University of California San Diego School of Medicine La Jolla, CA
Mili Parikh, BS, Priya Sharma, MD, Erica Feldman, MD, MPH; University of California San Diego School of Medicine, La Jolla, CA
Introduction: Ischemic colitis is an inflammatory condition due to a reduction in blood flow supplying the colon. It is characterized by insufficient oxygen and nutrient delivery leading to an imbalance between supply and demand. The colon is especially susceptible to hypoperfusion compared to the remainder of the gastrointestinal tract due to its significant vascular network(1).
Methods: Patient is a 54 year old female with past medical history significant for rheumatoid arthritis well-controlled on methotrexate, etanercept, and prednisone. Notably, she has a history of HTN and tobacco use with 37 pack-years. Patient initially presented with a 3-day history of bright red bleeding per rectum with no obvious inciting cause. Episodes of rectal bleeding were accompanied by dizziness, chills, nausea, and lightheadedness. Physical exam was notable for severe LLQ pain. Labs on admission showed leukocytosis of 19.2. Based on presenting symptoms, patient was initially treated for diverticulitis. Colonoscopy was performed, and biopsy pathology revealed fibrinopurulent exudate and hyalinized lamina propria, confirming the presence of ischemic colitis. Subsequent CT angiography was performed to assess for vascular etiology; however imaging was found to be normal. Upon literature review, case reports suggest a relationship between ischemic colitis and biologic use. Implicated biologics include anti-TNF agents, primarily infliximab(2). This case illustrates the potential for etanercept-mediated ischemic colitis, potentially through cytokine mediated pathogenesis(3). Discussion: Although the side effect seen here is rare, literature review suggests a potential link between biologic agents and ischemic colitis. As such, it is important to recognize this potential relationship, especially as it relates to at-risk patients with vascular disease. Acknowledging ischemic colitis as a serious complication related to biologic agents can help guide clinicians in selecting appropriate medications in the management of autoimmune disorders.
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Allison Salk (et al.), Ischaemic Colitis in Rheumatoid Arthritis Patients Receiving Tumour Necrosis Factor-α Inhibitors: An Analysis of Reports to the US FDA Adverse Event Reporting System, 2013 May, 36(5):329-34.
David Hass (et al.), Pharmacologically Mediated Colon Ischemia, 2007 August, 102(8):1765–1780.
Colonoscopy findings suggestive of ischemic colitis
Disclosures: Mili Parikh indicated no relevant financial relationships. Priya Sharma indicated no relevant financial relationships. Erica Feldman indicated no relevant financial relationships.