Ischemic Colitis Research Articles

Colon and Rectal Surgery.

Duggan, Ben S; Becker, Timothy; DeLeon, Genaro; Rao, Varun; Pei, Kevin MD, FACS Author Information

The use of surgical intervention for lower gastrointestinal bleeding and its association with clinical outcomes and resource use

BackgroundTo assess the use of surgical intervention for lower gastrointestinal bleeding and evaluate its associated factors. MethodsThe 2016 to 2019 National Inpatient Sample was queried to identify non-elective adult (≥18 years) hospitalizations for lower gastrointestinal bleeding. The International Classification of Diseases, 10th Revision, codes were used to ascertain patient characteristics, including signs of hemodynamic instability, potential lower gastrointestinal bleed source, and transfusion of blood products, as well as endoscopic, radiologic, and surgical intervention. Multivariable regression analyses were used to elucidate factors associated with operative management of lower gastrointestinal bleeding and evaluate its associated mortality, length of stay, and hospitalization costs. ResultsOf an estimated 364,495 patients, 1.7% underwent an operation for lower gastrointestinal bleeding. Compared to those managed conservatively, patients who underwent surgical intervention more commonly had diverticular-related bleeding, signs of hypovolemia, and less frequently underwent endoscopic intervention. After the adjustment of patient and hospital characteristics, ischemic colitis (adjusted odds ratio 7.5, 95% confidence interval 1.8–30.9, ref: hemorrhoids), hemodynamic instability (adjusted odds ratio 1.7, 95% confidence interval 1.5–2.0), and angiographic embolization (adjusted odds ratio 4.9, 95% confidence interval 3.9–6.0, ref: no endoscopic/radiologic intervention) were associated with greater odds of surgical intervention. Additionally, surgical intervention portended greater odds of in-hospital mortality (adjusted odds ratio 6.2, 95% confidence interval 4.5–8.5), a longer length of stay (8.5 days, 95% confidence interval 8.0–9.0), and greater hospitalization cost ($29.1K, 95% confidence interval 26.7K-31.5K). ConclusionOperative management of lower gastrointestinal bleeding is rare and associated with significant morbidity and mortality compared to those managed conservatively. However, when surgical intervention is indicated, preoperative patient characteristics should be used to identify those at greater risk of an operation to facilitate early surgical consultation and inform expectations during the perioperative period.

Single stem visceral debranching for complex aortic disease

What this paper adds Treatment of complex aortic diseases including thoracoabdominal aortic aneurysms and aortic dissection is highly challenging. Hybrid repair may be useful in some situations wherein anatomy, the need of emergent repair or patient comorbidities preclude the use of total endovascular or direct open reconstruction. This paper details an original hybrid repair in which a single branch is used to reroute all visceral vessels. Abstract: Objective: Hybrid treatment of complex aortic disease has been described with various techniques of retrograde visceral bypass. The use of a single branch to revascularize all renal and visceral vessels may be less cumbersome than multiple synthetic branches and may seems to be efficient in terms of patency. Methods: We retrospectively included 15 patients between 2013 and 2021. Indication was aortic dissection (AD) (type A, acute or chronic type B), thoracoabdominal aortic aneurysms (TAA), visceral occlusive disease. Surgery consisted in median laparotomy, visceral vessel debranching from native aorta or from an aortic graft. In case of AD, surgical fenestration was performed. Additional TEVAR completed the treatment when indicated, during the same procedure or later on Results: Mean age was 60 years. 9 (60%) patients were treated for AD, 3 (20%) for TAA, 3 (20%) for occlusive disease. A total of 65 target vessels were debranched through the single stem retrograde vascular graft (SSRVG) technique. Aortic surgical fenestrations were performed in 8 cases and TEVAR in 4 cases. In the postoperative course, 3 TAA patients died,7 patients developed renal insufficiency (47%), 4 patients presented pneumonia (27%) and 3 colonic ischemia (20%). After a mean follow up of 21 months, all vessels (but 2 IMAs) were patent and no endoleak was noted. Conclusion: SSRVG technique offers a feasible and safe solution in various complex aortic diseases. The use of a single graft makes the technique straightforward by reducing the volume of multiple branch assembly in the retroperitoneal space with satisfying patency rates. Further studies with larger patient sample size and longer follow up are needed to elucidated the efficacy and durability of the technique.

