Endoscopic extraction of an unusual colonic foreign body
Robert M. Richter, MD* leon littman, MD
Surgical Endoscopy Service Jewish Hospital and Medical Center Brooklyn, New York
It is fortunate that among the wide variety of foreign bodies inserted into the rectum, few mig~ate proximally into the bowel above the distal sigmoid colon. Especially long objects, particularly rigid ones, are hindered in retrograde passage by the flexures of the sigmoid. Without burdening the reader with a recitation of references to those which have made this circuitous journey prior to endoscopic extraction, we wish simply to present an oddity. CASE REPORT A 15 year old boy was admitted because of abdominal cramps, vomiting, and diarrhea since accidental "ingestion" of a ball-point pen refill several days earlier. Examination showed no positive findings except for moderate, generalized, abdominal tenderness without rebound. The white blood cell count was normal.
Subsequent to removal of the foreign body, which measured 16 cm in length (Figure 1c), the patient made an uneventful recovery. Further questioning elicited his admission that the pen had been inserted anally, not swallowed. COMMENT In view of the difficulty encountered in guiding this long objectthrough the sigmoid colon, we cannot account for its spontaneous retrograde passage. The clinical picture negates the possibility that, on insertion, it perforated the rectum and then re-entered the descending colon. It should be self-eVident that a radiopaque foreign body may be contained within a larger, more rigid, radiolucent object. This has obvious implications regarding expected size, flexi. bility, and ease of removal. Finally, to the credit of the manufacturer, it should be noted that the pen, the brand name of which had been obliterated, was found to be fully functional after extraction and was used to write the pathology requistion (after washing) when the endoscopist could not find his own.
Colitis cystica profunda: colonoscopic and pathological findings Emanuel Friedman, MD* Edward E. Tueller, MD Peninsula Hospital and Medical Center Burlingame, California
Plain abdominal radiographs showed a radiopaque ballpoint pen refill overlying the descending colon gas pattern (Figure 1a). There was no free intraperitoneal air. At colonoscopy 2 days later, the foreign body was found in the descending colon. To our surprise, it was an entire pen with a radiolucent sheath. It lay with its tip distal most, at the 50 cm level above the anus. (Figure 1b). A small amount of pus adjacent to the tip suggested perforation, but none was found. Using a sheathed wire snare, the pen and endoscope were withdrawn together. Because of considerable resistance to passage through the sigmoid flexure, manipulation of the bowel through the abdominal wall was required.
In February, 1966, 2 papers appeared simultaneously, by Epstein et aU and by Allen 2 , discussing colitis cystica profunda or hamartomatous inverted polyps of the rectum, bringing to 9 the number of reported cases in the American literature. Wayte and Helwig' from the Armed Forces Institute of Pathology in 1967 reported an additional 24 cases, 19 of which represented the localized form of colitis cystica profunda. Since then, only sporadic cases have been reported. 4 The first known case was described in 1766 by Stark,S and in a subsequent report. Virchow6 first used the term colitis cystica profunda to describe the lesions. The clinical findings in all these cases were essentially the same, with mild lower abdominal complaints, diarrhea, mucous discharge, and occasional rectal bleeding. At sigmoidoscopy, nodular polypoid or plaque-like lesions, generally with intact mucosa, were found close to the anal verge, usually from 5 cm to 12 cm. Biopsy of the lesions showed submucosal, dilated cysts lined with simple columnar epithelium, frequently containing mucoid material. Mild inflammatory infiltrate was sometimes noted in the lamina propria and submucosa. There was no evidence of malignant change although some patients had extensive surgical resections before the benign nature of the disease was recognized. CASE REPORT A 26 year old white man was seen for the first time in April 1974 with a 3 months' history of watery, loose bowel movements, up to 6 daily, associated with a constant urge to defecate. There had been a great deal of "gas" and rumbling and occasional nocturnal diarrhea. Immediately be-
'Reprint requests: Robert M. Richter, MD, Surgical Endoscopy Service, Jewish Hospital and Medical Center, 555 Prospect Place, Brooklyn, New York 11238.
'Reprint requests: Emanuel Friedman, MD, 931 W. San Bruno Avenue, San Bruno, California 94011.
