Severe Ischemic Colitis Research Articles

EP-408 Colonic mucosal dehiscence in a patient with ischemic colitis- A case report

Abstract Introduction Ischemic colitis (IC) is the condition that results when blood flow to the colon is reduced to a level insufficient to maintain cellular metabolic function. Case summary A 36 year old female; diabetic, hypertensive, with history of CVA and IHD, presented in ER with complaints of sudden onset, severe, colicky abdominal pain. Examination revealed a mildly tense, tender abdomen at left iliac fossa with a palpable ill-defined mass. Her TLC was 31.6/L and hemoglobin 9.3 g/dL. Serum amylase, lipase and lactate levels were normal. CECT abd/ pelvis showed thickened, edematous sigmoid and descending colon, with extensive mesenteric haze and stranding. Colonoscopy showed an illdefined, obstructing growth in rectosigmoid region at 25 cm from anal verge. There were multiple ischemic patches and underlying erythema and ulceration with bleed to touch mucosa at few sites. Scope could not be passed further. Biopsy showed active non-specific colitis with no evidence of malignancy. Patient improved on conservative management and was discharged. Patient presented in ER 2 weeks later with a long tubular structure that was expelled per-rectum. The histopathology of this structure revealed intestinal tissue with marked autolytic and ischemic changes. Patient again presented in ER with abdominal pain and vomiting with increased TLC. A diagnosis of severe ischemic colitis (ACG guidelines 2005)presenting as rectosigmoid mass was made and left hemi-colectomy was planned. Discussion This is a rare case of colonic mucosal shedding in ischemic colitis only described once in literature. Conclusion This case demonstrates the unusual way in which colonic ischemia can present.

Severe acute ischemic colitis: What is the place of endoscopy in the management strategy?

Background and study aims Ischemic colitis (IC) is potentially lethal. Clinical and biology information and results of computed tomography (CT) scan and/or colonoscopy are used to assess its severity. However, decision-making about therapy remains a challenge. Patients and methods This was a retrospective, single-center study between 2006 and 2015. Patients with severe IC who underwent endoscopic evaluation were included. The aims were to determine outcomes depending on endoscopic findings and assess the role of endoscopy in the management. Results A total of 71 patients were included (men = 48 (68%), mean age = 71 ± 13 years). There was hemodynamic instability in 29 patients (41 %) and severity signs on CT scan in 18 (38 %). Twenty-nine patients (41 %) underwent surgery and 24 (34 %) died. The endoscopic grades were: 15 grade 1 (21 %), 32 grade 2 (45 %), and 24 grade 3 (34%). Regarding patients with grade 3 IC, 55 % had hemodynamic instability, 58 % had severity signs on CT scan, 68 % underwent surgery, and 55 % died. The decision to perform surgery was based on hemodynamic status in 62 % of cases, CT scan data in 14 %, endoscopic findings in 10 %, and other in 14 %. Colectomy was more frequent in patients with grade 3 IC ( P < 0.05). A mismatch between mucosal aspect (necrosis) and serous (normal) was observed in 13 patients (46 %). Risk factors for colectomy in univariate analysis were aortic aneurysm surgery, hemodynamic instability, no colic enhancement on CT scan, and endoscopic grade 3. Risk factors for mortality in multivariate analysis were hemodynamic instability, colectomy, and Charlson score > 5 ( P < 0.05). Conclusions This study suggests a low impact of endoscopy on surgical decision making. Hemodynamic instability was the first indication for colectomy. A discrepancy between endoscopic mucosal (necrosis) and surgical serous (normal) aspects was frequently noted.