Polyarteritis nodosa: a case report of isolated large bowel involvement and surgical intervention

Polyarteritis nodosa (PAN) is a necrotizing vasculitis commonly affecting small-sized vessels and medium-sized vessels. We present the case of surgical resection for ischemic colitis secondary to PAN. A 26-year-old woman presented with left lower quadrant pain, diarrhea and bloody stools. Colonoscopy showed diffuse circumferential ulceration and necrotic lining from the sigmoid colon to the splenic flexure. A subsequent computed tomography angiography (CTA) revealed left colonic wall thickening, hypoenhancement and multiple inferior mesenteric artery aneurysms, concerning for vasculitis. Ensuing laboratory workup all returned negative. Worsening pain, left-sided peritonitis, tachycardia and rising white blood cell necessitated a colectomy from the proximal descending to upper rectum with an end colostomy. Surgical pathology showed features consistent with PAN. The patient improved significantly after surgery and was discharged on a steroid taper and later started on mycophenolate mofetil. This case is a unique presentation of isolated large intestinal involvement and was treated with both medical and surgical interventions.

A RARE PRESENTATION OF MYCOPHENOLATE MOFETIL-INDUCED SEGMENTAL COLITIS MASQUERADING AS ISCHEMIC COLITIS

Mycophenolate mofetil (MMOF) is an immunosuppressive pro-drug commonly used to prevent rejection in recipients of solid organ transplants. It is hepatically converted to mycophenolic acid which then acts to reversibly inhibit inosine monophosphate dehydrogenase, thereby preventing B and T lymphocyte proliferation, B cell antibody formation, and leukocyte recruitment to sites of inflammation. Diarrhea is the most common gastrointestinal side effect of MMOF usage with up to 40% of renal transplant patients on MMOF reporting this symptom and colonoscopy not infrequently shows injurious changes that range from edema and erythema to ulcerations and diffuse colitis. Isolated reports note that colonic histopathology from patients on MMOF sometimes mimic graft-versus-host disease, inflammatory bowel disease, or ischemic colitis. However, there are very few cases that describe segmental colitis in MMOF patients. We present a rare case of a renal transplant patient presenting with MMOF-induced segmental colitis after 4 years of medication usage.

Herpes Simplex Virus Type 2 (HSV-2) Infection

More than 90% of people worldwide are seropositive for herpes simplex virus (HSV) by the fourth decade of their lives. HSV is usually asymptomatic or follows a mild, self-limited course in healthy individuals. In severely immunocompromised hosts or in patients with underlying inflammatory bowel disease (IBD) treated with immunomodulators, HSV can cause significant morbidity and mortality, including mucocutaneous ulcerations, esophagitis, hepatitis, and encephalitis. This is a rare case of HSV-2 causing necrotizing ischemic colitis, toxic megacolon, and necroinflammation of the liver in the absence of transaminitis in a patient who received steroids for drug rash with eosinophilia and systemic symptoms (DRESS) syndrome.

