Accidental removal of ureteral stoma at colonoscopy C. B. Williams, BM, MRCP· P. E. Gillespie, MD Sf. Mark's Hospital London, England Urinary diversion by ureterosigmoidostomy can be complicated by electrolyte imbalance, renal impairment, and by the development of colonic tumors at the site of anastomosis.1.2 We wish to report an additional complication whereby a polypoid mass at the site of the procedure was mistaken for a malignant polyp and removed by colonoscopy, leading to the development of renal sepsis and subsequently to unilateral nephrectomy. CASE REPORT A 55-year-old man in 1967 underwent total cystectomy and insertion of both ureters into the sigmoid colon for widespread carcinoma of the bladder. Postoperatively he developed a sigmoid colon perforation and required re-insertion of the left ureter into the descending colon. In 1975 a hydronephrotic left kidney was diagnosed. In 1977 episodes of rectal bleeding commenced. Sigmoidoscopy to 20 cm was normal, and barium enema radiography was reported as normal. The Fujinon FC-QBF instrument was introduced to the proximal transverse colon. There was a 5-cm irregular, friable polypoid lesion with superficial exudate in the descending colon, the macroscopic appearance suggesting a malignant polyp (Figure 1). The lesion was snared and removed without immediate hemorrhage or pain. Five hours later, the patient had 2 episodes of rectal bleeding associated with the passage of clots. At repeated colonoscopy, fresh blood and clots were seen in the sigmoid colon, but no active bleeding site was visualized. The site of polypectomy was not clearly seen. local instillation of adrenaline and ice water through the biopsy channel of the colonoscope resulted in cessation of fresh bleeding. The total blood loss was estimated as 1500 ml. The following day the patient developed fever, rigors, and episodes of dull left loin pain radiating to the left buttock. No focal abnormality was detected on physical examination, and an intravenous pyelogram showed normal dye excretion from the right ureter. On the left side only a nephrogram was obtained, with no excretion into the pelvicalyceal system. Tobramycin, 80 mg, was given every 8 hours. Two days later a left pyonephrosis was drained, and a nephrostomy tube was inserted. There was no evidence at operation of colonic perforation. Postoperatively, a nephrostogram failed to demonstrate ureteric drainage. One month later a nephroureterectomy was performed, and the patient's recovery was uneventful. On histologic examination of the specimen removed at colonoscopy, the tissue was composed of colonic crypts separated by lamina propria and bands of smooth muscle and fibrous tissue. Many of the crypts were dilated and filled with mucus. There was very little inflammation, and • Reprint requests: Dr. C. B. Williams, St. Mark's Hospital, City Road, London EC 1V 2PS, England. VOLUME 25, NO. J, 1979
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1
2
3
4
Figure 1.
Ureteric stoma "polyp" removed by endoscopic snare I?olypectomy.
the epithelium, although hyperplastic in places, showed no evidence of dysplasia. There was a long cleft passing from the surface of the tumor into the center where it was lined by epithelium characteristic of the urinary tract. The appearance was that of inflammatory polypoid hypertrophy of colonic mucosa at the site of ureterocolonic anastomosis. DISCUSSION Reports of the development of adenomatous pOl ypS 3.4 and of carcinomas at the site of ureterocolonic anastomosis show that these occur many years after the initial surgery.6.7 The risk of colonic neoplasia in these patients has been calculated to be at least 500 times greater than would be expected,8 and they therefore require surveillance. It has been suggested 9 that this should be by regular intravenous pyelograms, sigmoidoscopy, and barium enema, but it would seem more logical for this to be by fiberoptic endoscopy. Although the majority of tumors occur at the site of ureteric implantation, cancers and benign polyps have been described arising separately in the colonic epithelium, presumably as a result of carcinogenic actions of the urinary flow. The histologic nature of the tumors has been found to vary from squamous cell, transitional, or adenocarcinomas to benign adenomas or "indeterminate" inflammatory excrescences. The focus of invasive carcinoma may be very small. This means that the endoscopist might expect to encounter a variety of appearances, and that forceps biopsy specimens alone, if benign, will not neces-
109
sarily exclude carcinoma. The endoscopist may therefore be faced with a dilemma as to whether to attempt snareloop biopsy or multiple forceps biopsies. In our case the endoscopic appearance of the ureterocolonic anastomosis was suggestive of a malignant polyp. The decision to attempt to remove the lesion in toto, although mistaken, was easier to take because we did not realize that it was the enlarged ureteric orifice. The site of the lesion in the descending colon led us to believe that it was not related to the previous surgery which we thought had been performed in the sigmoid colon. In fact, the ureter had been re-implanted in the descending colon at the time of the initial operation following an operative sigmoid colon perforation. These operative details were not available to us at the time of endoscopy. The histopathology of the stomal enlargement in our case was that of inflammatory tissue of colonic origin without evidence of neoplasm. Although forceps biopsies would presumably have given the same information, surgical excision and re-implantation of the stoma would probably have been the logical course in view of its sinister appearance and its bleeding tendency. Although the operation of ureterocolonic anastomosis has been largely replaced by the use of isolated ileal loops, those patients with ureterosigmoidostomies will have a high cancer risk for a long time. Anyone performing colon-
oscopy may be asked to help in follow-up or in the management of patients with bleeding or demonstrable radiographic abnormality. Our experience may lend caution to other endocopists faced with a similar situation.
