414

SIMPLE ULCERS OF THE COLONBy G. T. WATTS, F.R.C.S.

Senior Surgical Registrar, General Hospital, Birmingham

Although not frequently encountered, simpleulcer of the colon has been recognized as aclinical entity since the description of a case byCreuveilhier in his atlas of anatomy and pathology,published in I835. It was not until 1895, how-ever, that a case was recorded with microscopicconfirmation by Morel and Scheyron. The firstwide review of the condition was by Quenu andDuval in 1902.Clinical PictureThe clinical picture is unfortunately not a

characteristic one, and diagnosis is made as arule only when complications have appeared. Wewere in fact not able to find any case in theliterature where a diagnosis had been made beforeoperation or post-mortem. We feel, however,that if the cdhdition is borne in mind, it will bediagnosed and treated much more often. It seemsto us that the condition is probably more commonthan is at present realized, many cases beingdiagnosed wrongly as other inflammatory lesionsor healing spontaneously. It is interesting to notethat all the early cases recorded were found atpost-mortem and that most of the recent caseswere at first regarded as appendicitis, diverti-culitis or carcinoma.Age and sex do not appear to be significant,

cases having been recorded in every decade fromthe 'teens onwards, and with about equal sex dis-tribution. There are no general signs untilcomplications develop, when pyrexia, raised pulseand malaise may appear. Most cases suffer fromchronic constipation. Many of the early casesdescribed were, in fact, only stercoral ulcers dueto this. Diarrhoea, however, may be seen, butthis is probably a secondary manifestation. Insome cases in thin patients, the ulcer can actuallybe palpated and it is in these cases that an accuratediagnosis is most likely (cases i and 3 below).Macroscopic bleeding occurs very rarely, buttests for ' occult blood' are much more likely tobe of value.·

In the majority of cases, patients will presentthemselves only when complications develop. Of

these, the most frequent by far is an inflammatoryspread due to perforation or incipient perforation.As the commonest site is in the caecum, mostcases are diagnosed as appendicitis. Most casesin the ascending and proximal transverse colon arediagnosed similarly. Cases occurring in the restof the colon are usually treated as diverticulitis.Of the recorded cases, about three-quarters of

the proven ones occur in the caecum, most oftenopposite to the ileocaecal valve. The others arescattered along the rest of the colon with a slightincrease at the splenic flexure.

PathologyThe ulcer itself is very similar to a peptic ulcer

as seen in the stomach or duodenum; this hascaused much speculative and not very logicalthinking which has likened the two more than isreasonable. The size varies greatly; from a pin-hole to an inch or more in diameter. The mucousmembrane around is quite healthy, but ispulled into form radiating folds. The actual edge is clear-cut, the depth varying. The floor is usuallycovered in necrotic tissue or granulations if healingis occurring. The base is not indurated like amalignant ulcer, but is more oedematous due tothe inflammatory process. There may be ecchy-moses in the floor. The shape is regular; roundor oval. Not uncommonly, there are several ulcerspresent. Pigmentation has been described. Itprobably does not occur in the true simple ulcer,but only in stercoral ulcers.The course varies greatly. At the one extreme,

healing occurs, at the other a rapid perforationdevelops. The latter may be followed by a generalperitonitis in the cases where the ulcer is on theperitoneal aspect of the bowel. A local inflam-matory mass is common, or an abscess may de-velop. The latter may be intra- or retro-peritonealand resemble an appendix abscess. Wider spreadof the infective process may, on occasions, lead tosub-phrenic and liver abscesses, empyema ordistant adenitis or abscess. Haemorrhage is arare event on a large scale although reported byWilkie. So also is stenosis due to scarring. Malig-

copyright. on A

pril 25, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.358.414 on 1 A

ugust 1955. Dow

nloaded from

August 1955 WATTS: Simple Ulcers of the Colon 415

*·rii. ·L.'iii*' ·i:

.i ·:·'.iiiaPPLp. ': ':"

f

c' r.i ;.c:.L.:.:'i'";;

,.i··:·;·'.

"'1.Yii: :"

:I,::l.t.iar.L- -ii.ls2er.:is:::

:" .wa%.: d. ,ii;.. .." ·.

:iii!iii..il:sani".s. ·::i·:::· c

·''i.it: ..

