The case
A 37-year-old gentleman presented to the emergency room with colicky abdominal pain in the upper and lower abdomen, constipation, nausea and vomiting. The pain was not controlled, even on narcotics. The patient reported four days of constipation, but no obstipation was observed.
Upon examination, the abdomen was moderately distended, but soft and tender in the left lumbar/iliac fossa. Bowel sounds were scanty, the rectum empty and no masses were felt. An abdomen x-ray revealed marked distension of large bowel with air fluid levels suggestive of colonic obstruction. A CT scan of the abdomen showed a markedly dilated colon from cecum to the sigmoid colon, an abrupt change in caliber seen at the junction of the sigmoid and descending colon, with circumferential thickening with heterogeneous enhancement. Surrounding stranding was also observed.
Diagnosis and management
The findings were suggestive of a proximal sigmoid tumour with secondary large bowel obstruction. A sigmoidoscopy, inclusive of biopsy, was undertaken to confirm the diagnosis. A malignant stricture was identified at 70cm.
A catheter loaded with a 0.035 guidewire was introduced through the stricture. A water soluble contrast was injected through the catheter, and the stricture was delineated. A 20-mm diameter, 9 cm-long wallstent was inserted under fluoroscopic control, and a large amount of fecal material and air was released as the stent opened.
A post-procedure x-ray confirmed there was no perforation of the abdominal wall and the pain was resolved.
Discussion
Colorectal stenting is a very useful alternative treatment to emergency surgery with less morbidity and mortality. It is less often done due to lack of awareness among surgeons and lack of expertise in stent insertion, which need to be addressed.
Denesh Gopalan, MD, FRCP is a member of the Gastroenterology department at the American Hospital, Dubai.
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