P2509 - Volvulus With a Twist: A Case of Domestic Body Retrieval

Nicholas N. Totah, MD¹, Daniel Mai, MD², Nicholas Garcia, MD¹, Suhail Sidhu, MD², Frances Dang, MD, MSc³, Shannon S. Zhang, MD, MS¹, Peter H. Nguyen, MD¹, Vishal Chandan, MD³, Saman Karimi, MD², Jason Samarasena, MD, MBA, FACG²
1University of California Irvine Health, Orange, CA; 2University of California Irvine, Orange, CA; 3University of California Irvine, Irvine, CA

Introduction: Colonoscopy is a widely used diagnostic and therapeutic procedure in the management of malignant obstructions and volvulus. This report presents a rare case of suspected chemotherapy-induced enteritis and unexpected retrieval of two large ischemic tissue fragments during colonic decompression for volvulus. These findings suggest the potential for spontaneous bowel sloughing secondary to chemotherapy-induced enteritis. 

Case Description/

Methods: A 53-year-old male with stage 4 splenic flexure adenocarcinoma status post diversion with transverse colostomy followed by splenic flexure colectomy and transverse-descending anastomosis on FOLFIRI, bevacizumab, and floxuridine, presented with subacute abdominal pain. Initial imaging suggested partial small bowel obstruction. His symptoms persisted, and serial labs and imaging showed acute, progressively worsening enteritis of the mid to distal small bowel and persistent neutropenia. His oncologist reported recurrent episodes of enterocolitis following nearly every chemotherapy cycle. Repeat imaging revealed persistent severe enteritis and volvulus, and endoscopic detorsion was performed with symptomatic relief. Subsequently, the patient developed acutely worsening abdominal pain with imaging findings showing a conspicuous transition point near the anastomosis concerning for recurrent volvulus. Emergent colonoscopy revealed narrowing with twisting at the anastomosis. Two large ischemic tissue fragments (22.2cm and 19.8cm) non-adherent to the mucosa were identified near the anastomosis and successfully removed with Roth Net (Figure 1). Pathology showed gross findings of focally disrupted, elongated, possible bowel segments, with each fragment displaying open ends. Microscopic findings reported fibrinoinflammatory cast-appearing exudate (Figure 2).  

Discussion: This case presents a unique discovery of domestic tissue, likely representing sloughed segments of devitalized bowel. The patient’s recurrent episodes of neutropenic enteritis post chemotherapy ultimately led to segmental bowel sloughing. The gross and microscopic findings of cast-like luminal tissue support this hypothesis of bowel extrusion. The tissue may have served as a nidus for volvulus by reducing the intraluminal area and promoting twisting. This case underscores the importance of considering chemotherapy-induced enteritis as a cause of spontaneous bowel sloughing and its potential for obstructive pathology, including volvulus. 


Figure: Figure 1. Tissue material through the anastomosis in the descending colon (1a), retroflexion view of the anastomosis with tissue material visualized (1b), first tissue material in Roth Net (1c), gross view of the first tissue material (1d). Second tissue material being retrieved (1e), gross view of the second tissue material (1f).


Figure: Figure 2. Histology demonstrating fibrinoinflammatory exudate with no viable tissue at 4x magnification (2a) and 20x magnification (2b).

Disclosures:
Nicholas Totah indicated no relevant financial relationships.
Daniel Mai indicated no relevant financial relationships.
Nicholas Garcia indicated no relevant financial relationships.
Suhail Sidhu indicated no relevant financial relationships.
Frances Dang: Cook Medical – Speaker.
Shannon Zhang indicated no relevant financial relationships.
Peter Nguyen indicated no relevant financial relationships.
Vishal Chandan indicated no relevant financial relationships.
Saman Karimi indicated no relevant financial relationships.
Jason Samarasena: Applied Medical – Consultant. Boston Scientific – Consultant. Cook Medical – Consultant. Neptune Medical – Consultant. Olympus – Consultant.

Nicholas N. Totah, MD¹, Daniel Mai, MD², Nicholas Garcia, MD¹, Suhail Sidhu, MD², Frances Dang, MD, MSc³, Shannon S. Zhang, MD, MS¹, Peter H. Nguyen, MD¹, Vishal Chandan, MD³, Saman Karimi, MD², Jason Samarasena, MD, MBA, FACG². P2509 - Volvulus With a Twist: A Case of Domestic Body Retrieval, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.