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Gastroenterology & Hepatology: Open Access

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Received: January 01, 1970 | Published: ,

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Abstract

Adult large bowel obstruction is an infrequent cause of acute obstruction. in Africa and India and is seen to be caused commonly by sigmoid volvulus. Transverse colon obstruction is relatively uncommon. Carcinoma of the transverse colon accounts for 10 % of all colorectal cancer. We present the case of a 42 year old lady with intestinal obstruction who on evaluation revealed a stricture at the transverse colon on CT imaging. She underwent an extended right hemicolectomy for the same which on HPE gave a histological surprise of Crohn’s disease.

Keywords: colonic obstruction, unusual cause, crohn’s disease

Introduction

Adult large bowel obstruction is an infrequent cause of acute obstruction. In Africa and India it is caused commonly by sigmoid volvulus.¹ In developing countries tuberculous stricture may also be a likely cause.² Transverse colon obstruction is relatively uncommon. Carcinoma of the transverse colon accounts for 10 % of all colorectal cancer.³ When an obstructive lesion is seen in an adult, ruling out malignancy is of top priority but the biopsy gives the surprise. Such a case is reported.

Case

42 years old lady had presented with abdominal fullness and discomfort of 15 days duration. She was passing flatus infrequently and passing small quantity of stool daily. But in the last 2 days before her presentation she was neither passing flatus nor stool. She did not give any history of similar complaints or of undergoing any surgery in the past. There was no history of definite pain or fever. She was having her period regularly. On examination she was in good general health. There was mild pallor. The abdomen was distended but soft. PR examination was normal. Hemoglobin was 10.8 Gm% and the entire haematological and biochemical test including renal and liver parameters were normal. But the plain X-ray of the abdomen was showing dilated right colon on two successive days in spite of enema. Hence a CT scan was done to find out the cause of distention. The imaging revealed dilated right colon till right 1/3rd of transverse colon (Figure 1) with rest of the colon collapsed. A stricturing growth at the transverse colon was suspected. The patient and the family members were informed and counseled for surgery. At exploration there was no evidence of free fluid. The proximal part of the collapsed transverse colon was thickened and firm. There were no regional nodes. Thinking of Cancer an extended right colectomy was done. On opening the specimen, there was mucosal nodularity and wall was thickened involving full thickness with nodular lesion on the mucosa (Figure 2). A side to side ileo- transverse anastomosis was done. She recovered well. Biopsy came as Crohn’s disease (CD). During the 60 months follow up she is asymptomatic.

Figure 1 (CT scan section) Dilated transverse colon till right 1/3rd of transverse colon.

Figure 2 Specimen showing thickened wall and mucosal nodularity at the narrowed segment.

Discussion

CD is a trans-mural inflammatory disease that may involve any part of the gastrointestinal tract, but mainly involving distal ileum and colon. At the time of diagnosis approximately 40% present as ileocolic disease, 30 % as isolated ileal disease and 30 % as pure colonic disease.^4,5 CD shows segmental localization and the lesions changes only minimally over time, with only 10 %-15 % of patients presenting a change in lesion localization over 10 years after diagnosis. The present case had only the disease limited to a short segment of transverse colon and no other abdominal organ involvement at laparotomy. Approximately 50 % of CD patients have only a slight evolutive disease and, therefore, overtreatment should be avoided.⁶ Our case received no other treatment as the local disease was removed. In fact surgery plays an important role in the management of IBD. Up to 75 % of CD patients will require an operation at some point in the course of the disease⁷ Most of the indications are due to stricture, like our case. Although surgery is not curative, it appears to be the most efficacious treatment in inducing prolonged remission,⁸ thus justifying only the follow up in this case.