Endgames Picture Quiz

An abnormality at the hepatic flexure

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7035 (Published 25 October 2012) Cite this as: BMJ 2012;345:e7035
  1. Jawad Naqvi, academic foundation doctor,
  2. Gill Watts, consultant gastroenterologist ,
  3. Velauthan Rudralingham, consultant gastrointestinal radiologist ,
  4. Sarah Duff, consultant colorectal surgeon
  1. 1University Hospital of South Manchester, Manchester M23 9LT, UK
  1. Correspondence to: J Naqvi naqvi.jawad{at}gmail.com

A 92 year old woman presented to the emergency department after collapsing at home. She recalled standing from her chair, feeling lightheaded, and then collapsing. She had felt generally weak for more than a year, with weight loss of 56 lb (25.2 kg) but no change in bowel habit, dysphagia, or gastrointestinal bleeding. Her medical history included hypertension, hypothyroidism, and anaemia (which was currently being investigated by her general practitioner). Among other drugs, she was taking lisinopril, bendroflumethiazide, and levothyroxine. Her son had died at 60 years of age from large bowel obstruction and perforation secondary to colon cancer.

On examination she appeared cachectic with evidence of conjunctival pallor. Her blood pressure was 117/54 mm Hg when lying and 52/31 mm Hg when standing. No masses were palpable on abdominal examination.

Blood tests showed iron deficiency anaemia and hyponatraemia (haemoglobin 75 g/L (normal range 115-165), mean corpuscular volume 78 fL (80-97), iron 2 µmol/L (12-26), total iron binding capacity 42 µmol/L (45-70; 1 µmol/L=5.59 µg/dL), transferrin saturation (ratio of iron to total iron binding capacity) 4.76% (15-50), sodium 130 mmol/L (135-145; 1 mmol/L=1 mEq/L)). Lisinopril and bendroflumethiazide were stopped and the postural hypotension and hyponatraemia resolved. Oesophagogastroduodenoscopy showed no cause for the anaemia. Computed tomography of the abdomen showed an abnormality at the hepatic flexure (fig 1).

Fig 1 Axial computed tomogram of the abdomen


  • 1 What does the scan show and what is the most likely underlying diagnosis?

  • 2 What are the causes of this condition?

  • 3 What are the treatment options for this condition?

  • 4 What screening procedures are available to facilitate early diagnosis of this condition in the general population?


1 What does the scan show and what is the most likely underlying diagnosis?

Short answer

A large bowel stricture with shouldering at the hepatic flexure consistent with colonic carcinoma.

Long answer

The axial abdominal computed tomogram shows a shouldered colonic stricture at …

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