Image of the Month
A 9-year-old girl presented with a 2- to 3-week history of abdominal pain. The pain was described as cramping, occurring every 15 minutes, and occasionally waking her up from sleep. She had occasional vomiting and reported having 1 to 2 soft stools per day, some of them containing streaks of bright red blood. She complained of decreased appetite, with a 5-lb weight loss during the previous month. Physical examination was significant for mild diffuse tenderness to palpation of the abdomen, and heme-positive stool on rectal examination. Laboratory studies were remarkable for a white blood cell count of 4600/μL (50% neutrophils, 37% lymphocytes), hemoglobin 11.2 g/dL, and hematocrit 32.2%. Stool was sent for culture, ova and parasites, and Clostridium difficile, all of which were negative. The patient underwent a colonoscopy, at which point a large polypoid lesion was seen in the transverse colon (Fig. 1).
Because of its large size and inability to clearly visualize the stalk, the mass was not removed during the colonoscopy, and the decision was made to remove it surgically. During surgery a considerable amount of blood was seen in the peritoneal cavity. Upon further abdominal exploration, large necrotic tumors were seen in both ovaries, and an ulcerating mass was found in the transverse colon. The colon lesion was excised, which was complicated by profuse life-threatening bleeding. Pathology of the lesions revealed a small, round blue cell tumor, consistent with Burkitt's lymphoma. The patient was treated with multiagent chemotherapy for Burkitt's lymphoma group B and has been living disease-free for more than 5 years.
This case exemplifies the discretion that should be taken when encountering an atypical finding during endoscopy. Although this lesion could have been easily mistaken for a large juvenile polyp, excision of the mass during endoscopy could have led to disastrous consequences, as evidenced by the bleeding complications that occurred during surgical excision. It is important to carefully consider the differential diagnosis when confronted by an anomalous finding.
Submissions for the “Endoscopy Photo Case of the Month” should include high-quality TIF endoscopic images of unusual or informative findings. In addition, one or two other associated photos, such as radiologic or pathologic images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.
The “Image of the Month” feature is made possible by a grant from PENTAX Medical Company.