Year : 2010 | Volume
: 53 | Issue : 1 | Page : 138--140
Spontaneous perforation of solitary ulcer of transverse colon
Ioannis Galanis1, Dimitrios Dragoumis1, Thomas Kalogirou1, Sotiris Lakis2, Rodi Kotakidou2, Konstantinos Atmatzidis1,
1 G. Gennimatas Hospital, 2nd Surgical Clinic, Aristotle University of Thessaloniki, Thessaloniki, Greece
2 G. Gennimatas Hospital, Department of Pathology, Ethnikis Aminis, 41, p.o. 54635, Thessaloniki, Greece
I. Michail 7, p.o. 54622, Thessaloniki
Spontaneous ruptures of the colon and rectum are extremely uncommon clinical entities and always require laparotomy. A 44-year-old female was admitted with a 12-hour history of severe abdominal pain periumbilically and at the right hypochondrium. The patient was immediately transferred to the department of surgery for close surgical observation. Computed tomography (CT) of the entire abdomen performed just before the operation demonstrated thickening of the wall of the ascending colon with pericolic fat stranding. Surgery revealed a perforation at the antimesenteric wall of the transverse colon and segmental colectomy of the transverse colon was performed. The histological evaluation demonstrated a perforated solitary ulcer of the transverse colon. There are only few known etiologic factors concerning spontaneous ruptures of the colon and rectum and usually none of these causative factors can easily be recognised. Their clinical appearance is most of the times acute abdomen and, despite the use of all appropriate diagnostic methods, the diagnosis is usually set postoperatively.
|How to cite this article:|
Galanis I, Dragoumis D, Kalogirou T, Lakis S, Kotakidou R, Atmatzidis K. Spontaneous perforation of solitary ulcer of transverse colon.Indian J Pathol Microbiol 2010;53:138-140
|How to cite this URL:|
Galanis I, Dragoumis D, Kalogirou T, Lakis S, Kotakidou R, Atmatzidis K. Spontaneous perforation of solitary ulcer of transverse colon. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Sep 20 ];53:138-140
Available from: http://www.ijpmonline.org/text.asp?2010/53/1/138/59207
Solitary colonic ulcers are rare pathologic conditions that involve different segments of the colon. The etiology of these 'nonspecific' ulcers is unknown despite the elaboration of many theories. The most commonly proposed causes include nonsteroidal anti inflammatory drugs (NSAIDs), colonic stasis (stercoral ulcers), infection of the bowel and ischemic bowel disease.  Spontaneous perforation of a solitary ulcer of the transverse colon is being considered a rare clinical entity. This should be included in the differential diagnosis of acute abdomen because of the extremely high mortality rates if not diagnosed on time. We present a case of spontaneous perforated solitary ulcer of the transverse colon which was diagnosed during laparotomy performed for acute abdomen.
A 44-year-old female patient presented to the emergency unit complaining of a severe, crampy, persistent and gradually increasing diffuse abdominal pain of 12 hours duration. The pain started off suddenly, just after the completion of a heavy meal. No previous surgical operations and no intake of medications were referred, while her medical history revealed no abnormalities. On physical examination the patient had a low-grade fever of 37.5°C with localized rebound tenderness and guarding periumbilically and at the right hypochondrium. The white blood cell count was elevated to 18,600/mm 3 with a predominance of polymorphonuclear cells (88%) whereas other tests like blood analysis, urinalysis and biochemical tests were within normal limits. No mass was palpable and there were normoactive bowel sounds. Findings from the rectal examination were normal.
Plain abdominal X-rays showed no marks of bowel obstruction. Urgent ultrasonography of the abdomen was negative for free fluid, mass, and signs of inflamed intra-abdominal organs. A contrast-enhanced computed tomography scan of the abdomen and pelvis demonstrated segmental thickening of the ascending colon, pericolic fat stranding and a small amount of fluid between several bowel loops [Figure 1].
In the light of these findings and due to persisting pain, the patient was admitted to the operating room and a midline emergency laparotomy was performed. At the intraperitoneal exploration, there was no peritoneal contamination and the appendix vermiformis was normal. After mobilization of the hepatic flexure and dissection of omental adhesions, an inflammatory mass was found at the central segment of the transverse colon [Figure 2]. Careful exploration of this area revealed an inflammatory mass with several small abscesses and a visible perforation of 10mm in diameter at the antimesenteric wall of the transverse colon [Figure 3]. As these macroscopic findings couldn't rule out malignancy 10cm of the transverse colon was sent for biopsy. Frozen section analysis confirmed the benign nature of the lesion. Stains for amebiasis and fungus were negative. A segmental colectomy of the transverse colon was eventually performed.
The histological examination of the resected specimen showed a segment of the transverse colon with a perforated solitary ulcer, extending to all layers of the colon, edema, massive leukocyte infiltration, profound lymphoid hyperplasia at submucosa and lamina propria and a number of pericolic abscesses [Figure 4]. The recovery was uneventful and the patient was discharged on the seventh postoperative day.
