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Image of the Month—Quiz Case FREE

Tze-Woei Tan, MBBS; Rogers C. Griffith, MD; Michael P. Vezeridis, MD
[+] Author Affiliations

Author Affiliations: Section of Vascular Surgery, Department of Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, Massachusetts (Dr Tan); and Departments of Surgery (Dr Vezeridis) and Pathology (Dr Griffith), Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence.


Section Editor: Carl E. Bredenberg, MD


Arch Surg. 2011;146(1):115. doi:10.1001/archsurg.2010.296-a.
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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.)

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Figure 1

Computed tomographic scan showing thickening of the descending colon with an adjacent collection of air in the spleen. L indicates left; R, right.

Graphic Jump Location

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.

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Figure 2

A colonic mass was resected en bloc with the spleen.

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WHAT IS THE DIAGNOSIS?

A.  Colon cancer with splenic abscess

B.  Diverticulitis with perforation into the spleen

C.  Splenic cyst

D.  Splenic laceration

Figures

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Figure 1

Computed tomographic scan showing thickening of the descending colon with an adjacent collection of air in the spleen. L indicates left; R, right.

Graphic Jump Location
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Figure 2

A colonic mass was resected en bloc with the spleen.

Graphic Jump Location

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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