rate, recovery course, morbidity and mortality. Data were prospectively recorded. Results: Laparoscopic procedures were completed in 13 of the 14 patients. The average operation time was 238 minutes and the average postoperative hospital stay was 17.8 days. The postoperative staging was stage I in 2 patients, stage IIA in 2, stage IIIB in 4, and stage IV in 6, according to the American Joint Committee on Cancer (AJCC). One of the 14 patients experienced ureter injury and conversion of the procedure to open colectomy. Postoperative complications occurred in 3 patients, including respiratory failure in one, anastomosis leak in another one, and wound infection with dehiscence in the remaining one. The only patient whose body-mass index (BMI) was ＞30 kg/m^2 experienced conversion due to intraoperative ureter injury and died of postoperative respiratory failure. The patient with anastomosis leak had severe intraperitoneal adhesion due to 3 previous major intraabdominal operations. No positive margin was detected in the specimens and the average number of harvested lymph nodes was 16. These results closely follow the guidelines of colorectal cancer surgery in Taiwan. Conclusion: Our report indicates that laparoscopic colectomy for colorectal cancer can be developed safely by surgeons with adequate experience in other laparoscopic procedures in a regional hospital. Proper selection of patients, by avoiding cases with a BMI ＞30 kg/m^2 or previous major abdominal surgery, for example, is highly recommended to prevent conversion, and to reduce morbidity and mortality in the early period of the learning curve.

Purpose. Over the past decade, laparoscopic colectomy has been widely used for patients with colorectal neoplasm. However, there is little data about laparoscopic surgery among nonagenarians. This study discusses our clinical experience of laparoscopic colectomy for nonagenarians in a single institute. Methods. From January 2000 to July 2009, we performed a retrospective case control study of patients who underwent laparoscopic or open colectomy due to a primary colon tumor. Thirty-five patients were older than 90 years old. The demographics, tumor characteristics, surgical methods, lab data, morbidity, mortality, and survival were investigated and analyzed. Results. Eleven patients underwent laparoscopic colectomy and eleven underwent open colectomy were enrolled. The mean age entering surgery was 92.3 versus 93.3. The most common operation procedure was a laparoscopic anterior resection (45%) versus open right hemicolectomy (27.3%). The average of hospital stay was 16.9 (8-39) days versus 23.9 (10-69) days. Four patients in laparoscopic group (36.4%) and five in open group (45.5%) suffered complications. There was one 30 days-mortality (9.1%) in laparoscopic group. The median follow-up interval was 19 versus 13 months and the five year survival rate was 54.6% versus 33.8%. Conclusion. The short-tern and long-tern result of laparoscopic group are not worse than open group. The mortality and morbidity rates in our study are not higher than octogenarians or septuagenarians of other studies. For nonagenarians with colorectal neoplasm, laparoscopic colectomy is a feasible and safe option for selective patients.