The solitary ulcer of the colon is a rare entity of unknown etiology first described by Cruveilhier in 1832 as cited by Salvati.  Since Cruveilhier gave no name to that entity, a variety of trivial names were proposed in subsequent publications, such as 'nonspecific' ulcers of the colon, idiopathic colonic ulcers, ulcers of the cecum, solitary colonic ulcers, benign ulcers of the colon, simple ulcers of the colon and nonspecific ulcers of the ascending colon or discrete ulcers of the colon. ,
Solitary colonic ulcers are obscure pathologic entities that involve different segments of the colon.  Most commonly, they are located in the ascending colon and rarely involve the hepatic flexure. Most of the patients are usually over 50 years of age and there is a 2:1 predilection for males. The solitary colonic ulcers are often located on the antimesenteric wall of the cecum. According to the frequency of appearance they are also located in the sigmoid colon, in the transverse and descending colon. The size of the solitary colonic ulcer can be from 5 to 50mm. Colonic ulcers may develop as a result of vascular obstructive diseases (thrombosis or reduction of blood flow), administration of drugs such as NSAIDs or oral contraceptives, mechanical causes (intussusception, trauma) and diverticular disease. When all these factors have been excluded, an ulcerogenic disease of unknown etiology should be entertained. ,
Moreover, it is essential to note that lesions that penetrate beyond the muscularis mucosa are defined as ulcers while those that do not penetrate beyond the muscularis mucosa are regarded as erosions. In erosions, the most common histological finding in the surrounding tissues is vascular proliferation in the lamina propria mucosa and fibroblastic proliferation in the submucosa. On the contrary, in ulcerations, the most common lesion found is granulation tissue, some with beginning re epithelialization and increased vascularity in the lamina propria mucosa. The ulcerations are often surrounded by chronic inflammation in the lamina propria mucosa, as well as by increased vascularization and proliferation of fibroblasts. There is usually an inflammatory reaction of lymphocytes and fibroblasts, but the ulcers are well demarcated from normal tissues. Chronic ulcers show marked sub mucosal edema, which perhaps explains the false appearance of tumor often seen on barium-enema studies. Some investigators also have reported blood vessel thrombosis in the sub mucosa, but generally the proximal mesenteric vessels are free of thrombi. 
Histopathologic examination of our specimen was typical of a colonic ulcer and there was no bacterial or parasitic involvement in the adjacent area, or even sickling of red blood cells. Massive leukocyte infiltration and profound lymphoid hyperplasia at sub mucosa and lamina propria was present, whereas there were numerous thrombosed blood vessels in the adventitia adjacent to the necrotic bowel.
As all of these features are common to several other acute abdominal diseases, the symptoms or physical findings do not present any characteristic pattern that would suggest the diagnosis. Clinical presentation basically depends on the location of the ulcer.  Although lesions in the rectum and in sigmoid colon may be asymptomatic, proximal colonic ulcers usually produce acute abdominal pain and bleeding, as a result of the perforation of the colon. Perforation may be present, as in our case, with lesions located in the transverse colon.  Sometimes an abdominal mass can be palpated in the right lower quadrant and in these cases solitary colonic ulcers are often misdiagnosed as acute appendicitis, Crohn's disease, pelvic inflammatory disease and tuberculosis enteritis.  It is difficult to set a diagnosis preoperatively, which is usually verified during laparotomy. As regards uncomplicated cases, colonoscopy is the best diagnostic method.
Rubio et al.  suggested that a variety of conditions could be found and perhaps associated in patients with a nonspecific colonic ulcer. The most common causes seemed to be previous radiation treatment and ischemic bowel disease. There are also other etiologic factors like the use of NSAIDs, atherosclerosis, colonic stasis (stercoral ulcers), foreign body trauma, stress and infectious bowel diseases. , In our patient, however, none of these causative factors was recognized. It is also important to say that most reports in medical literature relate spontaneous colon ruptures with unusual connective tissue disorders such as Marfan, Ehlers-Danlos syndrome or polyarteritis nodosa. Connective tissue disorders affect the synthesis and structure of elastin and type III collagen, resulting in various systemic disorders. 
As discussed above, solitary colonic ulcer is usually detected during laparotomy for acute abdominal pain. Some surgeons have proposed conservative approaches in the case of a solitary, nonperforated ulcer and they strongly believe that the lesion can probably be safely oversewn. , However, the significant amount of edema associated with the ulcer, sometimes suggesting the presence of carcinoma or early perforation, indicates that a segmental resection or hemicolectomy may be a more appropriate and wise decision. If there is fecal contamination in the abdomen, resection and temporary colostomy will be the suitable therapeutic approach.
The nonspecific colonic ulcers are uncommon and may be easily overlooked. They tend to mimic more common clinical conditions such as acute appendicitis, diverticulitis, intestinal obstruction or even carcinoma. It is essential not to overlook this unusual entity among the differential diagnoses of acute abdomen, thereby allowing the choice for proper and immediate treatment when possible.
There are no conflicts of interest or sources of financial support of any kind.
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