Phlebosclerotic Colitis in a Healthy Young Female with Long-term Herbal Medicine Use.

Phlebosclerotic colitis is a rare form of intestinal ischemia. It is caused by calcified peripheral mesenteric veins and a thickened colonic wall. These characteristic findings can be identified on CT and colonoscopy. A 37-year-old female with a history of long-term herbal medicine use presented with acute lower abdominal pain and vomiting of sudden onset. Colonoscopic findings showed dark-blue discolored edematous mucosa and multiple ulcers from the ascending colon to the sigmoid colon. Abdominal CT findings showed diffuse thickening of the colonic wall and calcifications of the peripheral mesenteric veins from the ascending colon to the sigmoid colon. Based on these findings, the patient was diagnosed with phlebosclerotic colitis. We report this rare case of phlebosclerotic colitis in a healthy young female patient with a history of long-term herbal medicine use and include a review of the relevant literature.

Ischemic colitis after enema administration: Incidence, timing, and clinical features.

BACKGROUND: Enema administration is a common procedure in the emergency department (ED). However, several published case reports on enema-related ischemic colitis (IC) have raised the concerns regarding the safety of enema agents. Nevertheless, information on its true incidence and characteristics are still lacking. AIM: To investigate the incidence, timing, and risk factors of IC in patients receiving enema. METHODS: We consecutively collected the data of all adult patients receiving various enema administrations in the ED from January 2010 to December 2018 and identified patients confirmed with IC following enema. Of 8320 patients receiving glycerin enema, 19 diagnosed of IC were compared with an age-matched control group without IC. RESULTS: The incidence of IC was 0.23% among 8320 patients receiving glycerin enema; however, there was no occurrence of IC among those who used other enema agents. The mean age ± standard deviation (SD) of patients with glycerin enema-related IC was 70.2 ± 11.7. The mean time interval ± SD from glycerin enema administration to IC occurrence was 5.5 h ± 3.9 h (range 1-15 h). Of the 19 glycerin enema-related IC cases, 15 (79.0%) were diagnosed within 8 h. The independent risk factors for glycerin-related IC were the constipation score [Odds ratio (OR), 2.0; 95% confidence interval (CI): 1.1-3.5, P = 0.017] and leukocytosis (OR, 4.5; 95%CI: 1.4-14.7, P = 0.012). CONCLUSION: The incidence of glycerin enema-related IC was 0.23% and occurred mostly in the elderly in the early period following enema administration. Glycerin enema-related IC was associated with the constipation score and leukocytosis.

Idiopathic mesenteric phlebosclerosis associated with use of Chinese herbal medicine: Two case reports.

RATIONALE: Idiopathic mesenteric phlebosclerosis (IMP) is a rare form of ischemic colitis. It is more common in the Asian population people with Asian ancestry. Disease pathogenesis and etiology are not fully elucidated but may be associated with the long-term intake of toxins and other substances, including Chinese herbs. The disease has typical radiological and endoscopic features. Radiologic examination combined with endoscopy can lead to a conclusive diagnosis. PATIENT CONCERNS: We present 2 cases of IMP: in male patients aged 66 and 79 years. The first patient presented with diarrhea and abdominal pain, and the second patient presented with numbness of limbs and abdominal discomfort. These patients had a history of long-term use of Chinese herbal medicine (CHM). DIAGNOSIS: Both patients were diagnosed with IMP by endoscopy and radiology, and the diagnosis confirmed by biopsy in the first patient. INTERVENTIONS: The first patient was advised to stop using CHM. Both patients were given conservative treatment and were followed up regularly. OUTCOMES: Symptoms improved after conservative treatment. The patients had no obvious discomfort during the follow-up period. CONCLUSION: We suspect that the disease is induced by the long-term use of CHM, and dosage and duration of use may determine disease severity.

Ischemic colitis induced by indigo naturalis in a patient with ulcerative colitis: a case report.

BACKGROUND: Indigo naturalis is a Chinese herbal medicine that has currently been used to treat various inflammatory diseases, including ulcerative colitis. Recently, there are several reports concerning severe adverse events associated with indigo naturalis. CASE PRESENTATION: We described a case of a 44-year-old female with ulcerative colitis who presented with lower abdominal pain and hematochezia. She stopped taking her medicine for ulcerative colitis and started oral indigo naturalis 3 months before admission. Computed tomography showed segmental edematous wall thickening of the descending and sigmoid colon. Colonoscopy findings revealed erythema, edema, and submucosal hemorrhage, the surface of which presented a dark blue pigmentation. The histologic finding was consistent with ischemic colitis. We therefore considered an ischemic colitis induced by indigo naturalis, and the patient improved after supportive care and withdrawal of indigo naturalis. CONCLUSION: Indigo naturalis has currently been used in the patients with ulcerative colitis as an alternative therapy. However, physicians should be aware of possible severe adverse events such as ischemic colitis.

A Case-control Study on the Risk Factors for Ischemic Colitis.

