1982, British Journal of Radiology, 55, 868-870
Case reports
CASE REPORT
A 27-year-old male complained of abdominal pain. On
examination his abdomen was "tender and firm". He had an
apparent right inguinal hernia which was too tender to reduce.
A supine chest radiograph was normal. A "semi-upright"
film of the abdomen did not include the diaphragms, and
showed no free gas. A detail from a supine film is shown
(Fig. 1). A diagnosis of strangulated inguinal hernia was made.
On opening the peritoneum, through a groin incision, free gas
and purulent fluid were found; there was no bowel in the
inguinal hernia. A second, midline, incision revealed a
perforated duodenal ulcer which was successfully repaired. The
groin was closed (because of infection no attempt was made to
fix the hernia).
DISCUSSION
In this case no worthwhile horizontal beam film was
taken. The words "semi-erect", written in a dark corner
went unnoticed. No radiologist saw the films
FIG. 1.
Segmental colonic tuberculosis
By R. A. Greatorex, F.R.C.S. and E. Barton, M.B., M.R.C.P.
Departments of Surgery and Radiology, Addenbrooke's Hospital, Cambridge
(Received May 1982)
Tuberculosis of the gastro-intestinal tract is rare in the
non-immigrant British population. Multiple colonic
0007-1285/82/5511-868 $2.00/0 868
preoperatively. Thus, the pneumoperitoneum, which was
sizeable, went unrecognized. As a consequence the
wrong incision was made. This case emphasizes the fact
that there can never be enough radiographic signs of
pneumoperitoneum!
Why and how did the scrotum come to contain free
gas? I imagine that the tense abdominal muscles elevated
intra-abdominal pressure; this in turn forced gas into the
scrotum, which it inflated. In the same manner a balloon,
held between the lips, is inflated by contraction of the
thoracic muscles! In engineering terms the scrotum acted
as a surge tank. The only power available to push the gas
back, from the scrotum into the abdomen, was the
weakly dartos muscle. The contest was an unequal one.
Look carefully at the illustration. In retrospect, there
are two findings which suggest that the scrotal gas is free.
Firstly, the right scrotum is very inflated; the gas even
extends above the superior pubic ramus. Nevertheless,
the gas forms only a single locule. Moreover, this is
obviously thin walled; no abutting bowel walls, valvulae
conniventes or haustral folds are seen.
Secondly, notice how exquisitely the gas defines the
testis. Remember, the hernia was too tender to reduce—
in such irreducible hernias any incarcerated bowel loops
quickly become engorged, thickened and oedematous.
We see no sign of this. Even normal bowel is
insufficiently plastic to drape and delineate the testis so
perfectly.
I believe, using these clues, the gas, in this and similar
cases, can be reliably suspected of being free. These
appearances, then, constitute a bona fide sign of
pneumoperitoneum. If they had been appreciated pre-
operatively this patient would have been saved an
unnecessary groin exploration.
REFERENCES
JEWETT, T. C , KUHN, J. P. & ALLEN, J. E., 1976. Herniography
in children. Journal of Pediatric Surgery, 11, 451.
MILLER, R. E., 1973. The radiologic evaluation of
intraperitoneal gas (pneumoperitoneum). Critical Reviews in
Radiologic Science, 4, 61-84.
SNYDER, W. H., JR. & GREANEY, E. M., J R . , 1962. Inguinal
hernia. In Pediatric Surgery. Ed. by C. D. Benson, W. T.
Mustard, M. M. Ravitch et al. (Year Book Medical
Publishers, Inc., Chicago) p. 573.
lesions are unusual even in countries where intestinal
tuberculosis is common, and may be difficult to
 NOVEMBER 1982

Case reports
distinguish from carcinoma or Crohn's disease on
barium enema examinations. A case of synchronous
segmental colonic tuberculosis in a male Caucasian is
described. The diagnosis was made histologically
following laparotomy and resection.
CASE REPORT
A 71-year-old retired bus driver presented with a two-month
history of right iliac fossa pain after food and increasing
constipation. He had lost 15 kg in weight during the preceding
three months and felt generally unwell. He had never suffered
previous bowel symptoms and had never visited an endemic
tuberculous region.
Clinical examination revealed obvious signs of weight loss,
and a mobile non-tender mass to the right of the umbilicus.
Rectal examination and sigmoidoscopy were normal. There was
no detectable lymphadenopathy. Investigations revealed an iron
deficiency anaemia of 11 g% and an ESR of 47 mm in the first
hour. His white cell count and chest radiograph were normal. A
barium enema demonstrated two lesions: a long ulcerating
stricture deforming the caecum and ascending colon but not
involving the terminal ileum, and a more distal short stricture of
the descending colon with both ulceration and shouldering. It
was concluded that synchronous large bowel adenocarcinomata
were present, although the appearances were atypical and could
represent post-inflammatory strictures. A liver scan was
normal.
