3068 Ischemic Colitis With Unresolved Ileus

Abstract

INTRODUCTION: Ischemic colitis (IC) is the most common form of ischemic injury to the gastrointestinal tract. This can result in inflammation and superficial injury to full thickness necrosis of colon. Most of the non-gangrenous IC resolve spontaneously while gangrenous IC requires operative intervention and is associated with high morbidity and mortality. Almost 90% of the cases of IC are in patients over 60 years of age. Ileus is a common finding in patients with IC and usually self-limiting except in cases where necrosis is present. We present a rare case of unresolved ileus resulting from non-gangrenous ischemic colitis. CASE DESCRIPTION/METHODS: A 90-year-old female with past medical history of Hodgkin's lymphoma in remission for the past five years, presented with nausea, vomiting and non-bloody watery diarrhea for the past four days. She visited the Emergency Department on the first day where she tested positive for E.coli urinary tract infection and was treated with ceftriaxone and nitrofurantoin. Over the last day, she did not have any bowel movements but continued to have right lower quadrant abdominal pain, abdominal distension, and nausea. Her WBC count was 34,000 cells/mm3 and C. difficile testing was negative. CT scan showed distended small bowel loops without transition point and decompressed colon, indicating ileus. She was put on NPO and nasogastric suction and started on broad-spectrum antibiotics. After four days, she continued to have distended abdomen with sluggish bowel sounds. Repeat CT scan of the abdomen showed no changes. She was eventually taken to the OR for exploratory laparotomy. Intraoperative findings showed edematous and thickened right colon with small bowel distension. Subsequent colonoscopy showed significant ischaemic changes in the right colon and the pathology result was consistent with ischaemic colitis with no signs of necrosis. She was started on TPN. Even after our best efforts, her condition continued to deteriorate and she developed sepsis and passed away on the tenth day. DISCUSSION: Ileus in the setting of non-gangrenous ischemic colitis is usually self-limiting. Protracted ileus is observed in cases with necrosis of the colon. Even with no evidence of necrotic disease, our patient's ileus failed to resolve after prolonged medical management. Our patient had multiple indicators of poor prognosis, including old age, isolated right-sided colon involvement, and absence of hematochezia, which could have contributed to her condition.