A super ‘lead pipe’ colon: radio-pathological correlation of long-standing ulcerative colitis

A 59-year-old woman presented with a pink watery anal discharge. She had undergone a diverting end-ileostomy for ulcerative colitis 20 years previously. It is not clear why a colectomy was not done; possibly she had been too ill for extensive surgery, and thereafter was content with the outcome. She also had progressive pyoderma gangrenosum around the skin of the stoma. The ileostomy was functioning normally, and she had not been on steroids. She had a normal C-reactive protein, and no leukocytosis. Stool culture showed normal flora. At endoscopy, a small inflamed rectum with minute calibre of the more proximal bowel was seen, too narrow to proceed further. The plain film showed no thumbprinting or mural gas. A water-soluble enema (Fig. 1) demonstrated a complete colon of minute calibre – a real ‘lead pipe’ colon! Total proctocolectomy was performed; an ileo-anal pouch anastomosis was not recommended in view of the patient’s age and possible further complications. Postoperative recovery was uneventful. Histological examination revealed a florid acute(!) ulcerative colitis. The bowel was narrowed, with areas of stricture formation and marked bowel wall thickening (Fig. 2). Extensive mucosal ulceration with underlying inflamed granulation tissue was noted. The remainder of the non-ulcerated mucosa showed acute-on-chronic inflammatory cell infiltration with crypt-abscess formation, distorted glandular architecture, regenerative changes and gland loss (Fig. 3). No dysplasia or malignancy was seen. There was marked submucosal fat infiltration (Fig. 3). A super ‘lead pipe’ colon: radio-pathological correlation of long-standing ulcerative colitis