FIG. i.-View of a simple ulcer of the colon frommucosal aspect-Case 3.

nant change must be regarded as a theoreticalpossibility only.The histological picture is much more constant

than the clinical one. The mucosa shows only asimple breach with healthy mucous membraneadjacent to it. It is in the sub-mucous layer how-ever, that the most characteristic changes occur.There is an infiltration of this layer outside thearea of the ulcer, with cells of all types; poly-morphs, lymphocytes or plasma cells are seen invarying proportions depending on the acutenessof the ulcer. In the deeper layers, a less severe andmore localized inflammatory infiltration is seen.There is also usually some thrombosis in vessels,sometimes with peri-vascular fibrosis. When per-foration occurs, it is clearcut through all thelayers. In the stage just before it actually takesplace, the muscle layers show a region of necrotictissue infiltrated with polymorphs; on the surfaceof the bowel there is a layer of fibrin. Thesefeatures are all seen in the photo-micrographs andwere described by Morel and Rispail. The sub-mucous infiltration is very similar to that seen inthe rather rare condition of acute suppurativenecrotic colitis. A less-severe lesion of similar

ly^s^*, ^4f43fl̂^"r~lF*t^4i414^ t ' *

FIG. 2.-Ulcer with granulation tissue projecting fromits base-Case 2.

type is the chronic inflammatory process withacute exacerbations which is produced in thecaecum by chronic faecal accumulation.

AetiologyThe cause of this condition is still not known,

the theories being almost as numerous as the re-ported cases. Constipation is the only frequentcommon symptom and is often indicted. Nextis sepsis, and the Streptococcus, Staphylococcus,B. Coli, B. Proteus and others have all beenblamed in turn, despite the fact that they are all'normal' bowel inhabitants. Blood-borne sepsishas also been suggested. The macroscopic re-semblance to a peptic ulcer has caused them to becompared; many of the cases lie opposite the ileo-caecal valve (as a duodenal ulcer often is oppositethe pylorus) and the caecal mucosa is more ad-herent than that of the rest of the colon (as that ofthe gastric lesser curve). The survival of gastricacid is not likely (even if it is possible to produceulcers and a change of pH in rats with a deficientdiet!). Gastric mucosa has never been found inthese ulcers. A vascular cause might be possibleas there are sometimes changes in the vessels, butthis would make healing rarer than it is even aftersurgery. Other theories have cited foreign bodies,

copyright. on A

pril 25, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.358.414 on 1 A

ugust 1955. Dow

nloaded from

416 POSTGRADUATE MEDICAL JOURNAL August 1955

r. 4, r* rC

,,':".·. ,_:,r*a ~'-.: j,,'~~.~ '~.v..

i'~~:'tr'rQ'-.~~.,........E'i :~.J ~::.:,.~ l. :~,.. :i:4i.!:

,'....*.,*. ,,:

..,...:.~~· :.~ :,' ....

.."

.,~%·':*i'"·'i~::~..·tn.::::.'.i;'. :-::'". ii"r cs~,,/ ':".:'..~~:, .':a...~· .-:~,'~~.........~~~~~·...".::.%:% ~·.._(.:;(.<·-. - :~·

--~.-.-~:.

FIG. 3.-Chronic inflammatory change in the mucosa with oedema and infiltra-tion in the sub-mucous layer-Case 2.

·1:i···a:·: .

·ii

ii:,i·ii.·'.;ptkY%.i.:1 _-P-.BAIB.iL.·l.e.a.gZ..F

."·":::il:···

*:··. r·*., ·P

Lfic'

3..;..?pv.CltlL.e..

irJ.a.lYPjblG...*jCI(.i;·: .'9.9.E.a6L.1..:·

·i.

:::. r··:'**iS; .

.·ALP. *

*·

iiiii,:.·:':· i.a..ri..iF;3.irt.T.a.liii -·.ii···

iii

..i.i:· i·

FIG. 4.-Peritoneal inflammation with fibrin deposit-Case 4.

u.c"1;-- -.i

·.:d

.. .

;,. xi·.*., it

" .;;a, · .:·E.

t ·. *.:i·..jt· :&;

rI *$* .*.

- i"-%"f~+'· :·$:r*r, ·i.·.

*i .i·.i *.E'Q. ;.1".1·. .·-r·· v p·.·r ·:7.·:.I·. i

:· ·,·;.*,,2.dI II i

*":.se s-L·.;-- ·*

"r

i.: iu.ll. r·"'····'''"'*-'· .·f

·· .sr

.;·B i ·S'i*:-·'l*' '

''· ·.;i:r'I..i.i.rl " . . . .r· .bf i'''·.

