Chelsea M. Forbes, MD1, Thomas E. Mellor, DO1, Susan Chu, MD2; 1Naval Medical Center, San Diego, CA; 2Sharp Rees Stealy Medical Group, San Diego, CA
Introduction: We describe a case of phlebosclerotic colitis causing severe ischemia of the sigmoid colon and rectum in a young patient without comorbidities.
Methods: A 35-year-old healthy Filipino male presented with bloody diarrhea, tenesmus, and left lower quadrant (LLQ) abdominal pain. He noted one month of constipation prior to onset and unintentional weight loss. No recent travel, antibiotics, infection, or previous episodes, though he admitted to prolonged use of “Rhino pills” for sexual enhancement. Evaluation revealed tachycardia with LLQ tenderness, leukocytosis, elevated CRP and left-sided colitis on abdominal CT. Flexible sigmoidoscopy (FS) demonstrated severe, circumferential sigmoid colitis with abrupt transition in the transverse colon and rectal sparing. Infectious and rheumatologic workup including MR and invasive angiograms were negative. Despite treatment with methylprednisolone initially for presumed IBD, and IV antibiotics due to colonic ischemia on biopsy, his symptoms worsened and CRP markedly rose. Repeat CT and FS showed worsened colitis with rectal extension. He required urgent left hemicolectomy with rectal resection and end-colostomy. Surgical pathology indicated colonic ischemia due to acute and chronic phlebitis with phlebosclerosis and no arterial involvement. Viral and Congo Red stains were negative. Hypercoagulable work-up demonstrated hereditary Protein S deficiency and antiphospholipid antibody syndrome; lifelong anticoagulation was initiated and symptoms have not recurred. Discussion: Idiopathic phlebosclerotic colitis is an exceedingly rare cause of colonic ischemia in the young. Pathogenesis is unclear; there is a predilection for Asian populations and association with herbal supplements, but no previously reported link to hypercoagulable disorders. Colonic ischemia typically affects arterial watershed areas; however, this entity is identified by inflammation and sclerosis of the venous system. Involvement of mesenteric veins leads to ischemia from reduced drainage; involvement of submucosal veins, as in our case, results in congestion and interruption of vascular flow leading to ischemia across multiple vascular regions. Endoscopically, the mucosa is classically purple and dusky often with necrosis. Evaluation for phlebosclerotic colitis should include CT venography to look for threadlike serpentine, sclerosed veins of the mesentery. In any patient with colonic ischemia involving multiple vascular territories phlebosclerotic colitis should be suspected.
Sigmoid colon with circumferential erythema, edema, friability, hemorrhagic nodules and deep linear ulcerations consistent with severe colitis.
Dusky appearing mucosa with interspersed areas of necrosis.
Disclosures: Chelsea Forbes indicated no relevant financial relationships. Thomas Mellor indicated no relevant financial relationships. Susan Chu indicated no relevant financial relationships.