1665 A Baffling Case of Gastrocolitis

Abstract

INTRODUCTION: Chronic mesenteric ischemia often has a subtle presentation requiring a high index of suspicion. Average time to diagnosis is 10.7 months, often delayed due to the vague nature of complaints. We present a challenging case of severe chronic mesenteric ischemia in a young woman. CASE DESCRIPTION/METHODS: A 42-year-old female smoker presented with abdominal pain, constipation, and >70-lb weight loss. She had developed black, watery stools one week prior. Vital signs were normal, BMI was 12.6. She was cachectic, had abdominal distention and tenderness worse in the right lower quadrant. A contrasted CT scan revealed a distended colon and large stool burden. She failed conservative management. Endoscopy revealed multiple Forrest III gastric ulcers (Figure 1) and deep cecal ulcerations (Figure 2) with normal TI. Biopsies showed inflammation with granulation tissue. Work up was negative for vasculitis and infection. She failed a steroid trial for a presumptive diagnosis of Crohn’s disease. CT enterography was normal. Repeat endoscopy showed persistent gastric ulcers. Biopsies revealed ischemic gastritis with associated ulceration and submucosal blood vessels with fibrin thrombi. A CT angiogram showed severe stenosis of the celiac artery and chronic occlusion of the superior mesenteric artery (Figure 3.) Endovascular celiac and SMA stenting failed requiring surgically-placed retrograde celiac and SMA stents. Her symptoms recurred due to celiac stent thrombosis and SMA stent migration to the left iliac artery. Finally, an antegrade supraceliac to celiac and SMA bypass was performed with excellent results. DISCUSSION: A high index of suspicion is required to diagnose chronic mesenteric ischemia. Risk factors include age > 60, female gender, history of PAD, CVD, or CAD. Typical symptoms include weight loss, postprandial pain, and diarrhea though most people are asymptomatic or present with atypical symptoms including nausea, vomiting, early satiety, or bleeding which often lead to misdiagnosis or delayed diagnosis. Management is aimed at preventing further bowel infarction via endovascular or open revascularization. Patients who fail stenting or angioplasty have a much higher risk of perioperative mortality during open repair (15% vs. 2%.) Our patient’s young age, normal initial CT abdomen, gastric and cecal ulcerations with lack of vascular disease history blurred the clinical picture. A high index of suspicion is required in patients with an initial negative work up.