Figure 1 a, Plain abdominal roentgenogram showing radiopaque ball·point pen cartridge in descending colon. b, Endoscopic view of ball-point pen alongside endoscope in descending colon. c, Extracted foreign body.
40
GASTROINTESTINAL ENDOSCOPY
Figure 1. Colonic lesion showing submucosal epithelial-lined cystic structure, a; higher power view showing mild inflammatory exudate in the lamina propria, b.
fore his first visit, he had noticed blood mixed with his stool. There had been a 25 pound weight loss, ascribed by him to fear of eating which might initiate a diarrheal movement. Physical examination was unremarkable. Sigmoidoscopic examination showed a firm, indurated, raised, erythematous area on both sides of the bowel wall at 10 cm from the anus, without superficial ulceration. A biopsy was taken and showed cystic lesions within the submucosa lined with simple columnar epithelium (Figure 1). The overlying mucosa was intact. A mild inflammatory infiltrate was noted in the lamina propria. The patient was subsequently colonoscoped, using the Olympus CF-MB fiberscope, to the midtransverse colon. The mucosa was completely normal except for the finding at 10 cm of the lesions ,described above, almost occluding the lumen (Figure 2). Superficial biopsies taken through the colonoscope did not go deep enough to show the lesions preViously' noted. Radiographs of the upper gastrointestinal tract, the small bowel, and the colon revealed no other abnormalities. The patient was treated with corticosteroid enemas and had marked improvement in his symptoms. He regained most of his weight and returned to full time employment. DISCUSSION Epstein et aL' could find no method by which the pathogenesis of colitis cystica profunda could be definitely adduced. The previously described colitis cystica superficial is, the diffuse lesion of Wayte and Helwig,3 was generally found in patients with pellagra, sprue, or coexisting ulcerative colitis which did not obtain in this case. The question of congenitally ectopic colonic epithelium was considered because of Johnson's study9 of the colon in human embryos in which he described the occasional finding of epithelial cysts
Figure 2. Colonoscopic photograph of the colonic lesion showing raised, nodular area on a rectal valve. VOLUME 22, NO.1, 1975
in the appendix and rectum. These were not described in relation to the' muscularis mucosa, however, and he stated that the epithelial cells degenerated and the cystic structures disappeared. An acquired mechanism, such as reepithelialization of deep abscesses resulting either from massive dysentery or from ulcerative colitis has been considered, but in most of the cases recently reported there was no antecedent history of either dysentery or colitis. Epstein et al. finally concluded that a weakness or defect of the muscularis mucosa with herniation of the mucosal structures through the muscularis mucosa was the most likely explanation. Brock and Suckow,' and more recently Sternlieb,8 attributed the changes to obliterative arteriosclerosis with focal mucosal necrosis. The patients described by them had the roentgen appearance of colitis cystica profunda, and the lesions disappeared without specific therapy. The major problem involves differentiation of colitis cystica profunda as a benign intramural lesion from a malignant process which would require extensive resection.
REFERENCES 1. EPSTEIN SE, ASCARI WQ, ABLOW Re, SEAMAN WB, LATTES R; Colitis cystica profunda. Am} Clin Path 45:186,1966 2. ALLEN MS; Hamartomatous inverted polyps of the rectum. Cancer 19;257, 1966 3. WAYTE DM, HELWIG EB; Colitis cystica profunda. Am} Clin Path 48;159, 1967 4. GOLDBERG HI, BUCHIGNANI J, RULON DB; RPC of the Month from the AFIP. Radiology 96;447,1970 5. STARK W: Specimen septem historias et dissectiones dysentericorum exhibens. Thesis, Leiden, 1766 (citd by Epstein, et al.) 6. VIRCHOW R: Die Krankhaften Geschwulste, Vol. 1. Berlin: A. Hirschwald, 1863, p. 243 7. BROCK DR, SUCKOW EE: Obliterative arteriolar sclerosis of the colon with focal mucosal necrosis. Gastroenterology 44:190, 1963 8. STERNUEB I: Brock-Suckow polyposis of the colon (obliterative arteriolar sclerosis of the colon?). Gastroenterology 46:193, 1964 9. JOHNSON FP: The development of the mucous membrane of the large intestineand vermiform process in the human embryo. Am} Anat 14:187, 1913
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Robert M. Richter, MD* leon littman, MD
Surgical Endoscopy Service Jewish Hospital and Medical Center Brooklyn, New York
It is fortunate that among the wide variety of foreign bodies inserted into the rectum, few mig~ate proximally into the bowel above the distal sigmoid colon. Especially long objects, particularly rigid ones, are hindered in retrograde passage by the flexures of the sigmoid. Without burdening the reader with a recitation of references to those which have made this circuitous journey prior to endoscopic extraction, we wish simply to present an oddity. CASE REPORT A 15 year old boy was admitted because of abdominal cramps, vomiting, and diarrhea since accidental "ingestion" of a ball-point pen refill several days earlier. Examination showed no positive findings except for moderate, generalized, abdominal tenderness without rebound. The white blood cell count was normal.