Outcome Analysis Comparing Asymptomatic Juxtarenal Aortic Aneurysms Treated with Custom-Manufactured Fenestrated-Branched Devices and the “Off-The-Shelf” Zenith p-Branch Device

Numerous endovascular options have been used for the repair of juxtarenal aortic aneurysms (JRAAs) over the last 15years. This study aims to compare the performance between the Zenith p-branch device and custom-manufactured fenestrated-branched devices (CMD) for the treatment of asymptomatic JRAA. A single-center retrospective analysis of prospectively collected data was performed. Patients with a diagnosis of JRAA submitted to endovascular repair between July 2012 and November 2021 were included in the study, being divided into 2 groups: CMD and Zenith p-branch. The following variables were analyzed: preoperative information: demographics, comorbidities, and maximum aneurysm diameter; procedural data: contrast volume, fluoroscopy time, radiation dose, estimated blood loss, and technical success; and postoperative data: 30-day mortality, duration of intensive care unit and hospital stay, major adverse events, secondary interventions, target vessel instability, and long-term survival. From a total of 373 physician-sponsored investigational device exemption (Cook Medical devices) cases performed at our institution, 102 patients presented the diagnosis of JRAA. Of these, 14 patients were treated with the p-branch device (13.7%) and 88 (86.3%) with a CMD. Both groups presented similar demographic composition and maximum aneurysm diameter. All devices were successfully deployed, with no type I or III endoleaks observed at procedure completion. The contrast volume (P=0.023) and radiation dose (P=0.001) were significantly higher in the p-branch group. No significant difference was observed between the groups for the remaining intraoperative data. No paraplegia or ischemic colitis has been observed during the first 30days after the surgical procedures. There was no 30-day mortality in either group. One major cardiac adverse event was registered in the CMD group. Early outcomes were similar in both groups. No significant difference was found between the groups with respect to the presence of type I or III endoleaks during the follow-up. From a total of 313 target vessels stented in the CMD group (mean of 3.55 per patient) and 56 in the p-branch group (mean of 4 per patient), 4.79% and 5.35% presented instability, respectively, with no difference observed between the groups (P=0.743). Secondary interventions were required in 36.4% of the CMD cases and 50% of the p-branch group, but this was not statistically different (P=0.382). In the p-branch cohort, 2 of 7 reinterventions (28.5%) were target vessel-related and in the CMD group, 10 of 32 secondary interventions (31.2%) were target vessel-related. Comparable perioperative outcomes were obtained when appropriately selected patients were treated with either the off-the-shelf p-branch or CMD for JRAA. The long-term target vessel instability does not appear impacted by the presence of pivot fenestrations in comparison to other target vessel configurations. Given these outcomes, delay in CMD production time should be considered when treating patients with large juxtarenal aneurysms.

Back Up at the Pump? I Have a Gut Feeling About This: A Review of the Gastrointestinal Manifestations From Congestive Heart Failure.

Heart failure, which is a clinical syndrome characterized by the heart's inability to maintain adequate cardiac output, is known to affect various organ systems in the body due to its ischemic nature and activation of the systemic immune response, but the resultant complications specifically on the gastrointestinal tract and the liver are not well discussed and poorly understood. Gastrointestinal-related phenomena are common symptoms experienced in patients with heart failure and frequently found to increase morbidity and mortality in these populations. The relationship between the gastrointestinal tract and heart failure are strongly linked and influence each other much so that the bidirectional association of the two is oftentimes referred to as cardiointestinal syndrome. Manifestations include gastrointestinal prodrome, bacterial translocation and protein-losing gastroenteropathy by gut wall edema, cardiac cachexia, hepatic insult and injury, and ischemic colitis. More attention is needed from a cardiology perspective to recognize these common presenting gastrointestinal phenomena that affect much of our patient population with heart failure. In this overview, we describe the association between heart failure and the gastrointestinal tract, the pathophysiology, lab findings, clinical manifestations and complications, and the management involved.

