Apoptotic Colitis: A Rare Variant

Abstract

Introduction: The combination of abdominal pain and bloody diarrhea frequently arouses a suspicion for inflammatory bowel disease. Diagnostic and management dilemmas occur when histological features in colon biopsies show predominant apoptosis instead of inflammation. Case Report: A 34-year-old female with a history of NSAID-induced peptic ulcer disease, recurrent C. difficile infection, and asthma presented with generalized abdominal pain and bloody diarrhea with tenesmus. Family history was significant for a brother with Crohn’s disease (CD). Prior endoscopic history included a colonoscopy in the community about 2 years ago that showed internal hemorrhoids and a recent EGD that showed healed gastric mucosa. Systemic examination revealed a nontoxicappearing female with stable vital signs and mid and lower abdominal tenderness without peritoneal signs. Labs showed iron deficiency anemia and hypoalbuminemia with elevated ESR and CRP. CT scan of the abdomen revealed active colitis with thickened walls of the ascending and transverse colon with pericolonic stranding. Subsequent colonoscopy showed a normal appearing ileum but patchy, atrophic appearing erythematous areas in the entire colon. Biopsies revealed mild chronic inflammatory infiltrate but dramatically increased fibrosis in lamina propria and marked apoptosis consistent with an entity called, apoptotic colitis. She had rapid resolution of her symptoms after she was initiated on steroids, mesalamine, and azathioprine. Inflammatory markers were normalized after a month of induction therapy. Discussion: Apoptotic colitis is a very rare form of indeterminate colitis with scant published literature. Surface colonic apoptosis and deep crypt apoptotic bodies without inflammation are characteristic of apoptotic colopathy and are often seen in the setting of ischemic-type damage, Cytomegalovirus infection, chemotherapy, and use of mycophenolate mofetil. Our patient had no aforementioned risk factors for increased colonic apoptosis. Studies have also shown that apoptotic epithelial cell death is an early event in the development of both ulcerative colitis (UC) and CD. Our patient did not have other histological findings suggestive of UC or CD at the time of diagnosis. However, excellent response to immunosuppressive induction regimen makes indeterminate colitis the likely possibility. No specific treatment criteria has been established but given the good response to immunomodulation, this could form a basis of treatment. Since apoptotic colitis is so rarely seen, no clinical guidelines have been established but clinicians should be aware of such a disease process and its propensity to differentiate into other forms of colitis.