"'-··

,.· c" '^.^·;.4: ."cgy·liZYYi.·BFI1.II:'i cri...·:.*

- -- ··.:5·:·':·..Q.:.".s 5-·r*I;'. g

i - . ·* .SiC

FIG. 5.-Granulation tissue at the edge of the ulcerwhich has penetrated all coats-Case 3.

copyright. on A

pril 25, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.358.414 on 1 A

ugust 1955. Dow

nloaded from

WATTS: Simple Ulcers of the Colon

gout, alcohol, disease of the lymphoid tissue,toxaemia from poisons, pathogens or focal sepsis,trauma and lesions of the central nervous system.In connection with the last, several workers pro-duced lesions in rats by injury to the spinal cord(among them Brown Sequard), but no case hasever been recorded in a human with a paraplegia.When all these theories are considered, it seemsmost likely that the simplest is right and that theprocess is a local inflammatory and septic one dueto a temporary loss of local resistance of the tissues,a local increase of virulence, or both. The re-markable thing is that it does not occur much moreoften.

Case ReportsCase i. Male, aged 28 (Negro). For three

days before admission, patient had central ab-dominal pain aggravated by movement. Aftertwo days the pain moved to the right iliac fossa.The appetite was poor but there had been novomiting. Constipated for two days (enema onday prior to admission). Appendicectomy fiveyears before.On examination the patient was generally fit.

temperature 99.8, pulse 88. There was a mobiletender mass 2 in. in diameter beneath the appendi-cectomy scar.

Laparotomy showed an ulcer on the posteriorwall of the caecum at the level of the ileo-caecalvalve. Palpated through the bowel wall, it re-sembled a peptic ulcer. The caecum was re-attached and the wound closed.The patient has been observed for four years.

The mass disappeared in four weeks and has notreappeared. All other investigations have beennegative.

Case 2. Female, aged 43. For fourteen days,patient suffered from diarrhoea with anorexia andnausea. On the day before admission she de-veloped severe continuous pain in the right iliacfossa.On examination, the patient was generally fit,

with normal temperature and pulse. There wastenderness in the right hypochondrium above thesite of the pain.

Laparotomy showed an abscess 2 in. in diameterin the great omentum 5 in. distal to the hepaticflexure. This arose from an ulcer e in. in dia-meter on the anti-mesenteric border of the bowel.The ulcer closely resembled a peptic ulcer.Histologically, there were the signs describedabove, together with erosion of several smallmuscular arteries. The patient made an un-eventful recovery after a right hemi-colectomywith end-to-end anastomosis.

Case 3. Male, aged 45. The patient, a highlynervous individual, had suffered from headaches

for fourteen days and had vomited five timesduring this period. He had otherwise been well.On the day before admission a 'gnawing' painappeared in the right iliac fossa..On examination, he was generally well with

normal temperature and pulse. A mobile, tendermass, about the size of a walnut could be feltbeneath McIurney's Point.

Laparotomy showed an ulcer i in. in diameteron the posterior caecal wall level with the ileo-caecal valve. Macroscopically it resembled apeptic ulcer (see illustration). Histology showeda typical simple ulcer as described above. Thepatient made an uneventful recovery after righthemi-colectomy with end-to-end anastomosis.

Case 4. Female, aged 49. For two days thepatient had steady, generalised abdominal painwith anorexia, but no vomiting. On the daybefore admission, the pain became more severeand moved to the right iliac fossa.On examination, the patient was ill, temperature

I00.2, pulse i io. Tenderness, rigidity and guard-ing were present in the right iliac fossa.Laparotomy showed a retro-peritoneal in-

flammatory mass in the ileo-caecal angle, due to aperforating ulcer i in. in diameter just above theileo-caecal valve. Macroscopically the ulcer re-sembled a penetrating peptic ulcer. Histologyshowed a typical simple ulcer with sub-mucosalinfiltration and a perforation X in. across at thecentre. The patient made an uneventful recoveryafter a hemi-colectomy with end-to-end anas-tomosis.We have been told of two other cases when dis-

cussing the above at a clinical meeting, but haverefrained from including them as details were notcomplete. In one a perforated ulcer on theanterior wall of the ascending colon of a middle-aged male was treated successfully by simpleclosure. In the other, an ulcer diagnosed as acarcinoma of the caecum in an elderly woman,perforated while she was awaiting admission andshe died. Post-mortem showed a hole in theanterior wall of the caecum.