Case Report on Ogilvie Syndrome in a Non-Surgical Candidate

Ogilvie syndrome, also known as “paralytic ileus of the colon,” is characterized by pseudo- obstruction of the colon without any component of mechanical obstruction; and presents as a massively distended abdomen. If left untreated, it carries a high risk of colonic perforation and ischemia leading to death. Ogilvie syndrome usually presents as a post-surgical complication, mainly due to the lack and/or restriction of movement coupled with a possible electrolyte imbalance. In this case, the patient was a non-surgical candidate who presented with a hip fracture after a mechanical fall. Three days post-fall, she developed nausea, abdominal discomfort, and constipation during her hospitalization, which gradually resulted in a massively distended abdomen. The patient was managed conservatively with a nasogastric tube, rectal tube decompression, Metoclopramide, and Magnesium Citrate administration. Abdominal X-rays showed massively dilated bowel loops. An abdominal CT scan showed diffuse dilation of the large bowel without a transition point, suggesting obstruction favoring colonic paralytic ileus. She was discharged to a rehabilitation facility for further physical therapy.

NELA Risk Calculator Significantly Underestimates Mortality Risk of Laparotomy for Mesenteric and Colonic Ischaemia in Older Adult Surgical Patients

NELA Risk Calculator Significantly Underestimates Mortality Risk of Laparotomy for Mesenteric and Colonic Ischaemia in Older Adult Surgical Patients

Cierre dinámico y toxina botulínica: una alternativa novedosa para el cierre definitivo del abdomen abierto y contenido

We report the case of a 54-year-old male patient hospitalized for COVID-19 pneumonia who developed septic shock due to acute Hinchey IV diverticulitis and required Hartmann’s surgery. The patient evolved with colonic ischemia and underwent total colectomy and open abdomen (OA) with temporary abdominal closure (TAC) that was managed with a vacuum-assisted wound closure (VAWC) system for 7 weeks, resulting in a Björck grade 3A OA with a 16-cm gap. As he had a favorable clinic course, dynamic closure with mesh-mediated fascial traction was decided, associated with botulinum toxin (BT) injection. This strategy allowed primary fascial closure (PFC) of the abdominal wall 5 weeks after treatment was initiated, thus avoiding the complications of healing by secondary intention.

Gastrointestinal Bleeding in COVID-19-Infected Patients.

COVID-19 infection is an ongoing catastrophic global pandemic with significant morbidity and mortality that affects most of the world population. Respiratory manifestations predominate and largely determine patient prognosis, but gastrointestinal (GI) manifestations also frequently contribute to patient morbidity and occasionally affect mortality. GI bleeding is usually noted after hospital admission and is often one aspect of this multisystem infectious disease. Although the theoretical risk of contracting COVID-19 from GI endoscopy performed on COVID-19-infected patients remains, the actual risk does not seem to be high. The introduction of PPE and widespread vaccination gradually increased the safety and frequency of performing GI endoscopy in COVID-19-infected patients. Three important aspects of GI bleeding in COVID-19-infected patients are (1) GI bleeding is often from mucosal erosions from mucosal infalammation that causes mild GI bleeding; (2) severe upper GI bleeding is often from PUD or stress gastritis from COVID-19 pneumonia; and (3) lower GI bleeding frequently arises from ischemic colitis associated with thromboses and hypercoagulopathy from COVID-19 infection. The literature concerning GI bleeding in COVID-19 patients is presently reviewed.

A comparative study of scoring systems that accurately predict the prognosis of lower gastrointestinal bleeding.

Lower gastrointestinal (GI) bleeding can be fatal; therefore, several scoring systems have been developed to predict its prognosis. We compared the mortality predictions and evaluated the usefulness of various scoring systems. The medical records of 3794 patients who visited the emergency department with hematochezia between January 2016 and December 2021 were retrospectively reviewed. We calculated the areas under the receiver operating characteristic curves for 30-day mortality and prolonged hospital stay (≥ 10days) based on the age, blood tests, and comorbidities (ABC); AIMS65; Glasgow-Blatchford; Oakland; Rockall (pre-endoscopy); and SHA2PE scores and compared the predictive accuracy of each score. Data for 963 patients (median age, 69years; males, 54.5%; median hospital stay, 6days) with colonoscopy-confirmed lower GI bleeding were analyzed. The 30-day mortality rate was 3.5%; the most common causes of lower GI bleeding were ischemic colitis and diverticulum bleeding in 19.3% and 19.2% of the cases, respectively. The AIMS65 and ABC scores were superior in predicting 30-day mortality (p < 0.001). The SHA2PE score was the most accurate predictor of prolonged hospital stay (p < 0.001). Through multivariate regression analysis, 30-day mortality was correlated with albumin level ≤ 3.0g/dL, international normalized ratio > 1.5, blood urea nitrogen level ≥ 30mg/dL, and systolic blood pressure (SBP) < 100mmHg. A prolonged hospital stay was correlated with liver cirrhosis, hemoglobin ≤ 10g/dL, albumin level ≤ 3.0g/dL, and SBP < 100mmHg. The recently developed scoring systems accurately predict lower GI bleeding prognosis, and their usefulness in clinical decision-making was confirmed.

