The correct combination
Case 142
【Clinical progress】
All four cases received surgical procedure. The diagnosis was based on macroscopic and microscopic examinations of the resected specimen. In Case 1, the cause of sigmoid colon perforation was not found: no diverticulum was detected. The patient Case 2 passed away two months after surgical operation. Other three patients were recovered by the discharge being able tomake their own social life.
【Discussion】
Mesentery and mesocolon are vital for small intestine and large intestine because they contain artery, portal vein, lymphatics and nerves. On usual CT interpretation, mesentery and mesocolon are not conscious to find out and sometimes overlooked because they include fat tissue. Radiologists are apt to focus on the bowels themselves. When you look for mesocolon, the region from the marginal artery of the large bowels to superior mesenteric artery or inferior mesenteric artery is a landmark to identify it. Ascending mesocolon and descending mesocolon cover anterior surface of ascending colon and descending colon which fixed dorsal abdominal wall (extraperitoneal organ) and they are not so difficult to identify because they are immobile. But transverse mesocolon and the sigmoid mesocolon suspend transverse colon and sigmoid colon in the peritoneal cavity and they are not so easy to identify because they are mobile. However, we can trace the middle colic branch vessels originated from the marginal vessels of the transverse colon toward the pancreas to communicate with superior mesenteric artery and veins which serve as a landmark of transverse mesocolon. We can trace the sigmoid colic branches from marginal vessels of the descending colon or the sigmoid colon and they serve as a landmark of sigmoid mesocolon (1). The lesions of cancer, abscess, fluids and hematoma from transverse colon or sigmoid colon spread via the transverse mesocolon and the sigmoid mesocolon (1). In our four cases with sigmoid colon lesions presented this week, free air, hematoma, abscess or cancer spread into the sigmoid mesocolon.
The sigmoid mesocolon forms an inverted V-shaped configuration and the apex attaches to the bifurcation point of the external and internal of the common iliac artery. The sigmoid mesocolon suspend the sigmoid colon and attaches to the dorsal abdominal wall: the lateral limb descends along with the left major psoas muscle and the medial limb descends and ends at the level of the third sacrum vertebrae.
Sigmoid colon perforation occurs due to colon cancer, diverticulitis, ischemic colitis, radiation therapy, endometriosis and unknown cause. Of these, sigmoid colon cancer is the most for perforation; tumor itself: secondary of the elevated intraluminal pressure such as from ischemic colitis or diverticulum (1-3). In our patients, sigmoid colon perforation in Case 1 was from unknown origin and Case 2, from colon cancer itself. Sigmoid colon abscess in Case 4 was from colon cancer perforation.
Sigmoid colon hematoma occurs from abdominal trauma, postoperative complication, colonic diverticulum, vascular aneurysm, endometriosis and anticoagulants. Of these, anticoagulant given is the most for sigmoid colon hematoma (5-8). In Case 3, he was given warfarin and laboratory test revealed PTINR was 3.6 implying hemorrhagic tendency.
【Summary】
We present four cases with sigmoid colon lesions of perforation, abscess, and hematoma. Sigmoid colon perforation occurs from unknown cause and cancer. Sigmoid colon abscess occurs from colon cancer itself or diverticulitis or ischemic colitis secondary to cancer. Sigmoid colon hematoma occurs from warfarin given. It is borne in mind that mesocolon is identified by tracing colic branch vessels originated from the marginal vessels of the colon toward superior mesenteric artery and veins which serve as a landmark of mesocolon. The sigmoid mesocolon forms an inverted V-shaped configuration and the apex attaches to the bifurcation point of the external and internal of the common iliac artery: the lateral limb descends along with the left major psoas muscle and the medial limb descends and ends at the level of the third sacrum vertebrae. Sigmoid colon perforation, abscess or hematoma occurs from cancer, diverticulum, colitis, endometriosis and/or radiation therapy.
【References】
1.Okino Y, et al. Root of the small-bowel mesentery: correlative anatomy and CT features of pathologic conditions. Radiographics 21 (6): 1475-90.
2.Fujisaki S, et al. Gan To Kagaku Ryoho. Perforation associated with colorectal cancer 2012 Nov;39(12):1908-10.
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5.Chaiteerakij, R, et al. Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review. J. Med. Assoc. Thail., 91 (2008), pp. 1285-1290
6.Bekheit M, et al. Non-traumatic intramural hematomas in patients on anticoagulant therapy: report of three cases and overview of the literature. Afr. J. Emerg. Med., 4 (2014), pp. e1-e4
7.Yang CM, et al. Spontaneous intramural small-bowel hematoma due to a rare complication of warfarin therapy: report of two cases. J. Acute Med., 4 (2014), pp. 45-48
8.Moftah MR, et al. Spontaneous sublingual and intramural small-bowel hematoma in a patient on oral anticoagulation. Gastroenterol. Insights, 4 (2012), pp. 73-75
2019.4.17