Obstructive uropathy due to a vesical calculus around a foreign body.
Ulcerative colitis and Crohn's disease are the two major forms of idiopathic infiammatory bowel disease. The others, not fitting well into any well-defined clinico-pathological pattern, are labelled as non-specific inflammatory bowel disease. Out of these a new and distinctive entity, "indeterminate colitis" has been emerging of late.,  We had a case of indeterminate colitis under our care recently at the King Edward VII Memorial Hospital, Bombay. The rarity of this condition and the absence of similar reports in the available Indian literature have prompted us to report our experience.
Mrs. B. J., a female aged 80 years, was admitted on 19-9-1979 with the complaints of pain in the right lower quadrant of the abdomen and slight distension for five days prior to admission. There was no past history of any abdominal complaints. The only significant finding was tenderness in the right lower quadrant. Pelvic examination was normal. Temperature, pulse and respiration were nor final; a W.B.C. count showed 16,400 cells/mm3, with 80% polymorphs. X-ray of the abdomen in the standing position did not reveal any abnormality. X-ray chest was normal.
As the diagnosis at this stage was not clear, a decision was made to give supportive therapy and observe. The initial response was satisfactory. However, she took a turn for the worse on the third day, became toxaemic and had a persistent tachychardia; hence a laparotomy was carried out on 22-9-1979 under general anaesthesia.
At operation, the caecum and ascending colon were found to be inflamed, oedematous and congested. The posterior wall of the caecum showed a perforation 5 mm in diameter. There were 30 ml of turbid fluid in the retroperitoneal space adjoining the perforation. The rest of the abdominal viscera were normal and showed no dilatation; a restricted right hemicolectomy was carried out with anastomosis of ileum to the hepatic flexure.
At pathology, the resected specimen consisting of the terminal ileum (6 cms), caecum, appendix and the ascending colon (14 cms) showed, on gross examination, 3 ulcers varying in size from 0.5 cm to 4 cms in the longest diameter. The smallest had perforated. Intervening mucosa was normal. Three lymph nodes were found in the mesentery of the specimen and their cut section showed a greyish white appearance, Totally 7 blocks were studied histologically. They showed diffuse lymphoplasmocytic infiltration at the, base of the ulcers extending transmurally to the deeper part of the muscle coat and focally to the serosa [Fig. 1]. The site of perforation showed thinning of the wall and foci of transmural necrosis. Well defined lymphoid follicle or granuloma formation was absent. Occasional fissures extending into the muscle coat, with a lining of inflammatory cells and focal epthelization were present [Fig. 2]. The intervening mucosa showed a normal goblet cell population. Moderate submucosal fibrosis extending focally to the serosa was seen. Focal acute serositis was present.
The lymph nodes showed chronic nonspecific lymphadenibs. No granulomata were noted in the lymph nodes.
Post-operatively, the toxaemia persisted, and the urine output fell. Administration of frusemide did secure some urine output initially but on the second post-operative day, the patient sank further and became anuric. She expired about 48 hours after the operation. Autopsy was not available.
Indeterminate colitis has been recently delineated as a type of idiopathic inflammatory bowel disease.,  It shares some clinicopathological features of Crohn's disease and ulcerative colitis. In the Indian context, tuberculosis has to be considered. The above conditions were differentiated in the diagnosis of our case.
In the absence of a history of contact with tuberculosis, no previous chest or abdbminal complaints, no demonstrable focus (chest X-ray being normal) and the absence of caseating granulomata in the colon and lymph nodes, tuberculosis could be ruled out.
Transmural inflammation, fissure formation, normal goblet cell population with discontinuous mucosal lesions are against the diagnosis of ulcerative colitis but are suggestive of Crohn's disease. However, in our case, the transmural inflammation was diffuse and without the formation of lymphoid aggregates or granulomas. In Crohn's disease these aggregates are present and sarcoid type granuloma formation is seen in 40-60% of the cases.
Clinically, indeterminate colitis is characterized by a more frequent occurrence in elderly females, presenting as an acute episode with no previous gastrointestinal symptoms. There is a constant feature of abdominal pain and diarrhoea with or without rectal bleeding. These patients, after an initial unsuccessful supportive therapy, require emergency operation as they are more prone to perforation. Radiologically they may show toxic megacolon.
Resected colons show,  colitis with intermittent multiple ulceration separated by normal mucosa; usually the rectum is free of the disease. Histologically there is a pattern of severe ulceration with transmural inflammation. The lymphoid inflammatory cells do not show aggregation. Deep slit like fissures are seen with foci of myocytolysis. Intervening mucosa is only minimally congested with preservation of goblet cells.
The clinicopathological features of this case fit in well with a diagnosis of indeterminate colitis.
Although a definitive diagnosis can be made only by pathological examination of the colectomy specimens, the clinical features mentioned above should arouse the suspicion of indeterminate colitis in the clinician's mind. This is particularly important as cases of indeterminate colitis are more prone to perforation and toxic megacolon with or without radiological evidence of dilatation.
We thank the Dean, Seth G.S. Medical College and K.E.M. Hospital, Bombay, for allowing us to use the case records in reporting this case.