NON3PECIFIC GRANULOMA OF THE COLON

ALEXANDER PRESTON, M.D.

Associate in Surgery, Horton MemoriaI Hospital

MIDDLETOWN, NEW YORK

T HERE have appeared in the recent Iiterature a number of descriptions and case reports of non-specific granu-

Iomatous inffammatory Iesions of the in- testina1 tract. Numerous articIes, which are readiIy avaiIabIe, have appeared describing iIeitis, or hyperpIastic inff ammatory Iesions of the terminal iIeum, of which the cIinica1 picture and pathoIogic findings are becom- ing increasingIy famiIiar. In addition, the identity of a paraIIe1 Iesion of the Iarge bowe1 has been more wideIy recognized. The reIative infrequency of the occurrence of these granuIomatous lesions in the Iarge bowe1, however, and the rarity of Iocation in the hepatic Aexure make it worth whiIe to submit a description of the foIIowing case.

From the point of view of etioIogy, in a recent articIe FeIsen’ has presented an anaIysis of over 553 cases of acute baciIIary dysentery, acute and chronic dista1 ileitis, and chronic uIcerative coIitis, in which is presented convincing evidence of the path- ogenesis of acute baciIIary infection in the subacute and chronic types of what have been commonIy referred to as non-specific inffammatory Iesions of both smaI1 and Iarge bowe1.

Review of the Iiterature reveaIs the re- ports of onIy about thirty cases of non- specific inffammatory Iesions of the coIon. It is IikeIy that many have been unreported and that this figure gives a somewhat faIse impression of their rarity. Moschowitz and WiIensky2 in their first articIe on this sub- ject reported four cases in the Iarge bowe1, of which three invoIved the ascending coIon and cecum, and one the spIenic Aexure. Mock3 refers to two cases of granuIoma of the sigmoid reported by Monsarrat and one of the transverse coIon reported by Moyni- han. In 1931, this author4 reported a num-

ber of additiona cases, incIuding nine which invoIved stomach, cecum, spIenic ff exure, and sigmoid.

Erdman and Burt5 described these Iesions in some detai1 and reported severa of the iIeoceca1 area with successfu1 resection. They state that the diagnosis of non- specific granuIoma is usuaIIy possibIe onIy by microscopic examination of the tissue, which is taken at operation to be carcinoma or tubercuIosis. Ginzberg and Oppen- heimer6 describe a IocaIized hypertrophic colitis and report five cases in the cecum and ascending coIon, three in the recto- sigmoid, one in the sigmoid, and three in the descending coIon. They aIso state that most of these cases were subjected to resection under the operative diagnosis of carcinoma or tubercuIosis. Crane’ reports the resection of a Iarge inffammatory granuIomatous mass of the sigmoid. Mar- tinon reports without detai1 a case of Iarge benign tumor of the hepatic Aexure of the coIon in which section showed evidence of chronic inffammatory process only, and which faIIs into this group of non-specific, benign, inff ammatory Iesions. Two further articIes by Gunn and Howard9 and Yeo- mans lo report five cases of Iarge granu- Iomatous tumor masses which were proved to be caused by amebae.

The treatment of these Iesions is surgica1, and consists in either sidetracking oper- ations or resection of the affected area. When ‘the Iesion is Iocated in the termina1 iIeum, expIoration is not infrequentIy done in an acute phase under the diagnosis of acute appendicitis. Under these conditions, primary resection is usuaIIy not possibIe. In a certain number of cases spontaneous heaIing occurs under conservative treat- ment without radica1 operative procedure. Not infrequentIy the character of the

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NEW SERVES Vor. XLI, No. I Preston-GranuIoma of CoIon American ~~~~~~~ of surgery I I 3

lesion, particuIarIy if producing obstruc- tion, demands iIeo-transverse colostomy. This may be a11 that is necessary, whiIe a certain number Iater come to secondary resection of the iIeoceca1 area. When the Iesion occurs in the colon, primary resec- tion is usuaIIy possibIe, and as has been noted, is directIy indicated because of the. fact that the operator is not abIe to dis- tinguish this Iesion from carcinoma. Under this heading faI1 the cases which because of extensive infltration are considered inoperabIe carcinoma, and which, foIIowing a paIIiative procedure to reIieve obstruc- tion, recover and continue to do weI1. The prognosis in this group of granuIomata, following resection, is good.

CASE REPORT

Mrs. H. T., aged 59, was first seen in an attack of extremeIy severe, sharp, right-sided, abdomina1 pain, of sudden onset. The famiIy history and patient’s history were negative except for the fact that during the preceding few months she had Iost about 15 pounds in weight and feIt that she was “run-down.” The clinica picture at this time was that of renal colic with prostration, vomiting, and severe pain which was maxima1 in the center of the right abdomen and radiated to the Ioin. There were no urinary or bowe1 symptoms. There was a great dea1 of defense spasm and some tenderness on pressure over the right abdomen. The pain was relieved by morphine, but during the ensuing ten days the patient continued to have aching in the right side and occasiona bouts of severe pain. She entered the Horton Memorial HospitaI for study on August 27, 1935, ten days after her first attack. There was no history of previous gastrointestina1 infection, colitis, or any type of bowe1 disturbance. The absence of such history is worthy of note in view of the admitted reIationship between acute infections of the dysentery group and intestina1 granuIomata. Examination showed an easiIy paIpabIe mass about the size of a Iarge orange in the right ffank extending anteriorIy from the kidney region. The mass was firm, tender, and did not move with respiration. The rest of the physica examination was negative. The urine was negative. The white ceIIs were eIevated to 13,650 with 87 per cent

poIymorphonucIears. The urea nitrogen and sugar were normaI, the Wassermann was negative; there was no anemia. At this time she ran an irreguIar septic temperature be- tween IOO and 103 with corresponding puIse eIevation, and it was feIt that the mass prob- abIy represented an infected kidney. However, cystoscopic examination and pyeIograms were done and showed onIy a sIight constriction of the right ureter with norma kidneys. The gaII- bIadder was we11 visuaIized and fiIIed normaIIy. Barium enema discIosed a constant fiIIing defect in the upper portion of the ascending coIon. After five days the temperature feI1 to norma and the mass became sIightIy smaIIer and Iess tender. The Ieucocyte count returned to normal.