Parachute-like pull-through anastomosis for low rectal cancer: a new method for preservation of anal function

BackgroundWith recent improvements in surgical technique, oncological outcomes of low rectal cancer have improved over time. But the QoL impairment as a result of anal functional disorder cannot be ignored. And the incidence of anastomosis-related complications cannot be ignored. To address these problems, a personal technique for pull-through coloanal anastomosis (parachute-like intussuscept pull-through anastomosis) was introduced and evaluated. This technique can relatively reduce surgical complications, minimize the impact of anal function, and obviate a colostomy creation.MethodsBetween June 2020 and April 2021, 14 consecutive patients with rectal cancer underwent laparoscopic-assisted resection of rectal cancer in our hospital. Parachute-like pull-through anastomosis method was performed in all patients. Anal function, perioperative details, and postoperative outcomes were analyzed.ResultsThe mean (SD) operative time of first stage was 282.1 min (range 220–370) with an average estimated blood loss of 90.3 mL (range 33–200). And the mean (SD) operative time of second was 46 min (range 25–76) with an average estimated blood loss of 16.1 mL (range 5–50). Wexner scores declined significantly during the median follow-up of 18 months. Four postoperative anastomosis-related complications occurred in 14 patients, including perianastomotic abscess: 1 case (7%), anastomotic stricture: 1 case (7%), and colonic ischemia of the exteriorized colonic segment: 2 cases (14%).ConclusionThe results suggest that the method can facilitate safe and easy completion of coloanal anastomosis, using parachute-like pull-through anastomosis, with acceptable anal function.

Artificial-intelligence-based decision support tools for the differential diagnosis of colitis.

Whereas Artificial Intelligence (AI) based tools have recently been introduced in the field of gastroenterology, application in inflammatory bowel disease (IBD) is in its infancies. We established AI-based algorithms to distinguish IBD from infectious and ischemic colitis using endoscopic images and clinical data. First, we trained and tested a Convolutional Neural Network (CNN) using 1796 real-world images from 494 patients, presenting with three diseases (IBD [n=212], ischemic colitis [n=157], and infectious colitis [n=125]). Moreover, we evaluated a Gradient Boosted Decision Trees (GBDT) algorithm using five clinical parameters as well as a hybrid approach (CNN + GBDT). Patients and images were randomly split into two completely independent datasets. The proposed approaches were benchmarked against each other and three expert endoscopists on the test set. For the image-based CNN, the GBDT algorithm and the hybrid approach global accuracies were .709, .792, and .766, respectively. Positive predictive values were .602, .702, and .657. Global areas under the receiver operating characteristics (ROC) and precision recall (PR) curves were .727/.585, .888/.823, and .838/.733, respectively. Global accuracy did not differ between CNN and endoscopists (.721), but the clinical parameter-based GBDT algorithm outperformed CNN and expert image classification. Decision support systems exclusively based on endoscopic image analysis for the differential diagnosis of colitis, representing a complex clinical challenge, seem not yet to be ready for primetime and more diverse image datasets may be necessary to improve performance in future development. The clinical value of the proposed clinical parameters algorithm should be evaluated in prospective cohorts.

