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uestion: A 68-year-old man was admitted to the hospitalith asthenia, anorexia, and weight loss of 6 months’ duration,bdominal distention, and acute low back pain. His medicalistory included a successful surgical intervention during in-

ancy for an imperforated anus and chronic constipation with

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everal episodes of intestinal pseudo-obstruction over the last l

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0 years. Physical examination showed serious cachexia, a tightbdomen without signs of peritonitis, and reduced bowelounds. Palpation did not reveal masses or visceromegaly. Theectal examination showed stools of medium consistency andormal anal sphincter tone. The patient’s left thigh was swol-

en, tender, and erythematous. Laboratory studies only revealed

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Clinical Challenges and Images in GI continued

ypoalbuminemia (2.8 g/dL) with high carcinoembryonic anti-en (13.1 ng/mL). A radiograph of the abdomen was takenFigure A), which showed an absence of intestinal gas with aeterogeneous mass filling the abdomen. Computed tomogra-hy of the abdomen showed a large colorectal dilatation due togiant mass containing calcification that occupied the entire

bdominal cavity (Figure B), leading to displacement of visceraltructures and severe compression of the inferior vena cavaith dilatation of the right renal pelvis (Figure C, arrows)ithout signs of colon perforation. Doppler ultrasonographyf the lower left limb revealed an intraluminal thrombusFigure D, arrow) and noncompressibility of the commonemoral vein with the ultrasound transducer probe (Figure D,rrowhead). What is the diagnosis, and how should this case beanaged?

Look on page 983 for the answer and see the Gastroen-erology website (http://www.gastrojournal.org) for morenformation on submitting your favorite image to Clinicalhallenges and Images in GI.

CARLOS ÁLVAREZ, MDMIGUEL ÁNGEL HERNÁNDEZ, MD

AMAIA QUINTANO, MDDepartment of Intensive Medicine

University Hospital Marques de ValdecillaSantander, Spain

© 2006 by the American Gastroenterological Association (AGA) Institute0016-5085/06/$32.00

doi:10.1053/j.gastro.2006.07.043

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September 2006 CLINICAL CHALLENGES AND IMAGES IN GI 983

Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 702):Deep Venous Thrombosis due to Idiopathic Megarectum and Giant FecalomaThe patient was diagnosed with deep vein thrombosis and intestinal pseudo-obstruction secondary to giant fecaloma.Anticoagulation was started. Although the fecal impaction was initially treated with laxatives, enemas, and manual extraction,these measures failed. The patient suffered a progressive clinical deterioration and required surgery. Resection of the rectum,manual extraction of the fecal impaction, proctectomy, and terminal colostomy were performed following Hartmann’stechnique. The histopathologic study revealed hyperplasia of the muscularis mucosae, submucosal fibrosis, and minimalinflammatory infiltration with the presence of ganglionary cells, compatible with idiopathic megarectum. The initialpostoperative recovery was favorable.

Chronic constipation with fecal impaction is a common and underestimated problem. When associated with persistentintestinal dilatation in the absence of an organic cause, it is called idiopathic megacolon. Depending on the segment affected,3 types are distinguished: megacolon, megarectum, or both. Symptoms may begin in infancy or in adulthood, and recurrentfecal impaction is common (it is called fecaloma in extreme forms). Fecal incontinence, abdominal pain, and distention or amass that may appear as an abdominal tumor are also noted.1 Abdominal computed tomography was the diagnosticprocedure in our case, while other alternatives include a barium enema or flexible rectosigmoidoscopy.2 The initialmanagement is conservative, including enemas with periodic disimpaction and manual evacuation. Occasionally, the use ofgeneral anesthesia and laxatives or long-term polyethyleneglycol are the usual measures.2 Surgical intervention is indicated incases of refractory constipation, intolerance to medical treatment, and secondary complications.3 Protectomy with coloanalanastomosis and vertical reduction rectoplasty are the most commonly performed procedures.3 The complications describedinclude stercoral ulcer, which may lead to spontaneous colonic perforation associated with high mortality, sciatica caused bysacral nerve root compression, as well as recurrent volvulus and ureter obstruction with secondary hydronephrosis.1 Our caseis associated with an exceptional complication— compression of the inferior vena cava and deep vein thrombosis.

References1. Nguyen H, Simpson RR, Kennedy ML, Lubowski DZ. Idiopathic megacolon causing iliac vein occlusion and

hydronephrosis. Aust N Z J Surg 2000;70:539 –542.2. Rajagopal A, Martin J. Giant fecaloma with idiopathic sigmoid megacolon: report of a case and review of the

literature. Dis Colon Rectum 2002;45:833– 835.3. Gladmann MA, Scott SM, Lunnis PJ, Williams NS. Systematic review of surgical options for idiopathic

megarectum and megacolon. Ann Surg 2005;241:562–574.

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