At laparotomy the two lesions were found to be solid and
mobile and many fleshy lymph nodes were palpable around the
ileocolic and left colic vessels. The terminal ileum was not
involved and the liver was normal. A subtotal colectomy was
performed and an ileo-sigmoid anastomosis fashioned.
Histology revealed giant cell granulomas with caseation typical
of active tuberculosis, and acid-alcohol fast bacilli were
demonstrated. Attempts to culture the organism were
unsuccessful.
The patient made an uneventful post-operative recovery and
received Ethambutol for two months and Rifampicin and
Pyridoxine for nine months. His bowel function returned to
normal and he regained his lost weight. He remains well and
asymptomatic ten months post-operatively.
glands of the colon, ulceration may occur and can be
seen radiologically as spiculations. Less commonly,
ulcers become confluent and circumferential and a girdle
ulcer with undermined edges can develop; consequent
fibrosis produces a stricture, thereby mimicking an
annular carcinoma. If the mucosa is completely denuded
over a long segment a "pipe stem" appearance develops.
Caseation and fibrosis are most commonly seen in ileo-
caecal tuberculosis where it produces a "coned caecum"
and may give rise to a thickened distorted ileo-caecal
valve—the so-called inverted umbrella, or Fleischner,
sign—or alternatively a widely incompetent ileo-caecal
valve, the so-called Stierlin sign.
The radiological appearances of colonic tuberculosis
are well documented, but may still be difficult to
differentiate from adeno-carcinoma, Crohn's disease,
segmental ulcerative colitis, lympho-sarcoma, colonic
ischaemia, amoebiasis or schistosomiasis (Balthazar &
Bryk, 1980). The appearances on barium enema have
been classified into four groups: 1, hyperplastic (the
most common); 2, ulcerative; 3, mixed hyper-
trophic/ulcerative; 4, carcinoma-like (Balthazar & Bryk,
1980; Kolawole & Lewis, 1975; Lewis & Kolawole,
1972). These four appearances represent the end result of
varying degrees of ulceration, caseation, abscess
formation and attempted healing by fibrosis. In this
patient the proximal lesion was of mixed nature and the
distal lesion was a short ulcerating stricture, leading to
the diagnosis of synchronous malignant strictures.
Involvement of the distal colon in the absence of a
small bowel lesion is rare (Rhoades et al, 1960). In the

DISCUSSION
The origin of gastro-intestinal tuberculosis is
considered to be ingestion of infected sputum from
active pulmonary disease in most cases. Less commonly,
infected milk may be ingested or haematogenous or
lymphatic spread to the bowel may occur. However, as
in this case, chest radiographs reveal no evidence of
tuberculosis in 50 to 70% of cases (Vaidya & Sodhi,
1978; Werbeloff et al, 1973; Davis, 1933). Although the
disease is not uncommon amongst immigrants to this
country (Kaufman & Donovan, 1974), it remains rare in
the indigenous population. The clinical manifestations of
colonic tuberculosis are entirely non-specific. Weight
loss, malaise, and abdominal pain are seen in 90% of
cases, and a change in bowel habit with a palpable
abdominal mass in 40% (Kolawole & Lewis, 1975).
Anaemia, leucocytosis and a raised ESR frequently
occur but are not constant findings (Werbeloff et al, FIG. 1.
1973). Barium enema showing a long stricture of the caecum and
Following the entry of mycobacteria into the tubular ascending colon and a shorter stricture of the descending colon.

869
 1982, British Journal of Radiology, 55, 870-873
Case reports
English literature approximately 100 cases of segmental
tuberculosis of the colon, distal to the caecum, have been
reported and only 15 synchronous colonic lesions are
documented (Balthazar & Bryk, 1980; Vaidya & Sodhi,
1978; Kolawole & Lewis, 1975; Werbeloff et al, 1973).
In contrast, the incidence of synchronous adeno-
carcinoma of the colon is reported to be 2.26% in the
larger series of large bowel tumours (Lasser, 1978).
CONCLUSION
The clinical and radiological features of large bowel
tuberculosis may be identical to those of carcinoma or
post-inflammatory strictures, and indeed carcinoma and
tuberculosis may co-exist in the colon (Abrams &
Holden, 1964). The limitations of barium studies in such
cases should be recognised. When isolated colonic
lesions are demonstrated in patients who are "not at
risk", the majority will ultimately require laparotomy to
establish a histological diagnosis (Werbeloff et al, 1973).
ACKNOWLEDGMENT
We would like to convey our thanks to Mr. W. G. Everett for
his permission to report this case.