Subsequent to removal of the foreign body, which measured 16 cm in length (Figure 1c), the patient made an uneventful recovery. Further questioning elicited his admission that the pen had been inserted anally, not swallowed. COMMENT In view of the difficulty encountered in guiding this long objectthrough the sigmoid colon, we cannot account for its spontaneous retrograde passage. The clinical picture negates the possibility that, on insertion, it perforated the rectum and then re-entered the descending colon. It should be self-eVident that a radiopaque foreign body may be contained within a larger, more rigid, radiolucent object. This has obvious implications regarding expected size, flexi. bility, and ease of removal. Finally, to the credit of the manufacturer, it should be noted that the pen, the brand name of which had been obliterated, was found to be fully functional after extraction and was used to write the pathology requistion (after washing) when the endoscopist could not find his own.
Colitis cystica profunda: colonoscopic and pathological findings Emanuel Friedman, MD* Edward E. Tueller, MD Peninsula Hospital and Medical Center Burlingame, California
Plain abdominal radiographs showed a radiopaque ballpoint pen refill overlying the descending colon gas pattern (Figure 1a). There was no free intraperitoneal air. At colonoscopy 2 days later, the foreign body was found in the descending colon. To our surprise, it was an entire pen with a radiolucent sheath. It lay with its tip distal most, at the 50 cm level above the anus. (Figure 1b). A small amount of pus adjacent to the tip suggested perforation, but none was found. Using a sheathed wire snare, the pen and endoscope were withdrawn together. Because of considerable resistance to passage through the sigmoid flexure, manipulation of the bowel through the abdominal wall was required.
In February, 1966, 2 papers appeared simultaneously, by Epstein et aU and by Allen 2 , discussing colitis cystica profunda or hamartomatous inverted polyps of the rectum, bringing to 9 the number of reported cases in the American literature. Wayte and Helwig' from the Armed Forces Institute of Pathology in 1967 reported an additional 24 cases, 19 of which represented the localized form of colitis cystica profunda. Since then, only sporadic cases have been reported. 4 The first known case was described in 1766 by Stark,S and in a subsequent report. Virchow6 first used the term colitis cystica profunda to describe the lesions. The clinical findings in all these cases were essentially the same, with mild lower abdominal complaints, diarrhea, mucous discharge, and occasional rectal bleeding. At sigmoidoscopy, nodular polypoid or plaque-like lesions, generally with intact mucosa, were found close to the anal verge, usually from 5 cm to 12 cm. Biopsy of the lesions showed submucosal, dilated cysts lined with simple columnar epithelium, frequently containing mucoid material. Mild inflammatory infiltrate was sometimes noted in the lamina propria and submucosa. There was no evidence of malignant change although some patients had extensive surgical resections before the benign nature of the disease was recognized. CASE REPORT A 26 year old white man was seen for the first time in April 1974 with a 3 months' history of watery, loose bowel movements, up to 6 daily, associated with a constant urge to defecate. There had been a great deal of "gas" and rumbling and occasional nocturnal diarrhea. Immediately be-
'Reprint requests: Robert M. Richter, MD, Surgical Endoscopy Service, Jewish Hospital and Medical Center, 555 Prospect Place, Brooklyn, New York 11238.
'Reprint requests: Emanuel Friedman, MD, 931 W. San Bruno Avenue, San Bruno, California 94011.
