Katherine Janike, MD, Alexander Pan, MD, Asim Shuja, MD University of Illinois at Chicago, Chicago, IL
Introduction: Isolated cecal necrosis is a rare form of ischemic colitis that can mimic other causes of abdominal pain like appendicitis and malignancy. The etiology is not completely known, but most cases of isolated cecal necrosis are detected in patients with chronic renal disease. We present a case of focal cecal necrosis in an elderly patient without many comorbid conditions.
Case Description/Methods: A 77-year-old female with history of HTN and HLD presented to the ED with progressive sharp pain in the right lower quadrant. The pain was intermittent for the previous month but became acutely more frequent and severe days before admission. Associated symptoms included nausea with vomiting, intermittent melena, and a 5 lb. weight loss over the last month. On initial presentation, patient was afebrile, tachycardic to 100, and BP 132/64. Labs unremarkable other than elevated ESR (88) and CRP (54). Lactic acid 1.9. CEA 2.2. CT scan revealed 5.2 x 5.6 x 5.5 lesion in the RLQ with internal air and surrounding inflammatory changes concerning for ischemic colitis, mass, or infection. Colonoscopy revealed a large cecal mass, likely ischemic, with pneumatosis and surrounding area of necrosis. Biopsies showed multiple benign fragments of colonic mucosa with necrosis, ulceration, hyaline fibrosis, inflammation, and crypt miniaturization consistent with ischemic colitis. Patient underwent right hemicolectomy, surgical pathology with diverticulitis and focal ischemic bowel with abscess. Pathology was unable to determine if necrosis was due to abscess or primary ischemia with certainty.
Discussion: Isolated Cecal necrosis is a rare form of colonic ischemia found in patients with vascular disease, hypertension, hyperlipidemia, diabetes, and ESRD. Though many patients with cecal necrosis have comorbidities, our case shows this is not always the case as our patient was relatively healthy with few chronic conditions. Thought to be caused by vascular occlusion or non-occlusive events causing hypotension, if caught early colonic ischemia can be managed conservatively with revascularization and improvement in hypotension. Once necrosis occurs, treatment is surgical removal of the necrotic colon. The post-operative course is variable, some retrospective reports show a 38% mortality rate in cecal necrosis. It is important to recognize cecal necrosis as a cause of RLQ pain (even in the absence of co-morbidities like arrhythmia, shock, heart failure, MI etc.), as prompt treatment with surgical intervention can improve outcomes.
Figure: Isolated cecal necrosis with pneumatosis on endoscopy.
Katherine Janike indicated no relevant financial relationships.
Alexander Pan indicated no relevant financial relationships.
Asim Shuja indicated no relevant financial relationships.
Katherine Janike, MD, Alexander Pan, MD, Asim Shuja, MD. P2265 - Isolated Cecal Necrosis Mimicking a Colonic Mass, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.