Enterocolic lymphocytic phlebitis and lymphocytic colitis: drug-related coexistent pathology

Abstract

Dear Editor: Enterocolic lymphocytic phlebitis (ELP), a term coined in 1989, is an entity of unknown etiology and pathogenesis. This term is synonymous with mesenteric veno-occlusive disease, granulomatous phlebitis, necrotizing phlebitis, and myointimal hyperplasia. It is a spectrum of disease with lymphocytic phlebitis at one end of the spectrum, and thrombosis and myointimal hyperplasia at the other. ELP is a rare type of venulitis involving only the submucosal, subserosal, and mesenteric veins and venules of bowel wall. The arteries and arterioles, as well as the systemic circulation, are typically spared. Whilst a definitive cause has not been isolated, specific drugs have been associated with ELP. The entity of lymphocytic colitis (LC) was first described as “microscopic colitis” in 1980. An infiltrate of T lymphocytes within the epithelium in excess of 20 lymphocytes per 100 epithelial cells, features of epithelial injury, chronic inflammatory infiltrate in lamina propria, and absence of a prominent subepithelial collagen band, characterize LC histologically. The patients typically present with chronic diarrhea but the colon has a normal appearance endoscopically. LC was considered idiopathic until recently when infectious agents and drugs were proposed to be the possible triggers. We wish to report a 73-year-old man with a mechanical aortic valve (replaced twice), grade III left ventricular function, and a history of triple artery bypass graft, who presented with iron-deficiency anemia. Colonoscopy was performed to investigate the cause of the anemia and a large sessile polyp was found in ascending colon. Endoscopic removal of the polyp was unsuccessful, as the centre of the polyp could not be raised by saline instillation. Following a histopathological diagnosis of tubulo-villous adenoma with high-grade dysplasia, a right hemicolectomy was performed. It is noteworthy that the patient did not have any history of abdominal pain, diarrhea, alteration of bowel habits, or mass in abdomen at the time of presentation. The patient had been taking warfarin, aspirin, betablockers, angiotensin-converting enzyme inhibitor, statins, lasix, amiodarone, levothyroxine, and ferrous gluconate for several months for his cardiovascular complaints and irondeficiency anemia. The right hemicolectomy resection specimen was examined after formalin fixation and comprised an 18-cm segment of colon, 3 cm of terminal ileum, and an appendix measuring 6.5 cm in length. A polypoid mass, 2.5×2.5× 0.4 cm was identified in the proximal ascending colon. The rest of the resection specimen were grossly unremarkable, especially the mucosa which did not show evidence of ulceration, hemorrhage, or congestion. Histological examination of the mass was in keeping with the previous biopsy and the final diagnosis was tubulo-villous adenoma with isolated high-grade foci, no invasion, and complete excision. The grossly “normal” colon revealed thickening of the submucosal venous walls due to edema and a concentric, dense lymphocytic infiltrate. The lymphocytes permeated the entire thickness of the vessel wall and they did not show atypia. Several eosinophils were seen but neutrophils and plasma cells Int J Colorectal Dis (2009) 24:473–474 DOI 10.1007/s00384-008-0573-2