LewisGale Medical Center Roanoke, VA, United States
Richard Hargrove, DO1, Jane Lindsay, MD1, Loong Miao, MD, MPH2 1LewisGale Medical Center, Roanoke, VA; 2LewisGale Medical Center, Salem, VA
Introduction:
Microscopic colitis (MC) presents as significant intestinal inflammation causing profound non-bloody watery diarrhea2. Two main types of MC, Collagenous and Lymphocytic, are differentiated via histology2. As its severity increases, MC can manifest with other abdominal issues. This case presents the manifestation of hepatic portal venous gas (HPVG) as a result of severe MC. HPVG is an ominous radiologic finding that may accompany severe medical complications potentially requiring emergent operative involvement1. Correct identification of this condition improves patient outcomes.
Case Description/Methods:
A 75 year-old male presented to the emergency department (ED) after four days of severe abdominal pain and foul smelling, non-bloody, watery diarrhea. Prior to admission he developed severe vomiting causing dehydration. On evaluation, the patient appeared distressed as his abdominal pain was worsening over the past 10 months. He becomes significantly bloated with excess flatulence and diarrhea. The ED found he had an elevated WBC of 23.71 and a lactic acid of 3.9 (0.4-2.0). A CT-ABD/Pelvis showed moderate amounts of HPVG concerning for ischemic colitis, but no other abdominal pathology. General Surgery consult recommended that GI complete an urgent colonoscopy for ischemia, but no dusky tissue was appreciated, only normal colonic mucosa. Biopsies revealed severe MC characterized as collagenous. The patient began 9mg Budesonide daily with close GI follow-up resolving his abdominal sequelae.
Discussion: MC is a seditious condition causing chronic, non-bloody, watery diarrhea. The incidence is reportedly 5-8.6/100,000 person years with an unknown etiology2. Diagnosis requires normal appearing colonic mucosa on colonoscopy, no other disease process causing the diarrhea, and a definitive diagnosis by histology. MC does not usually present with other abdominal issues. Severe MC in this patient likely caused the manifestation of HPVG (Fig. 1,2). Three theories suggest the etiology of HPVG: mucosal wall alteration from ischemia or injury, bowel distention after insufflation during colonoscopy, and sepsis with bacterial overgrowth1. The severe MC likely caused excessive mucosal damage allowing for extravasation of gas from the lumen to track up the mesenteric vasculature and into the portal venous system. Expedient work up once HPVG is observed is key to securing positive patient outcomes as this may designate life threating processes.
1Alqahtani et al.,CJG,2007,309-313
2Gwen et al.,AJG,2015,749-759
Figure: Fig.1 - Pockets of gas within the hepatic portal venous system as a result of severe MC Fig. 2 - Moderate hepatic portal venous gas as a result of severe MC
Disclosures: Richard Hargrove indicated no relevant financial relationships. Jane Lindsay indicated no relevant financial relationships. Loong Miao indicated no relevant financial relationships.
Richard Hargrove, DO1, Jane Lindsay, MD1, Loong Miao, MD, MPH2. P0611 - A Case of Severe Microscopic Colitis With Ensuing Hepatic Portal Venous Gas, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
