Insult to Injury: A Multifactorial Etiology of Ischemic Colitis

Abstract

Ischemic Colitis (IC) is a common cause of intestinal tract ischemic injury and is caused by transient hypoperfusion to the gut. Ischemic colitis is associated with female and elderly patients but can occur in younger patients with a precipitating cause. Contributors include vascular abnormalities, coagulation disorders and medications, including oral contraceptives and antibiotics. Typical presentation includes sudden onset cramping lower abdominal pain and bright red blood per rectum with blood clots. Endoscopic evaluation and histology is the gold standard to diagnose colon ischemia, but this may be time consuming and invasive. Our patient is a 24-year old woman with abdominal pain and bloody diarrhea. She was in her normal state of health until experiencing two days of sudden onset left sided abdominal pain, cramping, tenesmus and multiple episodes of bloody diarrhea. She denied fevers or chills, weight loss, foreign travel, abnormal food intake or family history of IBD. She later endorsed intermittent hematochezia for the past two years. Medications included chronic combined estrogen-progesterone oral contraceptive and new medication of doxycycline po bid this year. She had no previous endoscopies. Labs were notable for leukocytosis, negative pregnancy test, positive fecal leukocytes and CT scan w/o contrast indicating a nonspecific colitis in the sigmoid and descending colon. The patient was given empiric antibiotics and supportive care with initial resolution of leukocytosis and symptom improvement. Stool studies were negative and antibiotics were discontinued, but recurrence of bloody diarrhea and blood clots in her stool prompted further workup. Sigmoidoscopy was performed showing ishemic colitis, confirmed on pathology. Patients may undergo unnecessary treatment and testing for other pathologies such as infection, IBD or malignancy. Our patient improved with conservative management but surgery may be required in cases of gangrene colitis or stricture. Associations between ocp, antibiotics and acute ischemic colitis have been described previously. Our patient endorsed intermittent hematochezia prior to starting doxycycline, suggesting chronic colonic ischemia due to ocp prior to developing acute ischemic colitis from doxycycline sensitivity. Our case illustrates the need for a high index of suspicion for IC in young patients and further research is needed to determine potential synergistic mechanisms of medications that may cause ischemic colitis.1595_A Figure 1. Images from the sigmoid colon showing loss of vascularity and as well as erythema and edema consistent with ischemic colitis.1595_B Figure 2. Images from the sigmoid colon showing loss of vascularity and as well as erythema and edema consistent with ischemic colitis.1595_C Figure 3. Demonstration of colonic mucosa with mucosal hemorrhage and detachment of surface epithelial cells from the basement membrane. Necrosis of the superficial crypts with hyalinization of the lamina propria is noted. Findings are consistent with acute ischemic colitis.