Ascending Colon Ulcerative Mass: An Unusual Manifestation of Ischemic Colitis

Document Type

Abstract

Publication Date

12-24-2024

Abstract

Introduction: Ischemic colitis refers to vascular pathology of the gastrointestinal tract involving vessels like superior mesenteric artery (SMA), inferior mesenteric artery (IMA) and internal iliac arteries. It may include thrombosis, embolic arterial occlusion or non-occlusive colitis often affecting 'watershed' regions such as hepatic and splenic flexure. It commonly presents as moderate to severe pain, tenderness, and bloody stools. Presentation as a colonic mass is rare and can be mistaken for cancer. We present a case with this unusual presentation. Case Description/Methods: 75-year-old woman with medical history of coronary artery disease with stents, smoking, hypertension, presented with 3 days of right sided abdominal pain with no diarrhea, nausea or vomiting. She had no pain with food intake, no recent illnesses or weight loss. She spiked a low-grade fever of 100.4 F but stable vitals. Physical examination revealed right lower quadrant tenderness only. Laboratory tests showed white cell count of 12.4; all other tests, including lactic acid, were normal. Computed tomography scan of abdomen showed ascending colon wall thickening and adjacent wall stranding, with no enlarged lymph nodes. Gastroenterology performed colonoscopy which showed circumferential ulcerated malignant appearing mass in the proximal and mid ascending colon with biopsies sent. Colorectal surgery was consulted and she was tentatively scheduled for surgical resection. Pathology results showed fibrinopurulent exudate with necrotic colonic mucosa and no malignancy. Surgery was cancelled. A CTA abdomen revealed partial improvement of inflammatory changes in ascending colon and mild to moderate stenosis of SMA and IMA. She was discharged with instructions for adequate hydration and seen by Gastroenterology in outpatient. Follow up colonoscopy in 6 weeks showed complete resolution of the mass. Discussion: Ischemic colitis should be considered as a differential diagnosis in patients with a colonic mass. Notably, about 20% of ischemic colitis cases have coexisting colonic carcinoma [1]. Hence, follow up with imaging and colonoscopy is imperative to assess improvement of ischemia after conservative management. No established guidelines for the timing of follow-up colonoscopy exist. Recommendations suggest repeating the scope within 7-10 days [2], adjusted based on the level of suspicion for cancer. This approach ensures timely detection of potential malignancies and avoidance of unnecessary surgical interventions, which carry long term complications (see Figure 1).

Publication Title

American Journal of Gastroenterology

Volume

119

Issue

10 Supplement

First Page

S1916

Last Page

S1917

Comments

Annual Scientific Meeting of the American College of Gastroenterology, ACG 2024 held 2024-10-25 to 2024-10-30 in Philadelphia, PA.

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