Correspondence / Digestive and Liver Disease 46 (2014) 475–478
Ugo Cioffi Division of Emergency Surgery, Maggiore Policlinico Hospital, Milan, Italy Manuela W. Ossola Division of Gynecology, Maggiore Policlinico Hospital, Milan, Italy Dario Conte Division of Gastroenterology and Endoscopy, Maggiore Policlinico Hospital, Milan, Italy ∗ Corresponding author at: Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza, 35, 20122 Milan, Italy. Tel.: +39 347 2719421. E-mail address: [email protected] (A.A. Lemos)
http://dx.doi.org/10.1016/j.dld.2013.12.020
An unusual colonic “tumour” Dear Editor A 56-year old woman was admitted for right lower abdominal pain, nausea, vomiting and diarrhoea. Past medical history was negative and vital signs at admission were normal. Abdominal examination showed diffuse abdominal tenderness, especially in the right iliac fossa. Bowel sounds were slightly increased. Laboratory tests were normal. Abdominal ultrasonography showed multiple concentric ring signs, suggesting colonic intussusception (CI). Abdominal computed tomography confirmed an ascending colon invagination. Colonoscopy was indicated in order to identify the potential cause of intussusception and to attempt pneumo-dynamic resolution. Colonoscopy revealed the presence of a polypoid lesion in the proximal ascending colon, 5 cm in diameter, with ulcerated mucosa covered with fibrin, suggestive of a malignant lesion (Fig. 1A). Surrounding mucosa was normal. Biopsies were performed and histology revealed fibrin embedding leukocytes and small fragments of eroded colonic mucosa. Because of clinical worsening (increasing abdominal pain, nausea, vomiting) and the strong suspicion of neoplastic disease,
477
the patient was referred to surgery, and an ileocecal resection was performed. Histology showed suppurative inflammation with eosinophilic infiltration, and sections of Anisakis larva were present (Fig. 1B). In a further clinical interview, the patient reported having eaten raw fish. Gastroscopy was performed to identify larvae in the upper gastrointestinal tract and was negative. Anisakiasis is a zoonosis transmitted by the ingestion of infected raw fish. After penetrating the gut mucosa the larva of Anisakis dies and causes eosinophilic infiltration with proliferation of connective tissue around the larval body forming an eosinophilic granuloma that may mimic a submucosal tumour. Granuloma usually decreases in size and gradually disappears, over the time. In Italy, few cases of Anisakis have been described [1]. In the present case, colonic Anisakis was the cause of a colonic “neoplasticlike” mass primarily responsible of CI. Adult intussusception is infrequent and accounts for 5–10% of all intussusceptions [2]. CI without ileocecal involvement occurs in about 20% of cases in adults, malignant tumours being the most frequent cause (60% of the cases). Less frequently CI can also be caused by benign conditions (i.e. lipoma, leiomyoma, Meckel’s diverticulum, adenoma and inflammatory fibrous polyps and adhesions), or can be idiopathic. Parasitic infection is an extremely rare cause of CI [3] in Western Countries and adult CIs caused by anisakiasis have been reported only in Japan [4,5]. Most of the cases occur in the stomach and small bowel. Colonic anisakiasis is extremely rare (0.1–0.9% of cases). About 50% of colonic anisakiasis occurs in the right colon [4,5]. Acute symptoms are caused by larval mucosal invasion or hypersensitivity to the larvae or its secretions and consist in epigastric pain, nausea and vomiting. Chronic anisakiasis results in abscesses or eosinophilic granulomas with fever, eosinophilia, diarrhoea and abdominal pain. It can mimic appendicitis, gastroduodenal ulcer, inflammatory bowel diseases, or intestinal obstruction. Endoscopy plays a major diagnostic and therapeutic role. Besides directly visualizing worms penetrating into the gut mucosa, endoscopy may reveal erythema, oedema, erosive, inflammation, tumour, or ulceration. When Anisakis is visualized, endoscopic extraction should always be attempted, avoiding further tests and surgery. In the present case, eosinophilic granuloma mimicked a “neoplastic” mass causing colonic intussusception and was misclassified endoscopically. This suggests that in presence of a history of raw fish intake, the presence of any “neoplastic-like” mass in the
Fig. 1. (A) Colonoscopy showing a “giant” polypoid lesion in the proximal ascending colon, 5 cm in diameter, with ulcerated mucosa covered with fibrin. (B) A section of Anisakis larva located in the inner part of colonic muscularis propria is shown. Cuticle (c), oesophagus (e) and lateral chords (lc) are evident. The worm is surrounded by an intense inflammatory infiltrate rich in eosinophilic granulocytes (haematoxylin and eosin, original magnification 100×).
