Unusual Cause of Abdominal Pain

Abstract

Question: A 61-year-old woman visited our emergency department for worsening right lower quadrant pain of 3 days' duration. She had suffered a similar condition 6 months ago and had undergone colonoscopy (Figure A). Physical examination revealed distended abdomen with hypoactive bowel sounds. Laboratory examination revealed moderately elevated C-reactive protein level of 4.16 mg/dL. Abdominal radiograph (Figure B) and computed tomography (CT) with and without contrast enhancement (Figure C, D) were taken. What are the findings of colonoscopy, abdominal radiograph, and CT? Look on page 1159 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Colonoscopy revealed multiple, purple, discolored patches in the colonic wall from the ascending to the transverse colon suggestive of venous obstruction (Figure A). Abdominal radiograph (Figure B) revealed increased bowel gas and multiple, tortuous, thread-like calcifications in the right hemicolon, which is perpendicular to the colonic wall, suggesting that the calcifications originated from the blood vessels (Figure E, arrow). Abdominal CT revealed numerous serpiginous calcifications within the right colon and adjacent venous mesentery causing edematous thickening of the colonic wall (Figure C, D, F, arrows). These findings are suggestive of phlebosclerotic colitis. The patient was managed with conservative therapy and recovered 1 week later. Mesenteric phlebosclerosis is a rare type of ischemic colitis first proposed by Iwashita et al in 2003.1Iwashita M. Yao T. Schlemper R.J. et al.Mesenteric phlebosclerosis: a new disease entity causing ischemic colitis.Dis Colon Rectum. 2003; 46: 209-220Crossref PubMed Scopus (95) Google Scholar It occurs mostly in the Asian population, with a female predominance. The etiology is unclear and the disease is characterized by sclerosis of the superior mesenteric vein causing chronic venous ischemia and calcification in the intestinal wall and adjacent mesentery, mostly involving the right colon. The clinical course of phlebosclerotic colitis is usually chronic and irreversible. About 10% of patients are asymptomatic and diagnosed upon radiologic examination. The most common symptoms are recurrent abdominal pain, diarrhea,2Chang K.M. New histologic findings in idiopathic mesenteric phlebosclerosis: clues to its pathogenesis and etiology—probably ingested toxic agent—related.J Chin Med Assoc. 2007; 70: 227-235Crossref PubMed Scopus (57) Google Scholar nausea, and vomiting. Some patients may develop symptoms of subacute colonic obstruction (20%) and hematochezia (10%). The most serious complication is colonic perforation, which is rare, and may require operative intervention.3Kato T. Miyazaki K. Nakamura T. et al.Perforated phlebosclerotic colitis—description of a case and review of this condition.Colorectal Dis. 2010; 12: 149-151Crossref PubMed Scopus (21) Google Scholar Diagnosis is based on clinical symptoms and radiologic findings. Treatment generally is conservative; surgery is required in case of complications.1Iwashita M. Yao T. Schlemper R.J. et al.Mesenteric phlebosclerosis: a new disease entity causing ischemic colitis.Dis Colon Rectum. 2003; 46: 209-220Crossref PubMed Scopus (95) Google Scholar, 2Chang K.M. New histologic findings in idiopathic mesenteric phlebosclerosis: clues to its pathogenesis and etiology—probably ingested toxic agent—related.J Chin Med Assoc. 2007; 70: 227-235Crossref PubMed Scopus (57) Google Scholar, 3Kato T. Miyazaki K. Nakamura T. et al.Perforated phlebosclerotic colitis—description of a case and review of this condition.Colorectal Dis. 2010; 12: 149-151Crossref PubMed Scopus (21) Google Scholar