Differential DiagnosisDifferential diagnosis must always be very

difficult in this condition. Most cases will in-evitably be discovered at operation. Even thenit is unlikely that in many, the diagnosis can becertain. It has been suggested that the bowel beopened in doubtful cases; the healthy state of themucosa around the ulcer being the criterion of asimple ulcer. More often, however, the compli-cations will overshadow the ulcer itself and maskits appearance. The most important disease to bedifferentiated is carcinoma of the colon. A simpleulcer can resemble the ulcerative and stenosing

August -1955 4I7

copyright. on A

pril 25, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.358.414 on 1 A

ugust 1955. Dow

nloaded from

4I8 POSTGRADUATE MEDICAL JOURNAL August 1955

forms and when leakage occurs the differentiationis doubly difficult. A peritonitis from appendi-citis, ulcerative colitis or diverticulitis will alsoresemble the condition. Stercoral ulcer shouldnot be confused. Amoebic ulcers will be detectedby discovery of the organisms in the stools.Tuberculous and syphilitic ulcers will, as a rule, beaccompanied by signs of the disease elsewhere.In Creuveilhier's atlas, ulcers were described inboth caecum and rectum. It seems likely, how-ever, that these cases were stercoral and syphiliticulcers respectively. Thus, as not often happens,he established the identity of a disease withoutactually seeing a case.

TreatmentOpinions on the best treatment vary. It will

obviously be affected by whether complicationshave developed as then they will take prior place.Subject to this, however, it is best to aim at com-plete extirpation. As the condition can rarely bedifferentiated from carcinoma with completecertainty, it is advisable to resect as though thiswere actually present. Less often, local excisionis safe. Perforations heal quite well with simpleclosure. In retrospect, we do not feel that our

treatment of Case i was ideal, as, although eventsshowed a satisfactory outcome, the risks we weretaking were probably greater than that of resection.

LiteratureThe literature on this condition has not, on the

whole, proved very rewarding. Cameron gives along and almost complete list. Like him, wefound most of the case reports very incompleteand unreliable. Many were not made first-handand a check of the original reports showed that thecase was one of ulcerative colitis, perforation,obstruction, or other lesion. Papers from thenineteenth century are especially poor, but anexcellent review was made in I902 by Quenu andDuval and should be read before consulting theearlier papers. A number of cases have beendescribed by Moore since Cameron's paper waspublished.

BIBLIOGRAPHYCAMERON, J. R. (I939), Brit. Surg., 26, 526.CREUVEILHIER, J. (1835-1842), 'Atlas d'Anatomie et Pathologie,

ii, Livarsion xxx, I; Livraison xxxiii, 4.MOORE (I940), Brit. J. Surg., 27, 600.MOREL and RISPAIL (1896), Soc. de Med de Toulouse.MOREL and SCHEYRON (1895), Soc. de Med. de Toulouse.QUENU, E., and DUVAL, P. (1902), Rev. de Chir., 26, 692.

BACK NUMBERS OF THIS JOURNALIf any subscribers have copies, in good condition, ofMARCH and APRIL 1952, the

Fellowship of Postgraduate Medicine, 60 Portland Place, London, W.I, will be gladto purchase them.

Bibliography continuedfrom page 396--. C. HoustonHAHN, P. F., BALE, W. F., ROSS, J. F., BALFOUR, W. M.,

and WHIPPLE, G. H., J. Exp. Med., 78, 169.HOUSTON, J. C. (I953), Lancet, i, 766.HOUSTON, J. C., and NIGHTINGALE, A. (1953), unpublished

data.HOUSTON, J. C., and THOMPSON, R. H. S. (1952), Quart.

Y. Med., 21, 215.

HOUSTON, J. C., and ZILKHA, K. J. (i955), Guis Hosp. Rep.(in the press).

HYNES, M. (1949), J. cdin. Path., 2. 99.McCANCE, R. A., andWIDDOWSON, E. M. (1937), Lancet, ii, 680,NISSIM, J. A. (I947), Ibid., 2, 49.RAMSAY, W. N. M. (I953), Biochem. J., 53, 227.

RUTHIN CASTLE, NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, technicians and nurses.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is, less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Cutle, Ruthin. Telephone: Ruthin 66

copyright. on A

pril 25, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.358.414 on 1 A

ugust 1955. Dow

nloaded from