SARS-CoV-2 identified by transmission electron microscopy in lymphoproliferative and ischaemic intestinal lesions of COVID-19 patients with acute abdominal pain: two case reports

BackgroundSARS-CoV-2 may produce intestinal symptoms that are generally mild, with a small percentage of patients developing more severe symptoms. The involvement of SARS-CoV-2 in the physiopathology of bowel damage is poorly known. Transmission electron microscopy (TEM) is a useful tool that provides an understanding of SARS-CoV-2 invasiveness, replication and dissemination in body cells but information outside the respiratory tract is very limited. We report two cases of severe intestinal complications (intestinal lymphoma and ischaemic colitis) in which the presence of SARS-CoV-2 in intestinal tissue was confirmed by TEM. These are the first two cases reported in the literature of persistence of SARS-CoV-2 demonstrated by TEM in intestinal tissue after COVID 19 recovery and SARS-CoV-2 nasopharyngeal clearance.Case presentationDuring the first pandemic peak (1st March–30th April 2020) 932 patients were admitted in Hospital Universitari Mútua Terrassa due to COVID-19, 41 (4.4%) required cross-sectional imaging techniques to assess severe abdominal pain and six of them (0.64%) required surgical resection. SARS-CoV-2 in bowel tissue was demonstrated by TEM in two of these patients. The first case presented as an ileocaecal inflammatory mass which turned to be a B-cell lymphoma. Viral particles were found in the cytoplasm of endothelial cells of damaged mucosa. In situ hybridization was negative in tumour cells, thus ruling out an oncogenic role for the virus. SARS-CoV-2 remained in intestinal tissue 6 months after nasopharyngeal clearance, suggesting latent infection. The second patient had a severe ischaemic colitis with perforation and SARS-CoV-2 was also identified in endothelial cells.ConclusionsSevere intestinal complications associated with COVID-19 are uncommon. SARS-CoV-2 was identified by TEM in two cases, suggesting a causal role in bowel damage.

Acute Ischaemic Enterocolitis Due to a Thrombotic Event in a COVID-19 Patient

We describe the case of a COVID-19 patient who developed an intestinal ischaemia with thrombotic origin, confirmed by anatomo-pathological examination. A middle-aged woman affected with COVID-19 was evaluated in March 2020. Reverse transcriptase-polymerase chain reaction (RT-PCR) to detect SARS-CoV2 was performed. On the 16th day of being hospitalized, she presented with hemodynamic and respiratory impairment. The physical examination revealed abdominal distension. An urgent abdominal CT scan reported signs of pneumatosis in the distal ileum and ascending colon suggestive of ischaemia (Figure 1D), with mural irregularity predominantly in the ileum. An urgent exploratory laparotomy was performed. Ischaemia of the right colon, as well as patched ischaemia of the distal and middle ileum, was found (Figures 2A &amp; 2B). A right hemicolectomy and resection of the distal-middle ileum with a terminal ileostomy were performed. Pathological examination reported: severe ischaemic colitis, with areas of mucosal necrosis and the presence of abundant small-calibre thrombi in the submucosa and medium-caliber vessels of the mesocolon. Re-examination of the CT scan revealed findings consistent with right lower lobe segmental pulmonary embolism, as well as inferior vena cava filling defects consistent with thrombi. COVID-19 is associated with a large and misleading field of complications, including coagulopathy. The combination of viral injury, cytokine release, and damage-associated molecular patterns induce localized microvascular inflammation, which triggers endothelial activation, leading to vasodilation and prothrombotic conditions. We report this case to alert physicians that they should be vigilant for signs of abdominal thromboembolic complications in patients suffering from COVID-19

Severe Ischemic Colitis in A Patient with Melas Syndrome

Severe Ischemic Colitis in A Patient with Melas Syndrome

The Uncertain Effect of Antimicrobial Therapy in the Treatment of Patients with Ischemic Colitis

