A 47-year-old man known to have hypothyroidism and hypertension on treatment presented to the gastroenterology clinic complaining of two-year history of abdominal distension that was worse after oral intake especially milk. He had normal bowel motions and denied nausea and vomiting. There was no previous abdominal surgery. On examination, the abdomen was distended with no tenderness. Colonoscopy was done and showed normal rectum, grossly dilated sigmoid with redundant colonic wall, and mild mucosal inflammation. Abdomen computerized tomography showed distended sigmoid colon with collapsed rectum and no obstruction ().\nAs his symptoms were severe and he already failed conservative management, the patient was referred to general surgery. He underwent laparotomy () and extended hemicolectomy of the affected segment, with colorectal anastomosis. He did well intra- and postoperatively. The pathology unexpectedly showed chronic schistosomiasis in the colonic wall (Figures and ). Upon further evaluation, we found that he lived in the north of Saudi Arabia (Hail) but denied exposure to unclean water or recent travel. His Schistosoma serology titer was high (1 : 1024). Other laboratory findings included slightly elevated direct and total bilirubin (12.3 and 41.5 μmol/L, respectively), normal aminotransferases, erythrocyte sedimentation rate = 11 mm/hour, and C-reactive protein < 3.50 mg/L. He was referred to the infectious disease clinic and was treated with praziquantel. At six-month follow-up, the patient was doing well with resolution of his abdominal symptoms.
A 67-year-old woman from the Philippines with a medical history of psoriatic arthritis, hypertension, osteoporosis, and resected left-sided invasive ductal carcinoma of the breast presented with complaints of chronic lower abdominal discomfort associated with constipation alternating with diarrhea for a year, along with decreased appetite and 20 lbs. weight loss. She denied fever, bright red blood per rectum, or melena. She migrated to the United States from the Philippines in 1998. She never had a colonoscopy in the past. Her family history was negative for cancer. Vital signs and physical examination were unremarkable. Laboratory tests were noncontributory other than normocytic anemia with hemoglobin of 11.6 g per deciliter, no eosinophilia.\nSubsequent colonoscopy revealed a malignant appearing obstructing mass in the distal sigmoid, around 20 cm from the entry site (Figure ). Biopsies from the mass revealed fragments of adenocarcinoma. Pelvic computed tomography (CT) revealed bladder wall thickening (Figure ). Thoracic and abdominal CT revealed no distant metastasis. She underwent successful anterior pelvic exenteration, sigmoid resection with primary anastomosis, and ileal conduit creation for sigmoid cancer invading the bladder. Surgical pathology showed invasive, moderately differentiated adenocarcinoma in the sigmoid colon and numerous Schistosoma eggs in the colon, ovaries, posterior cul de sac, and pelvic wall (Figure ). Along with surgical treatment, the patient was treated with praziquantel (60 mg/kg/d in 2 divided doses). Stool microscopic examination after 4 weeks of treatment was negative for ova and parasites.