Severe Long-Segment Ischemic Colitis Associated with an Underlying Colonic Vascular Malformation in a Patient with a Synchronous Rectal Tubulovillous Adenoma with High-Grade Dysplasia: A Case Report
Main Article Content
Abstract
Background: Ischemic colitis is the most common form of intestinal ischemia and usually affects elderly patients with vascular risk factors. Although most cases respond to conservative treatment, severe ischemia complicated by transmural necrosis, abscess formation, or impending perforation requires emergency surgical intervention. Colonic vascular malformations are uncommon vascular lesions that have rarely been associated with ischemic injury and may present with nonspecific clinical and radiological features that overlap with colorectal malignancy or inflammatory bowel disease. We report a rare case of severe long-segment ischemic colitis involving the descending and sigmoid colon, associated with an underlying colonic vascular malformation, in a middle-aged woman with a synchronous rectal tubulovillous adenoma with high-grade dysplasia.
Case Presentation: A 48-year-old woman with a 10-year history of diabetes mellitus presented with intermittent left-sided abdominal pain, altered bowel habits, constipation, and intermittent rectal bleeding. Ultrasonography suggested a pelvic bowel mass, and colonoscopy demonstrated an irregular anorectal lesion together with a polypoid upper rectal lesion. Histopathological examination revealed chronic nonspecific colitis in the anorectal lesion and a colonic adenoma with high-grade dysplasia in the upper rectal lesion. Endoscopic snare polypectomy confirmed a tubulovillous adenoma with high-grade dysplasia without invasive carcinoma. Despite treatment, she subsequently developed recurrent abdominal pain, fever, leukocytosis, anemia, and worsening renal function. Contrast-enhanced computed tomography demonstrated marked long-segment mural thickening involving the descending and sigmoid colon with inflammatory changes and ascites. Emergency laparotomy revealed extensive edema of the descending and sigmoid colon with retrocolic abscess, patchy ischemic changes, inflammatory fixation, and impending perforation. Resection of the affected colon with primary stapled colorectal anastomosis and diverting transverse loop colostomy was performed. Histopathological examination showed chronic colonic ulceration with peritonitis, impending perforation, and underlying colonic vascular malformation without evidence of malignancy, consistent with severe long-segment ischemic colitis. The patient recovered well and underwent successful colostomy closure five months later.
Conclusion: This case highlights severe long-segment ischemic colitis involving the descending and sigmoid colon, associated with an underlying colonic vascular malformation and complicated by retrocolic abscess, peritonitis, and impending perforation in a patient with a synchronous tubulovillous adenoma with high-grade dysplasia. Early recognition, repeated clinical reassessment, and timely surgical intervention are essential for achieving favorable outcomes.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
I. Brandt, L.J., Feuerstadt, P., Longstreth, G.F., and Boley, S.J. 2015. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia. Am J Gastroenterol. 2015, 110(1): 18-44.
II. Theodoropoulou, A., and Koutroubakis, I.E. 2008. Ischemic colitis: clinical practice in diagnosis and treatment. World J Gastroenterol. 2008, 14(48): 7302-7308.
III. Kaltenbach, T., Anderson, J.C., Burke, C.A., Dominitz, J.A., Gupta, S., Lieberman, D., et al. 2020. Endoscopic removal of colorectal lesions: recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2020, 91(3): 486-519.
IV. Feuerstadt, P., and Brandt, L.J. 2010. Colon ischemia: recent insights and advances. Curr Gastroenterol Rep. 2010, 12(5): 383-390.
V. Washington, C., and Carmichael, J.C. 2012. Management of ischemic colitis. Clin Colon Rectal Surg. 2012, 25(4): 228-235.
VI. Cappell, M.S. 2008. The etiology and pathogenesis of vascular disorders of the intestine. Med Clin North Am. 2008, 92(5): 925-944.
VII. Gorospe EC, Leggett CL, Sun G. 2012. Inferior mesenteric arteriovenous malformation: an unusual cause of ischemic colitis. Ann Gastroenterol. 2012, 25(2): 165.
VIII. Poullos, P.D., Thompson, A.C., Holz, G.S., Edelman, L.A., and Jeffrey, R.B. 2014. Ischemic colitis due to a mesenteric arteriovenous malformation in a patient with a connective tissue disorder. J Radiol Case Rep. 2014, 8(12): 9-21.
IX. Green, B.T., Tendler, D.A. 2005. Ischemic colitis: a clinical review. South Med J. 2005, 98(2): 217-222.
X. Rex, D.K., Boland, C.R., Dominitz, J.A., et al. 2017. Colorectal cancer screening: recommendations for physicians and patients from the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2017, 153(1): 307-323.
XI. Yadav, S., Dave, M., Edakkanambeth, V.J., et al. 2015. A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis. Clin Gastroenterol Hepatol. 2015, 13(4): 731-738.e6.
XII. Mosli, M., Parfitt, J., and Gregor, J. 2013. Retrospective analysis of disease association and outcome in histologically confirmed ischemic colitis. J Dig Dis. 2013, 14(5): 238-243.
XIII. Boley, S.J., Schwartz, S., Lash, J., and Sternhill, V. 1963. Reversible vascular occlusion of the colon. Surg Gynecol Obstet. 1963, 116: 53-60.
XIV. Brandt, L.J., Boley, S.J. 1992. Colonic ischemia. Surg Clin North Am. 1992, 72(1): 203-229.
XV. Montoro, M.A., Brandt, L.J., Santolaria, S., et al. 2011. Clinical patterns and outcomes of ischemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain. Scand J Gastroenterol. 2011, 46(2): 236-246.