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Correspondence / Digestive and Liver Disease 46 (2014) 475–478
gastrointestinal tract should prompt differential diagnosis between malignancy and Anisakis granuloma. Conflict of interest None declared. Funding This research received no specific funding. References [1] Bucci C, Gallotta S, Morra I, et al. Anisakis, just think about it in an emergency! Int J Infect Dis 2013;17:e1071–2. [2] Weilbaecher D, Bolin JA, Hearn D, et al. Intussusception in adults. Review of 160 cases. Am J Surg 1971;121:531–5. [3] Wong MT, Goh L, Chia KH. Intestinal schistosomiasis manifesting as colonic intussusception arising from a mucocele of the appendix: report of a case. Surg Today 2008;38:664–7. [4] Miura T, Iwaya A, Shimizu T, et al. Intestinal anisakiasis can cause intussusception in adults: an extremely rare condition. World J Gastroenterol 2010;16: 1804–76.
[5] Yorimitsu N, Hiraoka A, Utsunomiya H, et al. Colonic intussusception caused by anisakiasis: a case report and review of the literature. Intern Med 2013;52:223–6.
Gianluca Andrisani ∗ Cristiano Spada Lucio Petruzziello Guido Costamagna Digestive Endoscopy Unit, Catholic University, Rome, Italy ∗ Corresponding author at: Digestive Endoscopy Unit, Catholic University, Largo Agostino Gemelli 8, 00168 Rome, Italy. Tel.: +39 300630151. E-mail address: [email protected] (G. Andrisani)
http://dx.doi.org/10.1016/j.dld.2014.01.002
Ugo Cioffi Division of Emergency Surgery, Maggiore Policlinico Hospital, Milan, Italy Manuela W. Ossola Division of Gynecology, Maggiore Policlinico Hospital, Milan, Italy Dario Conte Division of Gastroenterology and Endoscopy, Maggiore Policlinico Hospital, Milan, Italy ∗ Corresponding author at: Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza, 35, 20122 Milan, Italy. Tel.: +39 347 2719421. E-mail address: [email protected] (A.A. Lemos)
http://dx.doi.org/10.1016/j.dld.2013.12.020
An unusual colonic “tumour” Dear Editor A 56-year old woman was admitted for right lower abdominal pain, nausea, vomiting and diarrhoea. Past medical history was negative and vital signs at admission were normal. Abdominal examination showed diffuse abdominal tenderness, especially in the right iliac fossa. Bowel sounds were slightly increased. Laboratory tests were normal. Abdominal ultrasonography showed multiple concentric ring signs, suggesting colonic intussusception (CI). Abdominal computed tomography confirmed an ascending colon invagination. Colonoscopy was indicated in order to identify the potential cause of intussusception and to attempt pneumo-dynamic resolution. Colonoscopy revealed the presence of a polypoid lesion in the proximal ascending colon, 5 cm in diameter, with ulcerated mucosa covered with fibrin, suggestive of a malignant lesion (Fig. 1A). Surrounding mucosa was normal. Biopsies were performed and histology revealed fibrin embedding leukocytes and small fragments of eroded colonic mucosa. Because of clinical worsening (increasing abdominal pain, nausea, vomiting) and the strong suspicion of neoplastic disease,
477
the patient was referred to surgery, and an ileocecal resection was performed. Histology showed suppurative inflammation with eosinophilic infiltration, and sections of Anisakis larva were present (Fig. 1B). In a further clinical interview, the patient reported having eaten raw fish. Gastroscopy was performed to identify larvae in the upper gastrointestinal tract and was negative. Anisakiasis is a zoonosis transmitted by the ingestion of infected raw fish. After penetrating the gut mucosa the larva of Anisakis dies and causes eosinophilic infiltration with proliferation of connective tissue around the larval body forming an eosinophilic granuloma that may mimic a submucosal tumour. Granuloma usually