Ivana Deyl, MD, Vincent Pronesti, DO, Ragunath Appasamy, MD, PhD; Allegheny Health Network, Pittsburgh, PA
Introduction: Colonic ischemia (CI) is caused by a lack of blood flow to the colon. Its incidence is approximately 16 cases in 100,000 person-years. The majority of cases occur in patients over 60 years old. Hence, occurrence during pregnancy is considerably rare. We present a case of a 31-year-old pregnant patient with CI leading to colonic perforation.
Methods: A 31 year old G1P0 female with a past medical history of iron deficiency anemia and scoliosis presented to the emergency room at 14 weeks gestation with a three week history of abdominal pain, nausea, non-bloody watery diarrhea, poor oral intake and a nineteen pound weight loss. On presentation laboratory values showed no significant abnormalities. Physical exam revealed a distended abdomen, mild diffuse tenderness, normal bowel sounds, no rigidity or rebound tenderness. Rectal exam revealed no stool in the vault. MRI of the abdomen was significant for large descending intracolonic stool burden with relative transition zone at the sigmoid colon concerning for partial obstruction, and colonic mucosal inflammation of the descending colon. On the second day she was tachycardic, with a leukocytosis of 16.25K, and a CRP of 27.7. Her abdomen was significantly more distended, with severe diffuse tenderness and guarding. A CT scan of the abdomen and pelvis showed gross pneumoperitoneum (Figure 1). She emergently underwent exploratory laparotomy revealing multiple perforations of the descending colon. She required a total abdominal colectomy with end ileostomy. Pathology revealed scattered mucosal ulcers in the right and transverse colon, the left colon with multiple perforations, ischemic changes, and rare vascular thrombi. She has no personal or family history of thrombophilia. Thrombophilia tests including lupus anticoagulant, anti-cardiolipin, and antinuclear antibody were all normal. The patient will continue to follow with surgery, obstetrics& gynecology, and hematology Discussion: CI may be related to acute arterial occlusion, venous thrombosis, or hypoperfusion of the mesenteric vasculature causing nonocclusive ischemia. There are currently only 3 reported cases of isolated CI during pregnancy. Although CI does occur in younger patients, the diagnosis of CI may be difficult during pregnancy given the risks of obtaining CT scans with contrast. CI should be considered in the differential diagnosis of acute abdominal pain, diarrhea, and weight loss in pregnancy.