Toxic Megacolon in a Patient with Clostridium Difficile Infection with Diverticulitis. Case Report

Toxic megacolon is a fatal condition defined as a rare, life-threatening, acute colonic dilatation of colitis. The case of a 41-year-old male with a history of irritable bowel syndrome is presented, who starts with diarrhea on more than 20 occasions accompanied by blood and mucus, emesis is added, and a fever of 39°C. Laboratories with hemoglobin 8.1g/dL, positive clostridium difficile toxin AB, positive glutamate dehydrogenase, simple abdominal tomography with distended intestinal loops, and presence of rectovesical fistula, performing total colectomy with ileostomy reporting ischemic colitis, perforation with ulcerated areas and pseudopolyps. Continued with well tolerated feeding. There are case reports of megacolon as a complication of inflammatory bowel disease and clostridium difficile infection. Total colectomy plus ileostomy is the surgical procedure of choice when conservative treatment fails. Inflammatory bowel pathology can show in its spectrum various clinical characteristics of debut or evolution, so a multidisciplinary approach and management must be taken from the diagnosis.

A RARE PRESENTATION OF MYCOPHENOLATE MOFETIL-INDUCED SEGMENTAL COLITIS MASQUERADING AS ISCHEMIC COLITIS

Abstract Mycophenolate mofetil (MMOF) is an immunosuppressive pro-drug commonly used to prevent rejection in recipients of solid organ transplants. It is hepatically converted to mycophenolic acid which then acts to reversibly inhibit inosine monophosphate dehydrogenase, thereby preventing B and T lymphocyte proliferation, B cell antibody formation, and leukocyte recruitment to sites of inflammation. Diarrhea is the most common gastrointestinal side effect of MMOF usage with up to 40% of renal transplant patients on MMOF reporting this symptom and colonoscopy not infrequently shows injurious changes that range from edema and erythema to ulcerations and diffuse colitis. Isolated reports note that colonic histopathology from patients on MMOF sometimes mimic graft-versus-host disease, inflammatory bowel disease, or ischemic colitis. However, there are very few cases that describe segmental colitis in MMOF patients. We present a rare case of a renal transplant patient presenting with MMOF-induced segmental colitis after 4 years of medication usage. A 52-year-old male with a history of native kidney end stage renal disease secondary to diabetic nephrosclerosis status post living unrelated kidney transplant 4 years ago from his wife presented to the emergency room for 1 week of intractable abdominal pain, vomiting, and diarrhea. His current transplant medications included atovaquone, tacrolimus, and mycophenolate mofetil. Lab work showed chronic pancytopenia with hemoglobin 10, MCV 85, platelets 58, BUN:Cr 87:5.6, and tacrolimus level 34.8. His last colonoscopy 7 years ago was unremarkable and the patient had never had an esophagogastroduodenoscopy (EGD) before. EGD while admitted showed significant erosive gastropathy with pathology showing the same. Sigmoidoscopy showed segmental colitis with punctate erythema and loss of vascularity up to the splenic flexure with the distribution of mucosal disruption suggestive of ischemic colitis. Histopathology showed fragments of colonic mucosa with patchy active cryptitis, surface erosion, distorted crypts with concurrent apoptosis and scattered eosinophils in the lamina propria – findings consistent with mycophenolate colitis. Symptomatic care was provided and the patient’s mycophenolate was tapered to cessation with complete resolution of symptoms. He was discharged with appropriate follow-up. Our case highlights a rare presentation of MMOF-induced injury whereby despite, appearance on endoscopy as a segmental ischemic colitis, histopathology was negative for ischemia but notable for MMOF-induced injury which was confirmed by symptom resolution following discontinuation of the immunosuppressive drug.. With early recognition of this pathology by clinicians with subsequent MMOF discontinuation, symptoms and prognosis can be remarkably improved. Colonoscopic image showing segmental colitis with punctate erythema and loss of vascularity. Fragments of colonic mucosa with patchy active cryptitis (star), surface erosion, mildly distorted crypts and apoptosis mainly in crypt bases with scattered eosinophils in the lamina propria, indicative of mycophenolate colitis. 400x magnification.