Operation was performed on September 7. A firm, indurated, adherent mass, 8 cm. in diameter was found. The mass was identified as a Iesion of the hepatic Aexure of the co&, intimateIy appIied to the lower portion of the right kidney. The abdomen was eIsewhere negative. Dissection around the mass was very dificuIt because of marked inffammatory reaction with adhesions on a11 sides. However, it was finaIIy freed and Iifted from the kidney. Presumptive (or preIiminary) diagnosis was carcinoma of the coIon. Resection of the right coIon was done, removing IO cm. of the ter- mina1 iIeum, cecum, ascending coIon, and haIf of the transverse coIon. The cIamps on the divided ends of iIeum and transverse coIon were brought together and a spur constructed (modified Mikulicz technique). The patient stood the operation satisfactorily. The cIamps were removed after seventy-two hours, and ten days Iater the spur between the iIeum and coIon was cut away with a crushing cIamp. The skin was protected by an aluminum paste. After the spur was cut, a great dea1 of the iIea1 contents flowed directIy into the coIon giving the patient frequent norma movements. She was sent home for six weeks during which time her gener4 condition steadiIy improved. Upon second admission at the end of this time an extraperitonea1 cIosure of the iIeocoIostomy was done.

The pathoiogic report described an irreguIar, firm mass at the hepatic ffexure of the coIon which represented an intramura1 process ex- tending in to the mucous surface and out to the roughened and irreguIar area where it had been adherent to the surrounding tissues. Grossly,

114 American Journal of Surgery Preston-GranuIoma of CoIon JULY, ,938

the mucous membrane itself was normal, but on section there were demonstrated two small sinus tracts about I cm. in length leading from a small sac-like area near the peritoneal surface of the tumor to the mucous membrane. There was considerable chronic intl ammatory reac- tion and fibrous tissue reaction about these two tracts and about the entire mass. Microscopic examination of the tissue showed exten- sive inflammatory granulation tissue through- out the mass with no evidence of neoplasm. The section showed non-specific inff ammatory reaction with small areas of necrosis about which were polymorphonuclear ceils. Many epithelioid cells and a number of giant cells were present. Acid-fast stains were made, but no tubercle bacilli were found. There were no features of the case, clinical or pathologic, to point to tuberculosis, and several patholo- gists concurred in the diagnosis of a non- specific granuloma. The probability is that an abscess formed within the mass and sponta- neously ruptured into the lumen of the bowel during the patient’s preoperative stay in the hospital. Since leaving the hospital, she has done well; and she is now, two years following operation, in perfect health, free of symptoms, and with normal gastrointestinal function.

SUMMARY

The frequent occurrence of non-specific granuIomatous inff ammatory Iesions of the smaI1 intestine, particuIarIy in the iIeum, is being more wideIy recognized, and the characteristics of these Iesions are becoming better known. However, there are reIa- tiveIy few reported cases of granuIomata in the coIon, which represent the same disease, and the same pathoIogic process, in this Iower segment of the intestina1 cana1.

A review of the Iiterature is presented with reference to the cases on record, and the report of an additiona case is added, in which the process was Iocated at the hepatic ffexure, and which was treated by a two-stage resection of the right coIon. The pathoIogic findings are described.

Non-specific granuIoma of the coIon can rareIy be distinguished from carcinoma either prior to, or at, operation. The indica- tion, in either case, is for wide resection, and in the inffammatory Iesions the end resuIts are very satisfactory.

REFERENCES

I. FELSEN, J. New concepts of bacillary dysentery; its relationship to non-specific ulcerative colitis, distaI iteitis and non-specific granuloma. Am. J. Digest. Dis. CY Nutrition, 3: 8690 (April) 1936.

2. MOSCHOWITZ, E., and WILENSKY, A. 0. Non-specific granuIomata of intestine. Am. J. M. SC., 166: 48-66 (JuIy) 1923.

3. MOCK, H. E. Infective granuloma of the intestine; with report of one case foIIowing trauma. Znternat. J. Surg., 41: 1-8 (Jan.) 1928.

4. MOCK, H. E. Infective granuIoma; non-specific chronic tumor-Iike productive inAammations of gastro-intestina1 tract. Surg., Gynec. e? Obst., 52: 672-689 (March) rg3 I.

5. ERDMANN, J. F., and BURT, C. V. Non-specific granuloma of the gastro-intestina1 tract. Surg., &nec. ti Obst., 57:~71-80 (July) 1933.

6. GINZBERG. L.. and OPPENHEIMER. G. D. Non- , , specific GranuIomata of the intestine. Ann. Stug., 98: 1046-1062 (Dec.) 1933.

7. CRANE, W. IntramuraI inffammation of coIon simuIating cancer. J. A. M. A., 95: 261-262 (JuIy 26) 1930.

8. MARTINON, A. R. Benign tumors of hepatic IIexure. Am. J. Surg., IO: 573-575 (Dec.) 1930.

g. GUNN. H.. and HOWARD. N. J. Amebic eranuIomas

IO.

of the Iarge bowel. J. A. M. A., 97: 166-170 (July 18) 1931.

YEOMANS, F. C. Amebic granuIoma simulating carcinoma of coIon and rectum. Am. J. Surg., I :3 365 (Feb.) 1936.