S3856 Volvulus With a Twist: A Case of Domestic Body Retrieval

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 2 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 man 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 (22.2 cm and 19.8 cm) non-adherent to the mucosa were identified near the anastomosis and successfully removed with Roth Net. Pathology showed gross findings of focally disrupted, elongated, possible bowel segments, with each fragment displaying open ends. Microscopic findings reported fibrinoinflammatory cast-appearing exudate. 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.