Although antimicrobial therapy is recommended for patients with moderate or severe ischemic colitis, its beneficial effects are unclear. In the present study, the role of antimicrobial therapy in the treatment of ischemic colitis was investigated. Patients with ischemic colitis were retrospectively identified between January 2004 and June 2019. The characteristics and outcomes of patients who received antibiotics (antibiotics group) and those who did not (no-antibiotics group) were compared. Clinical outcomes included death, surgery, and readmission within 30 days, fasting duration, and hospital stay. Data from 186 patients were analyzed; 122 patients were in the antibiotics group and 64 in the no-antibiotics group. Composite outcome of death, surgery, and readmission within 30 days occurred in 3.3% of patients in the antibiotics group and 3.1% of patients in the no-antibiotics group (p > 0.999). Fasting duration was not significantly different between the two groups (median days, 4.0 vs. 4.0, p = 0.253). However, hospital stays were longer in the antibiotics group than in the no-antibiotics group (median days, 9.0 vs. 7.0, p = 0.043). In patients with ischemic colitis, there was no statistically significant difference in the incidence of death, surgery, and readmission within 30 days between patients who received antibiotics and those who did not receive antibiotics.

Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies - An EFSUMB Position Paper.

An interdisciplinary group of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of three time-critical causes of acute abdomen: bowel obstruction, gastrointestinal perforation and acute ischemic bowel disease. Based on an extensive literature review, statements for a targeted diagnostic strategy in these intestinal emergencies are presented. GIUS is best established in case of small bowel obstruction. Metanalyses and prospective studies showed a sensitivity and specificity comparable to that of computed tomography (CT) and superior to plain X-ray. GIUS may save time and radiation exposure and has the advantage of displaying bowel function directly. Gastrointestinal perforation is more challenging for less experienced investigators. Although GIUS in experienced hands has a relatively high sensitivity to establish a correct diagnosis, CT is the most sensitive method in this situation. The spectrum of intestinal ischemia ranges from self-limited ischemic colitis to fatal intestinal infarction. In acute arterial mesenteric ischemia, GIUS may provide information, but prompt CT angiography is the gold standard. On the other end of the spectrum, ischemic colitis shows typical ultrasound features that allow correct diagnosis. GIUS here has a diagnostic performance similar to CT and helps to differentiate mild from severe ischemic colitis.

Combination Treatment with Antibiotics and Glucocorticosteroids for Severe Ischemic Colitis

Background/Aims: Ischemic colitis (IC) is most common in the elderly and patients with multiple comorbidities. It carries significant mortality. As yet no evidence-based therapeutic management exists. Aim of the study was to test therapeutic efficacy of a combination of prednisolone and antibiotics. Methods: Prospective cohort study with retrospective analysis performed in a single teaching hospital in Germany. Consecutive patients with strict diagnostic criteria of severe IC, including colonoscopy, histology, and laboratory tests, were recruited. Main outcome measures were in-hospital mortality and number of operations counted within the hospital stay. Severity scores were calculated and biomarkers determined during the course of the hospital stay. Results: A total of 342 patients with an International Classification of Diseases of IC were identified. About 151 patients met the diagnostic criteria and a total of 44 patients fulfilled all inclusion and exclusion criteria of severe IC and constituted the group of patients eligible for analysis. Five out of 44 patients (11.4%) died (in-hospital mortality). Surgery was performed in 3 patients (6.8%), 2 patients survived. The hospital stay lasted 14.0 ± 8.5 day and was significantly correlated with comorbidity (r_s = 0.314, p = 0.038). No serious adverse events were observed. Conclusion: This is the first prospective study on therapeutic efficacy and safety in severe IC. The combination of intravenous antibiotics and intravenous prednisolone turned out to be safe and revealed promising efficacy.

