Gastroenterology image challenge: A 49-year-old man was admitted for post-endoscopic retrograde cholangiopancreatography pancreatitis for biliary obstruction. The pancreatitis progressed to necrotizing pancreatitis leading to intra-abdominal sepsis and a perforated bowel. The patient was given broad spectrum antibiotics and underwent a laparoscopy for irrigation, drainage and a diverting loop ileostomy.
Two months later the patient began having bright red blood per rectum along with fresh blood from a retroperitoneal Jackson–Pratt drain but normal appearing liquid stool from the ileostomy. The drain was pulled, and a subsequent colonoscopy revealed a large hole within the descending colon containing necrotic debris (figure A). The lumen of the transverse colon contained necrotic debris and active inflammation in the colon with ulcerated, denuded colonic mucosa (figure B). Figure C reveals necrotic tissue found at the end of the false lumen.
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