1538 An Unusual Presentation of Ischemic Colitis

Abstract

INTRODUCTION: We present an unusual physical exam finding in ischemic colitis. CASE DESCRIPTION/METHODS: A 44 year old male with no known medical history presented to emergency department with complaint of abdominal pain and flu-like symptoms for 10 days. He had associated bloating and constipation which was minimally relieved with over the counter laxatives. There was no report of hematochezia or melena. Computed tomography of the abdomen and pelvis was notable for severe contiguous wall thickening and pericolonic fat stranding in the descending colon, sigmoid colon, and rectum. These findings were suspicious for either infectious or inflammatory colitis. There were no abnormalities in the mesenteric vasculature. The patient was discharged on an empiric course of ciprofloxacin and metronidazole, and was seen in the office two days later for follow up. On physical examination, there was an unusual finding of a tender, non-pulsating palpable mass over the left hemi-abdomen without rebound, guarding or rigidity. The patient's antibiotics were discontinued due to low suspicion for an infection. Given the finding of abdominal mass on exam, he was referred for urgent colonoscopy out of concern for colon cancer or lymphoma. On colonoscopic examination, findings were notable for altered vascularity, edema, erythema and linear erosions throughout the rectum, sigmoid colon and descending colon which were consistent with colitis. Biopsies from these sites showed edema and superficial prominence of capillary-sized vessels. The patient was given a diagnosis of colonic ischemia and he was provided with appropriate treatment. One week later on telephonic follow up, the patient reported resolution of his symptoms with plan for repeat computed tomography of the abdomen. DISCUSSION: This patient presented with an unusual finding of a palpable mass to his left hemi-abdomen in the setting of colonic ischemia. Abdominal masses on exam are most frequently due to hernias, neoplasms, infectious collections and hematomas. However, the diagnosis of colonic ischemia generally relies on history, imaging and colonoscopy. The available literature on physical exam is generally non-specific and limited to abdominal tenderness. This patient had the characteristic findings of colonic ischemia including edema, linear erosions and segmental erythema to support a diagnosis of colonic ischemia. It is suspected that his abdominal mass represented the affected colonic segments which makes this a rather unique finding for this disease.