1617 Colon Ischemia as Initial Presentation of Amyloidosis: A Rare and Challenging Diagnosis

INTRODUCTION: Amyloidosis is a systemic disease rarely involving gastrointestinal tract (GIT) and requires a high index of suspicion to diagnose. GI presentations including abdominal pain, bleeding, malabsorption or protein losing enteropathy. Predisposing conditions are plasma cell dyscrasia, chronic inflammatory conditions or hemodialysis. We present case of Amyloidosis involving entire GIT presented with severe colon ischemia required total colectomy. CASE DESCRIPTION/METHODS: A 59-year-old man with 6 months history of abdominal pain, bloating and constipation. He tried laxatives with partial relief. A colonoscopy revealed ulcerations in the sigmoid colon with biopsies consistent with ischemic colitis. CT angiography of the abdomen showed patent vessels with no findings to explain ischemic changes. A colonoscopy repeated 3 months later showed persistent inflammation in the sigmoid colon. He, subsequently, was diagnosed with multiple myeloma and initiated on bortezomib and dexamethasone. A few weeks after initiating this treatment, he presented to ED with significantly worsened abdominal pain, distension and nausea. CT A/P revealed thickening from the rectum to the descending colon with proximal dilation, concerning for pneumatosis and ischemic colitis. He was taken emergently for a total colectomy with end ileostomy. Pathology revealed that he, in fact, had extensive amyloidosis (transmural, interstitial, and vascular involvement) with hemorrhage and necrosis throughout the removed colon as well as the removed portion of the ileum with positive margins. There have been prior reports of colonic ischemia after initiation of bortezomib however this does not appear to be culprit in this case given the patient’s findings on initial colonoscopy prior to starting the medication. DISCUSSION: Amyloid deposition infiltrates multiple organs. GIT involvement is common, rectal biopsy can confirm diagnosis. However, severe colon ischemia is uncommon presentation. Our patient presented with severe ischemic colitis and pneumatosis on CT scan. Prior to this, he had 2 colonoscopies, EGD, and abdominal fat biopsy all was non-diagnostic. He subsequently, had total colectomy, pathology revealed Amyloidosis. Duodenal biopsies confirmed small intestine amyloidosis. Colon ischemia due to Amyloidosis is rare. Diagnosis is challenging but can lead to detrimental consequences when it is delayed. Early diagnosis is critical in preventing progressive disease and potentially fatal complications.

1461 Pseudomembranous Colitis, Bowel Ischemia, and Phentermine: A Case Report

INTRODUCTION: Pseudomembranous colitis, though classically associated with Clostridium difficile infection, can be a consequence of other disease processes including severe ischemic colitis. Several drugs have been proposed to predispose to colonic ischemia including the appetite suppressant phentermine. We present a case of pseudomembranous colitis from severe bowel ischemia that likely was compounded by concomitant phentermine use. CASE DESCRIPTION/METHODS: A 55-year-old obese Caucasian female with hypertension presented with a week of abdominal pain and progressively worsening diarrhea that had subsequently turned bloody. She was a former smoker. Medication history was significant for using a family member's weight loss medication Phentermine 37.5 mg daily for several days prior to developing gastrointestinal symptoms. At presentation she was mildly hypotensive needing fluid resuscitation and brief vasopressor support. Laboratory profile was significant for acute kidney injury with creatinine 8.86 mg/dl, lactic acid 3.2 mmol/L and white blood cell count 12.3 k/uL. A non-contrast CT abdomen showed findings suggestive of acute colitis involving the splenic flexure and descending colon (Figure 1). Supportive care and broad-spectrum antibiotics were continued. Multiple stool studies were negative for clostridium difficile infection, bacterial cultures, and assays for ova and parasites. Antineutrophil antibodies and antineutrophil cytoplasmic antibodies were negative as well. Flexible sigmoidoscopy revealed severe ulcerations covered by thick exudate of the rectum and sigmoid colon (Figure 2). Histopathology of biopsy specimens showed colonic mucosa with fibrinopurulent surface adherent exudate with abundant neutrophils consistent with pseudomembranous colitis (Figure 3). Patient recovered with supportive care alone and was subsequently discharged with instructions not to use Phentermine again. DISCUSSION: Our patient, with risks for vascular disease, had several days of abdominal pain with diarrhea. At the time of her initial hospital presentation, she was hypotensive likely from gastrointestinal volume loss. The inciting event for her colonic ischemia is unclear. Possibilities include Phentermine induced colonic ischemia that was further compounded by volume loss vs prodrome of gastroenteritis leading to volume loss and hypovolemia with subsequent colonic ischemia compounded by patient's Phentermine use. Phentermine use in this patient would have been contraindicated secondary to her vascular risk factors.

