Multi-System Organ Infarction Due to Ulcerative Colitis Induced Disseminated Intravascular Coagulation

Abstract

Introduction: Disseminated intravascular coagulation (DIC) has been reported in patients with ulcerative colitis (UC). However, these cases are rare. We report a case of DIC in the setting of UC with toxic megacolon leading to ischemia of the bowel, bladder and ureters. Case Presentation: A 24-year-old male with a history of ulcerative colitis, diagnosed 9 months prior to admission after an episode of pancolitis, presented with a two-week history of abdominal pain and bloody diarrhea. He had self-discontinued sulfasalazine 6 months prior to presentation. On admission, he was nontoxic, afebrile and normotensive with a heart rate of 120 beats per minute. Abdominal exam revealed diffuse tenderness without peritoneal signs and normoactive bowel sounds. Labs demonstrated a WBC of 16.4 K/uL with 9% bands; Hb 12.4 g/dL; platelets 189 K/uL; CRP 248 mg/L. Creatinine, urinalysis and lactate were normal. Blood, urine, and stool cultures had no growth. C. difficile toxin PCR was negative. CT scan was consistent with pancolitis with filling defects in the SMV and IMV. Solumedrol, sulfasalazine, ciprofloxacin and metronidazole were started. Within 12 hours of presentation, the patient became toxic in appearance with gross hematuria, tachycardia, and hypotension. Abdominal exam was unchanged from admission. Repeat labs demonstrated WBC 34.5 K/uL; Hb 8.0 g/dL; platelets 64 K/uL; lactate 7.3 meq/L; creatinine 2.9 mg/dL; PTT 43 sec; INR 2.5; fibrinogen 175 mg/dL. Urgent laparotomy revealed frank ischemia of the bowel extending from the ascending colon to the rectum, as well as the prostate, bladder and ureters. A proctocolectomy with end ileostomy and cysto-prostatectomy was performed with placement of bilateral percutaneous nephrostomy tubes. Pathology showed chronic severely active colitis with ulceration and pseudomembranous formation as well as diffuse thrombosis with mucosal and transmural necrosis of the colon, rectum, bladder, prostate, and ureters consistent with DIC. Following surgical intervention, patient's condition improved. He is currently undergoing rehabilitation with plans for neobladder construction and ileostomy reversal in the future. Discussion: This case highlights the rare but serious complications of coagulopathic disorders in UC. There are several possibilities for the driving force behind the patient's progression to DIC including toxic megacolon. Although workup was negative, an unrecognized infection could have precipitated DIC in our patient. Also, filling defects suggestive of thrombus in the SMV and IMV on admission could have caused endothelial injury thus leading to DIC. Further investigation into UC-associated coagulopathies must ensue.