Cholesterol embolization as a cause of cecal infarct mimicking carcinoma

A Case of Isolated Cecal Necrosis Preoperatively Diagnosed with Perforation of Cecum

Isolated cecal necrosis (ICN) is a rare condition which is developed under decreased mesenteric perfusion. Only a few dozen cases of ICN have been reported previously. The patient was a 59-year-old male with a previous history of atrial fibrillation. He presented to our emergency room with the chief complaint of lower abdominal pain. Computed tomography imaging revealed a dilated cecum and presence of free air. With a preoperative diagnosis of perforation of the cecum; an urgent surgery was conducted. Intraoperative findings revealed an ischemic change of the cecum and a laparoscopic-assisted ileocecal resection was performed. The pathological findings showed transmural ischemic change on the anti-mesenteric side of the cecum, and the diagnosis of ICN was achieved. Preoperative diagnosis of ICN is difficult because of its non-specific radiological features. In patients with right lower abdominal pain, ICN should be considered as a differential diagnosis especially if the patient has a comorbidity causing hypotension attack.

Atheromatous embolization

Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.

Isolated cecal necrosis: our surgical experience and a review of the literature

OBJECTIVE

Isolated cecal necrosis is a rare cause of ischemic colitis. Ischemic colitis is further divided into two groups: occlusive mesenteric ischemia and non-occlusive mesenteric ischemia. The aim of this study was to investigate the cause of isolated cecal necrosis.

MATERIAL AND METHODS

We operated on 3 male and 3 female patients with a mean age of 60.3±18.7 (38-85) years with a preliminary diagnosis of acute appendicitis between 2007 and 2012. Four of these patients were on hemodialysis, 1 patient had an aortofemoral bypass, and 1 patient had coronary artery disease with atrial fibrillation.

RESULTS

The diagnosis was made intraoperatively in all cases. Five patients died postoperatively. One patient survived.

CONCLUSION

In the case of right lower quadrant pain, the possibility of isolated cecal necrosis should be kept in mind, especially in patients on hemodialysis, elderly patients with diabetes, and heart disease; surgical strategies should be planned accordingly, and it should be understood that a high mortality rate will be inevitable.

Cholesterol crystal embolization presenting as either solid or cystic pancreatic lesion

Cholesterol crystal embolization (CCE) can result in end-organ ischemia. Retrospective review of clinicopathologic data. The first patient was anticoagulated with coumadin for chronic atrial fibrillation and presented subacutely with a solid mass. The second patient suffered from coronary artery disease post-angioplasty/stenting and presented with acute pancreatitis and pancreatic cystification. CCE should be considered in patients with significant vascular disease, arrhythmias or vascular manipulation who present with a pancreatic mass.

Isolated ileocolic artery occlusion presented with segmental bowel infarction: a case report

Acute mesenteric ischemia is a serious acute abdominal condition requiring early diagnosis and intervention to improve the outcome. Although transmural acute bowel infarction represents about 1% of all cases of acute abdomen, it has a higher annual mortality rate than colon cancer. It tends to affect the colon in segmental fashion, mostly the splenic flexure and rectosigmoid portions of the colon. Isolated ischemia of the right side of the colon is rarely reported, especially in association with shock. Diagnosis of acute colonics ischemia is challenging as it may easily be confused with other non ischemic conditions both clinically and radiologically. Surgical resection is still the main curative approach. We present a case of segmental terminal ileum, cecum and part of ascending colon infarction due to isolated IleoColic artery thrombosis.

Isolated infarction of the cecum: CT findings in two patients

Colonic ischemia isolated to the cecum is a rare entity. The authors evaluated two patients who underwent computed tomography (CT) because appendicitis was suspected at clinical examination. CT findings were suggestive of isolated cecal ischemia or infarction. Surgical-histopathologic findings helped confirm the presumptive CT diagnoses. Isolated cecal infarction should be included in the differential diagnosis of acute right lower quadrant pain.

Cholesterol crystal embolisation to the alimentary tract

The features of cholesterol crystal embolisation (CCE) to the alimentary tract were studied by retrospective analysis of the clinical and pathological data of 96 patients (70 men, 26 women, mean age 73.8 (58-95) years) with this diagnosis in the Dutch national pathology information system (Pathologisch Anatomisch Landelijk Geautomatiseerd Archief (PALGA)) from 1973-92. In the 96 patients, 130 CCE sites were found throughout the alimentary tract, mostly in the colon (42.3%). Most patients had a history of atherosclerotic disease and presented with abdominal pain, diarrhoea, or gastrointestinal bleeding, sometimes after surgical or radiological vascular procedures. A number were taking oral anticoagulant treatment. The diagnosis of CCE had been considered before the histological diagnosis in only 11 patients. In the remaining cases, ischaemic colitis, tumour, and inflammatory bowel disease were suggested in the differential diagnosis. A premortem diagnosis of CCE was made in 70.8% of the cases. In 24 of the 35 necropsy examinations, CCE seemed to be directly or indirectly related to the cause of death. It is concluded that in this unselected, homogenous group of patients, CCE sites were most frequently found in the colon. They generally presented with abdominal pain, diarrhoea, and gastrointestinal blood loss. CCE often mimicked common gastrointestinal disease, leading to incorrect diagnosis.

Recurrent anaemia due to ischaemic colonic ulceration caused by cholesterol embolism

We describe an elderly patient with generalized atherosclerosis who presented with recurrent iron-deficiency anaemia. He underwent right hemicolectomy which revealed ischaemic colonic ulceration caused by cholesterol embolism. Surgery appeared to be curative. Cholesterol embolism should be considered as a possible cause of unexplained gastrointestinal blood loss in the elderly.

How common is cholesterol embolism?

Histological sections of spleen and both kidneys from 372 necropsies were examined for the presence of cholesterol emboli. These were identified in nine (2.4%) cases and the clinical histories of these cases were reviewed. All the subjects with cholesterol emboli were older than 60 years and eight out of nine were male. Lesions of differing ages were found in individual cases, suggesting that the process of embolism was recurrent. Two of the cases had undergone arteriography procedures in the month before death and, if these were excluded, then the incidence of "spontaneous" cholesterol embolism was 1.9%. This incidence is much lower than that of previously published studies and may be due to a lower incidence of cholesterol embolism in Britain compared with North America or a decrease in incidence over the past two decades. In three of the subjects with cholesterol embolism the cause of death could be related to systemic atherosclerosis, but in the other six cases there was no apparent correlation between the finding of cholesterol embolism and the cause of death. The clinical relevance of the histological finding of cholesterol embolism can only be assessed in conjunction with clinical information.

Cholesterol crystal embolization and the digestive system

Atherosclerotic vascular disease can give rise to provoked or spontaneous cholesterol crystal embolization to organ systems. Lodging in downstream arterioles, these crystals can produce granuloma formation, infarction, ulceration, and perforation. Histologic sections of the tissue concerned invariably show pathognomonic empty needle-shaped clefts left by the crystals after processing of the material. In the digestive system these events can cascade to many and often misleading presentations. They can be the cause of massive bleeding, acute acalculous cholecystitis, pancreatitis, or teleangiectasis with chronic intractable blood loss. Owing to the progressive nature of the disease the treatment options described in this paper can only give temporary, but nevertheless often worthwhile relief.