Catastrophic antiphospholipid antibody syndrome presenting as severe ischaemic colitis

Catastrophic antiphospholipid antibody syndrome presenting as severe ischaemic colitis

Severe ischemic colitis induced by Sheng Xuexiaoban Capsules: A case report and literature review

Severe ischemic colitis induced by Sheng Xuexiaoban Capsules: A case report and literature review

Predictors of severity in ischemic colitis: Usefulness of early ultrasonography

PurposeThe main objective was to evaluate the usefulness of early ultrasonography for determining prognosis of patients with ischemic colitis. Materials and methodsWe reviewed the histories of patients with diagnosis of ischemic colitis over a period of 11 years. Two hundred twenty nine patients with ischemic colitis were included. Demographic, clinical, laboratory and sonographic findings were retrospectively analyzed. Patients were divided into two groups according to the outcome: mild (those who improved with conservative treatment) or severe (those who died or required surgery), and the findings of each group were compared.In addition, we developed a predictive model of multivariate logistic regression analysis, and then it was validated in a different population of 58 consecutive patients with ischemic colitis. ResultsThe mild ischemic colitis group consisted of 184 patients (age 74,7±8,8years), and the severe group of 45 patients (age 78,6±7,7years). More pancolitis (p=0.005), altered pericolic fat (p=0.032) and free fluid (p=0.013) was observed in the severe ischemic colitis group compared with the mild group. Severe ischemic group had lower wall thickness (p=0.020) and higher resistive index than mild group (p=0.025).Multivariate analysis identified as protective factors to severe ischemic colitis: pain (p=0.026), diarrhea (p=0.034), rectal bleeding (p=0.000), and hypertension (p=0.001). Altered pericolic fat (p=0.008) and pancolitis (p=0.017) were sonographic findings significantly related to severe ischemic colitis.Our model correctly classified 88.4% of the study patients and 89.6% of the population of 58 patients used in validation. ConclusionsSonographic features with clinical findings can predict the outcome of ischemic colitis. Our predictive model could differentiate properly between patients with mild or severe ischemic colitis.

Cytomegalovirus (CMV): associated ischemic colitis in an immunocompetent patient

Cytomegalovirus (CMV) colitis is a common entity in immunocompromised patients, being rare among immunocompetent individuals. In addition, its association with ischemic colitis is unusual in both groups of population. Rectal bleeding might occur in both entities and, occasionally, urgent surgical treatment may be required, associating high morbility rates. We report one case of cytomegalovirus colitis associated with severe ischemic colitis in a non- immunocompromised patient with favourable response to conservative management with antiviral therapy.

Outcome of emergency surgery for severe neuroleptic-induced colitis: results of a prospective cohort.

The study evaluated the outcome of severe acute antipsychotic (neuroleptic) drug related colitis requiring emergency surgery. From 2009 to 2014, 20 patients underwent emergency surgery for acute and severe neuroleptic-related ischaemic colitis. Neuroleptic-induced colitis was defined as another cause besides inflammatory, infectious or ischaemic colitis with a relationship to treatment by antipsychotic drugs. The main drugs involved were cyamemazine (n=9, 45%), loxapine (n=5, 25%), haloperidol (n=4, 20%) and alimemazine (n=4, 20%). Most (n=14, 70%) patients presented with haemodynamic instability requiring massive resuscitation and vasopressive drugs. CT signs of digestive impairment were found in 13 (65%) patients having emergency surgery. The lesions were pancolonic in 40%; transparietal necrosis was found in 45% and 15% had colonic perforation. Twelve (60%) patients had total or subtotal colectomy and eight (40%) a segmental colectomy with colostomy or ileostomy in all cases. The postoperative mortality was 15% and morbidity was 70%, necessitating surgical reintervention in two (10%) patients. Of the 17 surviving patients, 11 (64.7%) had restoration of intestinal continuity after a median delay of 103days, with a postoperative morbidity rate of 36.3%. In the intent-to-treat population, the permanent stoma rate was 30%. The morbidity and mortality of surgery for neuroleptic-drug-induced colitis is higher than for colitis due to other causes. A better knowledge of this condition should lead to early diagnosis.