Haemangiopericytoma of the larynx
By *Y. Hertzanu, M.D., *D. B. Mendelsohn, M.D., tG. Kassner, M.D. and t M . Hockman, M.D.
Departments of 'Diagnostic Radiology and tOtolaryngology, Johannesburg Hospital and University of the
Witwatersrand, Jubilee Road, Parktown 2193, Republic of South Africa
{Received May 1982)
Haemangiopericytoma was first described in 1942 by
Stout and Murray as a vascular tumour derived from
Zimmermann's pericytes. Ultrastructural study supports
the concept of a pericyte origin (Battifora, 1973;
Nunnery et al, 1981).
Haemangiopericytomas may arise in any part of the
body with subcutaneous and muscular tissue predomina-
ting, but the larynx is an exceptionally rare location. The
CT scan, angiographic examination and pre-operative
embolisation in this situation have not previously been
reported.
CASE REPORT
A 34-year-old man was admitted with a six-month history of
hoarseness getting progressively worse. Dyspnoea was present
only two weeks prior to admission. There was no associated
pain.
Physical examination with special reference to the neck
revealed no abnormality. Indirect laryngoscopy showed a large
supraglottic cyst-like mass, vascular in appearance, which
produced significant stridor. Direct laryngoscopy confirmed
these findings.
Address for reprints: Dr. Y. Hertzanu, Department of
Radiology, Johannesburg Hospital, Private Bag X39,
Johannesburg, 2000, Republic of South Africa.
0002 1285 82 5511 870 S2.00 0
870
REFERENCES
ABRAMS, J. S. & HOLDEN, W. D., 1964. Tuberculosis of the
gastro-intestinal tract. Archives of Surgery, 89, 282-293.
BALTHAZAR, E. J. & BRYK, D., 1980. Segmental tuberculosis of
the distal colon. Radiographic features in seven cases. Gastro-
intestinal Radiology, 5, 75-80.
DAVIS, A. A., 1933. Hypertrophic intestinal tuberculosis.
Surgery, Gynecology & Obstetrics, 56, 907-913.
KAUFMAN, H. D. & DONOVAN, I., 1974. Tuberculous disease of
the abdomen. Journal of the Royal College of Surgeons of
Edinburgh, 19, 377-380.
KOLAWOLE, T. M. & LEWIS, E. A., 1975. A radiological study of
tuberculosis of the abdomen (gastro-intestinal tract).
American Journal of Roentgenology, 123, 348-358.
LASSER, A., 1978. Synchronous primary adenocarcinomas of the
colon and rectum. Diseases of the Colon and Rectum, Jan.
Feb. 1978, pp. 20-22.
LEWIS, E. A. & KOLAWOLE, T. M., 1972. Tuberculous ileocolitis
in Ibadan. Gut, 13, 646-653.
RHOADES, E. R., KLEIN, L. J. & WELSH, J. D., 1960. A case of
probable tuberculosis of the distal colon. Gastro-Enterology,
38, 654-658.
VAIDYA, M. G. & SODHI, J. S., 1978. Gastro-intestinal tract
tuberculosis. A study of 102 cases including 55 hemi-
colectomies. Clinical Radiology, 29, 189-195.
WERBELOFF, L., NOVIS, B. H., BANK, S. & MARKS, I. N., 1973.
The radiology of tuberculosis of the gastro-intestinal tract.
British Journal of Radiology, 46, 329-336.
Radiological findings
The plain lateral radiograph of the neck revealed a large well-
defined supraglottic soft tissue mass extending up to the hyoid
bone. No calcification or bony destruction was noted (Fig. 1).
The CT scans before and after contrast medium, showed the
presence of a large enhancing vascular mass (Fig. 2A, B). A pre-
operative angiogram demonstrated the hypervascular mass
supplied predominantly by the superior thyroid artery (Fig. 3A).
A persistent tumour blush without early venous filling was
noted. A Gianturco 5 mm wool coil standard type manu-
factured by the Cook Co. was introduced into the superior
thyroid artery. A control picture after 10 minutes showed
arterial occlusion (Fig. 3B).
The following day, under general anaesthesia, the mass was
exposed via a Sorensen neck incision. The tumour was found to
be situated submucosally in the thyrohyoid interval close to the
superior laryngeal nerve. The feeding vessel came off the left
superior thyroid artery. The spring was felt in the thrombosed
proximal portion of this vessel.
The tumour was dissected out, leaving an intact pharyngeal
mucosa. The intra-operative blood loss was minimal compared
with that usually expected from vascular neck masses.
The histopathological report revealed on macroscopic
examination a firm, solid, nodular, well-encapsulated mass
measuring 4 x 4 x 3 cm. Microscopic examination showed a
vascular lesion composed of groups of cells with eosinophilic
cytoplasm and regular vesicular nuclei. Special stains revealed a