Endoscopic observations of hemobilia
liver biopsy. The liver had a firm, rounded edge, and its span was 10 cm. The tip of the spleen was palpable. No ascites was present. Percutaneous liver biopsy was performed through the ninth intercostal space in the right anterior axillary line. Three passes were required with the 2.1-mm Tru-Cut disposable needle to obtain an adequate specimen of liver tissu~. Microscopic examination of the liver specimen revealed continuing chronic aggressive hepatitis with early cirrhosis. The patient experienced mild abdominal pain during the biopsy. Vital signs were normal over the next 24 hours. The day following liver biopsy there was no abdominal tenderness, and the patient was discharged. She remained symptom-free until 3 days after discharge when she returned with complaints of hematemesis and intermittent right upper abdominal discomfort of 12 hours' duration. Physical examination disclosed no icterus. There was mild right upper quadrant tenderness, and the stool was black. After iced saline gastric lavage, emergency peroral panendoscopy (Olympus GIF-D2) was performed. Small esophageal varices were noted without evidence of bleeding. The stomach was normal. The duodenal bulb and descending duodenum contained a small amount of bile and dark blood mixed with small clots. No bleeding site was seen, although the papilla of Vater could not be specifically identified. In view of the patient's recent liver biopsy, the end-viewing endoscope was withdrawn and a side-viewing instrument (Olympus JF-B2) was inserted. An apparently normal papilla was readily identified, but no bleeding was seen (Figure 1, A and B). After observation of
Glen A. Lehman, MODavid Bash, MO Indiana University Medical Center Indianapolis, Indiana Hemobilia is an uncommon cause of gastrointestinal bleeding seen most frequently in association with hepatic trauma. Less commonly hemobilia is associated with cholelithiasis, hepatic abscesses, cholecystitis, hepatobiliary neoplasms, biliary parasitic diseases, hepatic vascular disorders, and pancreatic pseudocysts.' Endoscopic confirmation of hemobilia has been reported by observation of (a) filling defects in the biliary tree at ERCP,2-4 (b) direct bleeding from the papilla,3,5-7 and (c) red blood in the duodenum in the vicinity of the papilla with an otherwise normal endoscopic examination. 8 If blood loss into the biliary tree is slow, blood flow into the duodenum may be intermittent. We here report 3 cases in which red blood was intermittently seen in the descending duodenum. Only prolonged observation of the papilla specifically identified the site of bleeding. CASE REPORTS Case 1. A 30-year-old black woman with chronic active liver disease of 8 years' duration was admitted to the Indiana University Medical Center for her fourth
* Reprint requests: Glen A. Lehman, MD, Indiana University Medical Center, 1100 West Michigan Street, Indianapolis, Indiana 46202.
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ACKNOWLEDGMENTS The authors are grateful to Mr. J. P. Williams of SI. Peter's Hospital for permission to publish details of this case and to C. Canaway for secretarial assistance.