Ischemic Colitis Complicated by Consumptive Coagulopathy

Colonic ischemia-induced reperfusion injury can lead to multisystem organ failure, regardless of ischemic colitis etiology. However, it rarely leads to consumptive coagulopathy. A review of the current literature shows that there have been limited reported cases of colonic ischemia-induced consumptive coagulopathy. Known etiologies of disseminated intravascular coagulopathy (DIC) include sepsis, malignancy, trauma, and intravascular hemolysis. Ischemic colitis is not a known cause of disseminated intravascular coagulopathy; however, we can relate it to the mechanism of sepsis-induced disseminated intravascular coagulopathy as sepsis is frequently complicated by disseminated intravascular coagulopathy. Disseminating intravascular coagulopathy is the activation of intravascular coagulation culminating in intravascular fibrin formation and deposition into the microvasculature. Secondary fibrinolysis accompanies coagulation activation. Intravascular deposition of fibrin in sepsis leads to a diffuse obstruction of the microvascular bed resulting in progressive organ dysfunction, such as in acute respiratory distress syndrome, acute kidney injury, hypotension, and shock liver. Both the coagulation activation and the consumption of coagulation inhibitors leading to anticoagulation pathways are activated in sepsis, leading to consumptive coagulopathy. Consumptive coagulopathy was an unexpected response to ischemic colitis. We present a case of a 71 year old Hispanic female with past medical history significant for hypertension presented to our facility with sudden onset diffuse abdominal pain and bright red blood per rectum. Work up revealed hematologic profile significant for DIC in addition to acute kidney injury and ischemic hepatitis, negative for schistocytes on peripheral blood smear. Colonoscopy revealed severe ischemic colitis with submucosal hemorrhage and necrosis involving descending colon. Biopsy from colonoscopy was consistent with observation, revealing acute colitis with focal ischemic changes, granulation tissue, and acute inflammatory exudate of descending colon. We believe that the intense inflammatory reaction of ischemic colitis led to this consumptive coagulopathy. While the known etiologies of disseminated intravascular coagulopathy are numerous, ischemic colitis is rarely presented as one.Table 1: Initial labsTable 2: Resolution of disseminated intravascular coagulopathy in a case of ischemic colitisFigure 1Figure 2

Induction of potentially lethal hypermagnesemia, ischemic colitis, and toxic megacolon by a preoperative mechanical bowel preparation: report of a case.

A 67-year-old man was diagnosed with rectal cancer. The tumor invaded the subserosal layer, but it was not large, and there was no sign of obstruction. Neo-adjuvant chemotherapy reduced the size of the tumor. The patient was admitted to our hospital for surgery. For mechanical bowel preparation, he ingested 34 g of magnesium citrate (Magcorol P®), but then developed severe shock, a disturbance of consciousness, and acidemia, and he required catecholamines and mechanical ventilation. X-ray, CT, and laboratory tests revealed ischemic colitis, toxic megacolon, and hypermagnesemia (16.3 mg/dL). After 2 days of temporary hemodialysis and an enema to reduce his blood magnesium concentration, he recovered and left the intensive care unit. However, the left side of his colon had suffered ischemic damage and become irreversibly atrophied. One month later, he underwent laparoscopic abdominoperineal resection and left-side colectomy for the rectal cancer and severe ischemic colitis of the left side of the colon. Histopathology confirmed the rectal cancer with a grade 2 chemotherapeutic effect and severe ischemic colitis of the left side of the colon. Hence, the present case suggests that severe ischemic colitis, toxic megacolon, and hypermagnesemia can occur after taking a magnesium laxative without obstruction of the intestine.

