Abstract
Ischemic colitis refers to an inflammatory condition of the large bowel caused by ischemia. It usually presents with an acute onset abdominal pain followed by hematochezia. It can occur as a result of arterial occlusion (embolic or thrombotic), venous thrombosis, or hypoperfusion of mesenteric circulation secondary to dehydration, surgery, or medications. Herein, we present an unusual case of sumatriptan-induced ischemic colitis. Sumatriptan succinate is a selective serotonin (5-hydroxytryptamine-1) receptor agonist that is usually prescribed for refractory migraine headaches. This is a 59-year-old female who presented with acute onset abdominal pain followed by bloody diarrhea after vigorous physical activities. She has a past medical history of non-specific colitis (one time, 15 years ago) and chronic migraine for which she was on low-dose sumatriptan therapy (one tab once or twice a week). On the day of the event, the patient took sumatriptan in the morning and had strenuous activities throughout the day, and overnight she developed abdominal pain. It was followed by bouts of bloody diarrhea. The colonoscopy revealed erythematous mucosa with significant ulceration and necrosis involving the distal transverse colon, splenic flexure, descending colon, and proximal colon, suggestive of ischemic colitis. Unlike previously reported cases, this patient was only on low-dose sumatriptan therapy without frequent dosing. So, her risk of ischemic colitis from triptan therapy could have been accelerated by excessive sweating and strenuous physical activities. The patient was treated with intravenous hydration, bowel rest, intravenous antibiotics, and withdrawal of sumatriptan and her condition improved within the next two to three days.
Highlights
Nonocclusive ischemia is due to vasoconstriction of splanchnic vessels leading to hypoperfusion; usually involving the watershed areas of the colon because of limited collateral circulation [2]
Nonocclusive ischemia usually results from severe hypotension, dehydration, surgery, trauma, or medications
Drug-induced IC is less common compared to other causes and is usually related to antihypertensives, nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptive (OC) pills, digoxin, vasoconstrictors, and cocaine [3,4]
Summary
The EGD report showed diffuse erythematous mucosa in the antrum and body of the stomach, suggestive of gastritis Her colonoscopy revealed erythematous mucosa with significant ulceration and necrosis involving some area of ascending colon (Figure 1a), distal transverse and splenic flexure (Figure 1b), descending colon (Figure 1c), and up until sigmoid colon (Figure 2), suggestive of ischemic colitis. An echocardiogram was ordered to exclude any vegetations and embolic cause of IC but it was normal Her diet was slowly advanced to a regular diet and her nausea and abdominal pain were resolved by the time of discharge. Before her discharge, the patient was educated that her bowel ischemia and inflammation were most likely caused by reduced blood supply due to transient narrowing of colonic blood vessels as a result of sumatriptan use. She was instructed to discontinue sumatriptan and to follow up with her neurologist for an alternative medication
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