REFERENCES 1. HAMMER E: Cancer du colon sigmoide dix ans apres implantation des ureteres d'une vessie exstrophies. JUral Nephrol 28: 260, 1929 2. WHITAKER RH, PUGH RCB, Dow D: Colonic tumours following uretero-sigmoidostomy. Br J Urol 43:562, 1971 3. MARKOWITZ AM, KOONTZ P: The development of colonic polyps at the site of ureteral implantation. Surgery 60:761, 1966 4. MACGREGOR AMC: Mucus-secreting adenomatous polyp at the site of uretero sigmoidostomy. Br J Surg 55:591, 1968 5. RIVARD IY, BEDARD A, DIONNE L: Colonic neoplasms following ureterosigmoidostomy. J Uro/113:781, 1975 6. CARSWELL IL SKEEL DA, WITHERINGTON R, OTKEN LB: Neoplasia at the site of ureterosigmoidostomy. J Ural 115:750, 1976 7. HANEY ML MCGARITY WC: Uretero sigmoidostomy and neoplasms of the colon. Arch Surg 103:69, 1971 8. URDANETA LF, DUFFELL D, CREEVY CD, AUST IB: Late development of primary carcinoma of the colon following ureterosigmoidostomy. Ann Surg 164:503, 1966 9. TANK SE, KARSCH DN, LAPIDE I: Adenocarcinoma of the colon associated with ureterosigmoidostomy. Dis Colon Rectum 16: 300, 1973
GASTROINTESTINAL ENDOSCOPY
1--.....- -.....__....__...' em.
1
2
3
4
Figure 1.
Ureteric stoma "polyp" removed by endoscopic snare I?olypectomy.
the epithelium, although hyperplastic in places, showed no evidence of dysplasia. There was a long cleft passing from the surface of the tumor into the center where it was lined by epithelium characteristic of the urinary tract. The appearance was that of inflammatory polypoid hypertrophy of colonic mucosa at the site of ureterocolonic anastomosis. DISCUSSION Reports of the development of adenomatous pOl ypS 3.4 and of carcinomas at the site of ureterocolonic anastomosis show that these occur many years after the initial surgery.6.7 The risk of colonic neoplasia in these patients has been calculated to be at least 500 times greater than would be expected,8 and they therefore require surveillance. It has been suggested 9 that this should be by regular intravenous pyelograms, sigmoidoscopy, and barium enema, but it would seem more logical for this to be by fiberoptic endoscopy. Although the majority of tumors occur at the site of ureteric implantation, cancers and benign polyps have been described arising separately in the colonic epithelium, presumably as a result of carcinogenic actions of the urinary flow. The histologic nature of the tumors has been found to vary from squamous cell, transitional, or adenocarcinomas to benign adenomas or "indeterminate" inflammatory excrescences. The focus of invasive carcinoma may be very small. This means that the endoscopist might expect to encounter a variety of appearances, and that forceps biopsy specimens alone, if benign, will not neces-
109
sarily exclude carcinoma. The endoscopist may therefore be faced with a dilemma as to whether to attempt snareloop biopsy or multiple forceps biopsies. In our case the endoscopic appearance of the ureterocolonic anastomosis was suggestive of a malignant polyp. The decision to attempt to remove the lesion in toto, although mistaken, was easier to take because we did not realize that it was the enlarged ureteric orifice. The site of the lesion in the descending colon led us to believe that it was not related to the previous surgery which we thought had been performed in the sigmoid colon. In fact, the ureter had been re-implanted in the descending colon at the time of the initial operation following an operative sigmoid colon perforation. These operative details were not available to us at the time of endoscopy. The histopathology of the stomal enlargement in our case was that of inflammatory tissue of colonic origin without evidence of neoplasm. Although forceps biopsies would presumably have given the same information, surgical excision and re-implantation of the stoma would probably have been the logical course in view of its sinister appearance and its bleeding tendency. Although the operation of ureterocolonic anastomosis has been largely replaced by the use of isolated ileal loops, those patients with ureterosigmoidostomies will have a high cancer risk for a long time. Anyone performing colon-
oscopy may be asked to help in follow-up or in the management of patients with bleeding or demonstrable radiographic abnormality. Our experience may lend caution to other endocopists faced with a similar situation.