Transarterial embolization of acute non-neurologic bleeding using Ethylene Vynil Alcohol Copolymer: a single-Centre retrospective study

BackgroundTo evaluate feasibility, safety and effectiveness of transarterial embolization of acute non-neurologic hemorrhage with Ethylene Vynil Alcohol Copolymer (EVOH).MethodsBetween January 2018 and June 2021, 211 patients (male 123, mean age 69.7 y + 17.9) who underwent transarterial embolization with Onyx™ for acute non-neurologic arterial bleeding were retrospectively reviewed. Most frequent etiology of bleeding was post-operative (89/211, 42.2%), trauma (62/211, 29.4%) and tumor (18/211, 8.5%). Technical success was defined as the angiographic evidence of target vessel complete occlusion. Clinical success was defined as resolution of bleeding. Any rebleeding within the primitive site, requiring a new intervention during the first 30-days following embolization, was considered a clinical failure. Occurrence of procedure-related complication and mortality within 30 days of the embolization were examined.ResultsA total of 229 embolization procedures was performed in 211 pts.; technical success rate was 99.5% (210/211 pts). Clinical success rate was 94.3% (199/211 pts). In 11 patients (5.2%) a reintervention was needed because of a rebleeding occurring within the primitive site, whereas in five patients (2.4%) rebleeding occurred within a site different from the primitive. Factors more often associated with clinical failure were coagulopathy/ongoing anticoagulant therapy (5/11, 45.4%), and post-operative etiology (3/11, 27.3%). EVOH was used as the sole embolic agent in 214/229 procedures (93.4%), in association with coils in 11 cases (4.8%), and with microparticles in 4 cases (1.7%). In the present series, major complications occurred in 6 cases (2.8%): respectively, four cases (1.9%) of colonic ischemia and two groin hematomas (0.9%) with active extravasation were observed. 26 (12.3%) patients died during the follow-up.ConclusionEmbolization of acute arterial bleeding with EVOH as a first-line embolic agent is feasible, safe and effective.

Gangrenous ischemic colitis localized to the cecum: a case report

BackgroundIschemic colitis affects the left colon in elderly individuals and localization on the right side, especially in the cecum, is rare. We report a case of gangrenous ischemic colitis localized in the cecum of a patient undergoing hemodialysis.Case presentationA 73-year-old man had been undergoing hemodialysis for chronic renal failure caused by diabetic nephropathy. He experienced frequent vomiting, diarrhea, and abdominal pain. Contrast-enhanced computed tomography revealed thickening of the cecal wall, poor enhancement, dilation of the cecum, and intrahepatic portal emphysema. No obvious abnormal findings were observed in the appendix. The patient was diagnosed with cecal necrosis and ileocecal resection was performed. Histopathological examination revealed gangrenous ischemic colitis of the cecum. He was discharged 12 days after surgery without postoperative complications.ConclusionIt is important to consider the possibility of ischemic colitis of the right colon in the event of renal failure requiring dialysis, to ensure that opportunities for surgical intervention are not missed.

PROTEIN C DEFICIENCY CAUSING RECURRENT DEEP VEIN THROMBOSIS (DVT) IN A YOUNG MALE: CASE REPORT.

Protein C deciency (PCD) is a rare genetic disorder that occurs due to mutation in PROC gene and results in increased predisposition to thrombosis, PCD can be 'autosomal dominant 'which is relatively more common occurs in adults and usually presents as recurrent DVT, ischemic colitis or may remain asymptomatic. 'Autosomal recessive PCD' is relatively rare, more severe and presents in neonates as 'neonatal purpura fulminans'. I report a case of 41-yearold male who came with history DVT (recurrent) and diagnosed as 'Protein C deciency: Type 1'