Acute Ischemic Colitis and Portal Vein Thrombosis in a Young Female Smoker on an Oral Contraceptive

Abstract

Previous studies have shown an increased risk of arterial and venous thrombosis in the mesenteric vasculature in patients using an oral contraceptive pill (OCPs) that includes estrogen. While a few case series since the 1980s have detailed the severity of intestinal ischemia caused by this phenomenon, this case report highlights the important clinical features of a mesenteric thrombosis. Patient is a 23-year-old female who presented with a 1-day history of multiple syncopal events followed by acute onset abdominal pain and bloody diarrhea. Her PMH was significant for an H pylori infection treated three years prior. On admission, her only medication was an estrogen-including OCP. She reported smoking about one pack-per-day of cigarettes for the past year. Pertinent GI family history included colorectal cancer in a grandfather and two paternal uncles. Her stool studies were negative for an acute infection. CT imaging demonstrated wall thickening along the entire descending colon, nonspecific intrahepatic biliary duct dilation in the right hepatic lobe, and bilateral sacroiliitis. Follow-up MRCP visualized a portal vein thrombus without evidence of collateralization. Diffuse circumferential inflammation from the proximal sigmoid to the distal transverse colon was found on colonoscopy. Random biopsies demonstrated surface degeneration and withering of surface crypts, consistent with brisk acute inflammation. Due to the acute ischemia presumbly from a thrombus, the patient was started on coumadin with a weight-based lovenox bridge. Her abdominal pain improved without recurrence of bloody diarrhea. She was eventually discharged in stable condition. A laboratory workup for an inherited thrombophilia was ultimately negative. The etiology of the patient's “reversible” acute ischemic colitis was attributed to a transient occlusion in the mesenteric vasculature, as suggested by the portal vein thrombosis and the patient's clinical recovery. While the CT result was more consistent with an IMA distribution, the colonoscopy's watershed findings suggested a vascular blockage at the SMA/IMA junction due to the spared sigmoid colon and rectum. The incidence of thromboembolic events in the mesenteric vasculature, which result in reversible ischemic colitis or progression to intestinal infarction, have been documented less as a complication of OCPs due to the decreasing estrogen dose. However, the combination of an estrogen-containing OCP with regular tobacco use caused an acquired hypercoagulable state placing this patient at higher risk for a mesenteric thrombosis. The combination of OCPs and smoking increase the risk for thromboembolism, which can result in transient reversible ischemic colitis if a thrombosis occurs in the mesenteric vasculature.