A 66-year-old man with a history of diabetes mellitus presented with 3 days of chills and nausea but with no abdominal or chest pain. On physical examination, he was afebrile with mild left upper-quadrant tenderness. His white blood cell count was 4200/μL, and his hemoglobin level was 12 g/dL at admission. A computed tomographic scan of the abdomen showed thickening of the splenic flexure and descending colon with an adjacent collection of air in the spleen (Figure 1). An electrocardiogram showed signs of a myocardial infarction with ST-segment changes, and his troponin I level on presentation was 1.6 ng/mL. (To convert white blood cell count to number of cells ×109/L, multiply by 0.001; hemoglobin to grams per liter, multiply by 10; and troponin to micrograms per liter, multiply by 1.)
Computed tomographic scan showing thickening of the descending colon with an adjacent collection of air in the spleen. L indicates left; R, right.
The patient was treated with intravenous antibiotics, and he underwent cardiac catheterization with coronary artery stent placement. Further workup that included a barium enema showed focal narrowing of the descending colon with no evidence of perforation or fistula. The patient improved clinically and was discharged home with a regimen of oral antibiotics and clopidogrel bisulfate. Results of an outpatient colonoscopy showed an ulcerated, partially obstructing mass in the descending colon, but examination of the tissue biopsy specimen was not diagnostic.
Two months after coronary stent placement and after he had completed antiplatelet therapy, the patient underwent exploratory laparotomy that showed a splenic flexure mass invading the spleen with no evidence of any other metastatic disease. The colonic mass was resected en bloc with splenectomy (Figure 2). The patient had an uneventful postoperative course and was discharged home 13 days after surgery.
A colonic mass was resected en bloc with the spleen.
A. Colon cancer with splenic abscess
B. Diverticulitis with perforation into the spleen
C. Splenic cyst
D. Splenic laceration
Tan T, Griffith RC, Vezeridis MP. Image of the Month—Quiz Case. Arch Surg. 2011;146(1):115. doi:10.1001/archsurg.2010.296-a