Endoscopic observations of hemobilia
liver biopsy. The liver had a firm, rounded edge, and its span was 10 cm. The tip of the spleen was palpable. No ascites was present. Percutaneous liver biopsy was performed through the ninth intercostal space in the right anterior axillary line. Three passes were required with the 2.1-mm Tru-Cut disposable needle to obtain an adequate specimen of liver tissu~. Microscopic examination of the liver specimen revealed continuing chronic aggressive hepatitis with early cirrhosis. The patient experienced mild abdominal pain during the biopsy. Vital signs were normal over the next 24 hours. The day following liver biopsy there was no abdominal tenderness, and the patient was discharged. She remained symptom-free until 3 days after discharge when she returned with complaints of hematemesis and intermittent right upper abdominal discomfort of 12 hours' duration. Physical examination disclosed no icterus. There was mild right upper quadrant tenderness, and the stool was black. After iced saline gastric lavage, emergency peroral panendoscopy (Olympus GIF-D2) was performed. Small esophageal varices were noted without evidence of bleeding. The stomach was normal. The duodenal bulb and descending duodenum contained a small amount of bile and dark blood mixed with small clots. No bleeding site was seen, although the papilla of Vater could not be specifically identified. In view of the patient's recent liver biopsy, the end-viewing endoscope was withdrawn and a side-viewing instrument (Olympus JF-B2) was inserted. An apparently normal papilla was readily identified, but no bleeding was seen (Figure 1, A and B). After observation of
Glen A. Lehman, MODavid Bash, MO Indiana University Medical Center Indianapolis, Indiana Hemobilia is an uncommon cause of gastrointestinal bleeding seen most frequently in association with hepatic trauma. Less commonly hemobilia is associated with cholelithiasis, hepatic abscesses, cholecystitis, hepatobiliary neoplasms, biliary parasitic diseases, hepatic vascular disorders, and pancreatic pseudocysts.' Endoscopic confirmation of hemobilia has been reported by observation of (a) filling defects in the biliary tree at ERCP,2-4 (b) direct bleeding from the papilla,3,5-7 and (c) red blood in the duodenum in the vicinity of the papilla with an otherwise normal endoscopic examination. 8 If blood loss into the biliary tree is slow, blood flow into the duodenum may be intermittent. We here report 3 cases in which red blood was intermittently seen in the descending duodenum. Only prolonged observation of the papilla specifically identified the site of bleeding. CASE REPORTS Case 1. A 30-year-old black woman with chronic active liver disease of 8 years' duration was admitted to the Indiana University Medical Center for her fourth
* Reprint requests: Glen A. Lehman, MD, Indiana University Medical Center, 1100 West Michigan Street, Indianapolis, Indiana 46202.
110
ACKNOWLEDGMENTS The authors are grateful to Mr. J. P. Williams of SI. Peter's Hospital for permission to publish details of this case and to C. Canaway for secretarial assistance.
REFERENCES 1. HAMMER E: Cancer du colon sigmoide dix ans apres implantation des ureteres d'une vessie exstrophies. JUral Nephrol 28: 260, 1929 2. WHITAKER RH, PUGH RCB, Dow D: Colonic tumours following uretero-sigmoidostomy. Br J Urol 43:562, 1971 3. MARKOWITZ AM, KOONTZ P: The development of colonic polyps at the site of ureteral implantation. Surgery 60:761, 1966 4. MACGREGOR AMC: Mucus-secreting adenomatous polyp at the site of uretero sigmoidostomy. Br J Surg 55:591, 1968 5. RIVARD IY, BEDARD A, DIONNE L: Colonic neoplasms following ureterosigmoidostomy. J Uro/113:781, 1975 6. CARSWELL IL SKEEL DA, WITHERINGTON R, OTKEN LB: Neoplasia at the site of ureterosigmoidostomy. J Ural 115:750, 1976 7. HANEY ML MCGARITY WC: Uretero sigmoidostomy and neoplasms of the colon. Arch Surg 103:69, 1971 8. URDANETA LF, DUFFELL D, CREEVY CD, AUST IB: Late development of primary carcinoma of the colon following ureterosigmoidostomy. Ann Surg 164:503, 1966 9. TANK SE, KARSCH DN, LAPIDE I: Adenocarcinoma of the colon associated with ureterosigmoidostomy. Dis Colon Rectum 16: 300, 1973
GASTROINTESTINAL ENDOSCOPY
