Case Study - A child's problem in an adult

Dr Keith Barnard found an unexpected cause for bloody diarrhoea in a 59-year-old woman.

Mrs Johnson was 59, and well known to me because of frequent battles over her smoking. She was not long back from a holiday, where I knew she would have stocked up on her duty frees.

She had not come to tell me about her holiday, but to complain about the intermittent abdominal pain and bloody diarrhoea she had been suffering the last few days. It wasn't that bad, she said, three or four times a day and not watery, and she was not vomiting, but she was understandably worried about the small amounts of blood.

X-ray of a lipoma in the colon. A lipoma can obstruct the passage of digested food through the intestine (CNRI / SPL)

History
Despite her smoking, Mrs Johnson was in robust health and had an unremarkable medical history. She was not taking any regular medication. She said she'd been feeling fine until the last three or four days, and blamed 'that funny foreign food' on her current predicament, although she had returned from her trip some two weeks previously.

Abdominal tenderness
Mrs Johnson did not look ill, and there was nothing to find on examination except some mild, non-specific abdominal tenderness. The bowel sounds were active.

I thought she was probably right in her assumption that she had picked up a bug while on holiday, and arranged a stool culture and gave her some general advice. Because the possibility of malignancy was lurking in the back of my mind, I also asked for a blood count and ESR.

She was quite unwell when she returned for the results. The tests showed a mild normochromic anaemia, with a haemoglobin of 10.1 g/dl, but everything else was normal. The stool confirmed the presence of blood, but the culture was negative.

I examined her again, with the possibility of a neoplasm now high on my list of probabilities, but although her abdomen was more tender, there were no masses. A rectal examination was negative.

I felt I needed to refer her, but she looked so much worse than she had days earlier that I decided to discuss the case with the medical team at the hospital. They agreed to see her in the medical assessment unit.

Laparotomy
I didn't see Mrs Johnson again for three weeks, when she came to see me clutching her discharge letter and practically glowing with pride at her new-found fame. Her problem had caused quite a stir, it seemed.

Her condition had worsened in hospital and she ended up in the surgical ward where she had a laparotomy.

This revealed an intussusception of the colon, precipitated by a lipoma that projected into the lumen of the bowel.

'They're going to write me up,' she said. 'They thought I'd got cancer but now they've taken out that bit of my bowel, I'm right as rain.'

I decided to do some reading, as I was not really aware that intussusception occurred in adults. No wonder the hospital were excited, as only about 5 per cent of cases occur outside of childhood.

While those in young children are nearly all idiopathic, most adult examples are associated with some underlying organic condition, with half of cases involving the colon being due to malignancy.

At a medical meeting a few weeks later I talked to Mrs Johnson's surgeon. She was pleased with herself, as the diagnosis is not easy in adults. A palpable mass is found in less than 10 per cent of patients and plain X-rays are usually not much help.

Mrs Johnson was a lucky woman. I just hope her insistence of continuing to smoke won't lead to something that turns out to be less amenable to treatment.

  • Dr Barnard is a former GP in Fareham, Hampshire.

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