Figure 1 a, Plain abdominal roentgenogram showing radiopaque ball·point pen cartridge in descending colon. b, Endoscopic view of ball-point pen alongside endoscope in descending colon. c, Extracted foreign body.
40
GASTROINTESTINAL ENDOSCOPY
Figure 1. Colonic lesion showing submucosal epithelial-lined cystic structure, a; higher power view showing mild inflammatory exudate in the lamina propria, b.
fore his first visit, he had noticed blood mixed with his stool. There had been a 25 pound weight loss, ascribed by him to fear of eating which might initiate a diarrheal movement. Physical examination was unremarkable. Sigmoidoscopic examination showed a firm, indurated, raised, erythematous area on both sides of the bowel wall at 10 cm from the anus, without superficial ulceration. A biopsy was taken and showed cystic lesions within the submucosa lined with simple columnar epithelium (Figure 1). The overlying mucosa was intact. A mild inflammatory infiltrate was noted in the lamina propria. The patient was subsequently colonoscoped, using the Olympus CF-MB fiberscope, to the midtransverse colon. The mucosa was completely normal except for the finding at 10 cm of the lesions ,described above, almost occluding the lumen (Figure 2). Superficial biopsies taken through the colonoscope did not go deep enough to show the lesions preViously' noted. Radiographs of the upper gastrointestinal tract, the small bowel, and the colon revealed no other abnormalities. The patient was treated with corticosteroid enemas and had marked improvement in his symptoms. He regained most of his weight and returned to full time employment. DISCUSSION Epstein et aL' could find no method by which the pathogenesis of colitis cystica profunda could be definitely adduced. The previously described colitis cystica superficial is, the diffuse lesion of Wayte and Helwig,3 was generally found in patients with pellagra, sprue, or coexisting ulcerative colitis which did not obtain in this case. The question of congenitally ectopic colonic epithelium was considered because of Johnson's study9 of the colon in human embryos in which he described the occasional finding of epithelial cysts
Figure 2. Colonoscopic photograph of the colonic lesion showing raised, nodular area on a rectal valve. VOLUME 22, NO.1, 1975
in the appendix and rectum. These were not described in relation to the' muscularis mucosa, however, and he stated that the epithelial cells degenerated and the cystic structures disappeared. An acquired mechanism, such as reepithelialization of deep abscesses resulting either from massive dysentery or from ulcerative colitis has been considered, but in most of the cases recently reported there was no antecedent history of either dysentery or colitis. Epstein et al. finally concluded that a weakness or defect of the muscularis mucosa with herniation of the mucosal structures through the muscularis mucosa was the most likely explanation. Brock and Suckow,' and more recently Sternlieb,8 attributed the changes to obliterative arteriosclerosis with focal mucosal necrosis. The patients described by them had the roentgen appearance of colitis cystica profunda, and the lesions disappeared without specific therapy. The major problem involves differentiation of colitis cystica profunda as a benign intramural lesion from a malignant process which would require extensive resection.
REFERENCES 1. EPSTEIN SE, ASCARI WQ, ABLOW Re, SEAMAN WB, LATTES R; Colitis cystica profunda. Am} Clin Path 45:186,1966 2. ALLEN MS; Hamartomatous inverted polyps of the rectum. Cancer 19;257, 1966 3. WAYTE DM, HELWIG EB; Colitis cystica profunda. Am} Clin Path 48;159, 1967 4. GOLDBERG HI, BUCHIGNANI J, RULON DB; RPC of the Month from the AFIP. Radiology 96;447,1970 5. STARK W: Specimen septem historias et dissectiones dysentericorum exhibens. Thesis, Leiden, 1766 (citd by Epstein, et al.) 6. VIRCHOW R: Die Krankhaften Geschwulste, Vol. 1. Berlin: A. Hirschwald, 1863, p. 243 7. BROCK DR, SUCKOW EE: Obliterative arteriolar sclerosis of the colon with focal mucosal necrosis. Gastroenterology 44:190, 1963 8. STERNUEB I: Brock-Suckow polyposis of the colon (obliterative arteriolar sclerosis of the colon?). Gastroenterology 46:193, 1964 9. JOHNSON FP: The development of the mucous membrane of the large intestineand vermiform process in the human embryo. Am} Anat 14:187, 1913
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