Severe Ischemic Colitis from Gastric Ulcer Bleeding-Induced Shock in Patient with End Stage Renal Disease Receiving Hemodialysis

Upper gastrointestinal bleeding is a common condition and has various clinical courses and prognosis. End stage renal disease (ESRD) patients receiving hemodialysis have a high risk of vascular complications and increased risk of ischemic colitis. A 59-year-old male patient with ESRD receiving hemodialysis visited due to hematemesis. After admission, he showed recurrent hematemesis and hypovolemic shock. Upper esophagogastroduodenoscopy revealed gastric ulcer bleeding and endoscopic hemostasis was successfully performed. Blood transfusion and norepinephrine was administered for hypovolemic shock during initial 3 days. Ten days later, he exhibited hematochezia. Sigmoidoscopy revealed necrotic ischemic colitis in sigmoid colon and segmental colectomy was performed. However, recurrent leakage and ischemia were developed in colon as well as small bowel, and he finally died after 55 hospital days in spite of additional operations. Here, we report a case of peptic ulcer bleeding in patient with ESRD who suffered a severe form of ischemic colitis with transmural necrosis. (Korean J Helicobacter Up Gastrointest Res 2016;16:165-168)

A Case of Severe Ischemic Colitis in the Setting of a Type B Aortic Dissection

A Case of Severe Ischemic Colitis in the Setting of a Type B Aortic Dissection

A Rare Case of Ischemic Colitis Due To Cryoglobulinemic Vasculitis

Case Report: A 64-year-old female presented with sudden onset of nausea, vomiting, blurry vision, and dizziness. She was also found with mild ST elevations and an elevated troponin level. She underwent cardiac catheterization, which showed cardiomyopathy and normal coronary arteries. An MRI of the brain was also performed, and this demonstrated an acute left cerebellar infarct and high-grade stenosis of the left vertebral and posterior inferior cerebellar arteries. She was started on aspirin. Her past history was notable for hypertension, osteoarthritis, and a reported history of ulcerative colitis at the age of 16 years without any treatment for the last 40 years. Her last colonoscopy was normal 2 years ago. On the second day of admission, the patient experienced worsening headache and diplopia. Subsequent head CT showed worsening hydrocephalus and brain stem compression, for which she underwent urgent C1 laminectomy and sub-occipital decompression. She also developed acute renal failure, thought to be due to contrast nephropathy. On hospital day 10, the patient developed diffuse abdominal pain with multiple, small-volume, maroon-colored stools. Her nausea and vomiting had persisted since admission. PT and PPT were mildly elevated and her platelet count was 142,000. Serum haptoglobin was normal, so the diagnoses of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome were felt to be unlikely. Her aspirin was held. Flexible sigmoidoscopy revealed significant inflammation in the rectum, and biopsies were consistent with ischemic colitis. Further evaluation included a renal biopsy, which showed a cryoglobulinemic glomerulonephritis and a bone marrow aspirate, which demonstrated a low-grade lymphoplasmacytic lymphoma. lasmapheresis was initiated for treatment of the cryoglobulinemia and prednisone and Rituximab were started for treatment of the lymphoma. Due to continuing abdominal pain and hematochezia, colonoscopy was performed, which showed severe ischemic colitis in the ascending to mid-transverse colon, in addition to the previously noted rectal involvement. The patient expired due to severe neurologic decline and continued multi-organ failure. Discussion: Gastrointestinal involvement is rare (5%) in patients with cryoglobulinemic vasculitis, and is thought to be due to the hyperviscosity syndrome (from IgM overproduction), which occurs in 6-20% of patients. Manifestations include ischemic bowel disease, gastrointestinal hemorrhage, peritonitis, and acute lesions of any of the intra-abdominal organs, including the pancreas and gallbladder. Although it did not work in our patient, plasmapheresis is generally the treatment of choice in order to improve the hyperviscosity.