decreases in size and gradually disappears, over the time. In Italy, few cases of Anisakis have been described [1]. In the present case, colonic Anisakis was the cause of a colonic “neoplasticlike” mass primarily responsible of CI. Adult intussusception is infrequent and accounts for 5–10% of all intussusceptions [2]. CI without ileocecal involvement occurs in about 20% of cases in adults, malignant tumours being the most frequent cause (60% of the cases). Less frequently CI can also be caused by benign conditions (i.e. lipoma, leiomyoma, Meckel’s diverticulum, adenoma and inflammatory fibrous polyps and adhesions), or can be idiopathic. Parasitic infection is an extremely rare cause of CI [3] in Western Countries and adult CIs caused by anisakiasis have been reported only in Japan [4,5]. Most of the cases occur in the stomach and small bowel. Colonic anisakiasis is extremely rare (0.1–0.9% of cases). About 50% of colonic anisakiasis occurs in the right colon [4,5]. Acute symptoms are caused by larval mucosal invasion or hypersensitivity to the larvae or its secretions and consist in epigastric pain, nausea and vomiting. Chronic anisakiasis results in abscesses or eosinophilic granulomas with fever, eosinophilia, diarrhoea and abdominal pain. It can mimic appendicitis, gastroduodenal ulcer, inflammatory bowel diseases, or intestinal obstruction. Endoscopy plays a major diagnostic and therapeutic role. Besides directly visualizing worms penetrating into the gut mucosa, endoscopy may reveal erythema, oedema, erosive, inflammation, tumour, or ulceration. When Anisakis is visualized, endoscopic extraction should always be attempted, avoiding further tests and surgery. In the present case, eosinophilic granuloma mimicked a “neoplastic” mass causing colonic intussusception and was misclassified endoscopically. This suggests that in presence of a history of raw fish intake, the presence of any “neoplastic-like” mass in the
Fig. 1. (A) Colonoscopy showing a “giant” polypoid lesion in the proximal ascending colon, 5 cm in diameter, with ulcerated mucosa covered with fibrin. (B) A section of Anisakis larva located in the inner part of colonic muscularis propria is shown. Cuticle (c), oesophagus (e) and lateral chords (lc) are evident. The worm is surrounded by an intense inflammatory infiltrate rich in eosinophilic granulocytes (haematoxylin and eosin, original magnification 100×).
478
Correspondence / Digestive and Liver Disease 46 (2014) 475–478
gastrointestinal tract should prompt differential diagnosis between malignancy and Anisakis granuloma. Conflict of interest None declared. Funding This research received no specific funding. References [1] Bucci C, Gallotta S, Morra I, et al. Anisakis, just think about it in an emergency! Int J Infect Dis 2013;17:e1071–2. [2] Weilbaecher D, Bolin JA, Hearn D, et al. Intussusception in adults. Review of 160 cases. Am J Surg 1971;121:531–5. [3] Wong MT, Goh L, Chia KH. Intestinal schistosomiasis manifesting as colonic intussusception arising from a mucocele of the appendix: report of a case. Surg Today 2008;38:664–7. [4] Miura T, Iwaya A, Shimizu T, et al. Intestinal anisakiasis can cause intussusception in adults: an extremely rare condition. World J Gastroenterol 2010;16: 1804–76.
[5] Yorimitsu N, Hiraoka A, Utsunomiya H, et al. Colonic intussusception caused by anisakiasis: a case report and review of the literature. Intern Med 2013;52:223–6.
Gianluca Andrisani ∗ Cristiano Spada Lucio Petruzziello Guido Costamagna Digestive Endoscopy Unit, Catholic University, Rome, Italy ∗ Corresponding author at: Digestive Endoscopy Unit, Catholic University, Largo Agostino Gemelli 8, 00168 Rome, Italy. Tel.: +39 300630151. E-mail address: [email protected] (G. Andrisani)
http://dx.doi.org/10.1016/j.dld.2014.01.002