OBJECTIVE: Ischemic colitis (IC) is a relatively common acute inflammation disorder of the intestine. It was considered to be a disorder of elderly people with risk factors for arteriosclerosis; however, a considerable number of young people with IC have been reported recently. We performed a case-control study to determine the risk factors for IC and compare the risk factors between elderly and non-elderly people. METHODS: The study included 209 consecutive patients diagnosed with IC between December 2004 and March 2017 at Tokai University Hospital. The study also included 209 randomly selected controls in the same calendar year so as to match age and sex. Possible risk factors for IC were identified and compared between age groups. RESULTS: The mean age of IC group was 64.9 with 60 males and 115 elderly patients aged 65 or more in each group. On multivariable conditional logistic regression analysis, drinking, abdominal surgery, hypertension, and malignant diseases were risk factors for IC in all ages. In non-elderly patients, only hypertension and laxative/enema use were significant factors, while in elderly, abdominal surgery, hypertension, COPD, malignant disease and antiplatelet drugs were significant. CONCLUSION: The risk factors in elderly people might be quite different from younger ones, while hypertension seemed to be a common risk in all ages.

Therapeutic effects of Ginkgo biloba extract against acute ischemic colitis.

Ginkgo biloba extract (GBE) is a plant extract obtained from the leaves of G biloba tree. The aim of this study was to evaluate the clinicopathologic characteristics and therapeutic effects of GBE on ischemic colitis (IC).Forty-seven patients with IC were divided as GBE group (n = 30) and routine group (n = 17). The routine group was given routine therapy, and the GBE group was given routine therapies plus GBE intravenous injection. Clinicopathologic characteristics, endoscopy findings, serum antioxidant enzymes, and inflammatory mediators were evaluated.About 89.3% initial symptom was acute-onset abdominal cramping and abdominal pain followed with hematochezia. The lesions were mainly located in sigmoid colon (80.8%). Serum level of superoxide dismutase (SOD) in patients with IC was significantly decreased (P < .05), while methane dicarboxylic aldehyde (MDA), tumor necrosis factor alpha (TNF-α), and interleukin-6 (IL-6) levels were significantly increased (P < .05). However, serum procalcitonin (PCT) level showed no significant change. Treatment of GBE resulted in quick remittance of abdominal pain and hematochezia, and significant attenuation of colon macroscopic and histologic damage in all patients. Furthermore, the treatment also significantly increased SOD levels, decreased MDA, TNF-α, and IL-6 levels (P < .05).Acute-onset abdominal cramping or abdominal pain followed with hematochezia was the mainly initial symptom of IC, and sigmoid and descending colons were the common vulnerable sites. GBE exerted a beneficial effect on IC with faster symptom relief and better mucosal healing, possibly through scavenging oxidative-free radicals and downregulating inflammatory mediators. GBE may be a promising candidate for protection against IC.

Stercoral colitis complicated with ischemic colitis: a double-edge sword.

BACKGROUND: Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis. CASE PRESENTATION: An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia. CONCLUSION: Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Ischemic colitis associated with acute carbon monoxide poisoning--a case report.

Carbon monoxide (CO) poisoning is common, but it has rarely been reported to cause ischemic colitis. In this case, a 34-year-old female with depression presented to an emergency department after a period of unconsciousness, with urinary and bowel incontinence, following exposure to car exhaust. Her carboxyhemoglobin level was 23%. She had metabolic acidosis. She was transferred to our facility for hyperbaric oxygen treatment, where she had intractable nausea/vomiting with abdominal pain and bright-red bleeding per rectum. She exhibited lower abdominal tenderness and hypoactive bowel sounds. Vital signs were: temperature 36.8 degrees C; blood pressure 137/ 86 mmHg; heart rate 114 beats/minute; respiratory rate 28 breaths/minute. The patient's electrocardiogram showed sinus tachycardia with T-wave inversions in leads I, aVL and V3-V6. The troponin I level peaked at 3.7 ng/ml. Echocardiogram showed a reduced ejection fraction of 30%-35%, with akinesis in the posterior lateral and distal anterior distributions. Computed tomography of the abdomen revealed diffuse colonic mural thickening, supporting mesenteric ischemia. Sigmoidoscopy showed edematous friable pale mucosa from rectum to distal sigmoid colon. Hyperbaric oxygen was deferred based on the patient's status. Over three days, the initial hematochezia progressed to melena and then resolved. Adenosine cardiac stress MRI was normal. She was transferred to the psychiatry service and discharged four days later. Four years later, she has no gastrointestinal, cardiac or cognitive problems.

Phlebosclerotic colitis: case report and literature review focused on the radiologic findings in relation to the intake period of toxic material.

Phlebosclerotic colitis (PC) is a rare disease entity of intestinal ischemia characterized by calcification at the right hemicolon and is predominant in Asian populations. We present a 57-year-old Korean patient who was an Oriental medicine practitioner himself and had been taking herbal medicine for decades. We reviewed previous literature on similar cases and analyzed radiologic features of PC in relation to the intake period of toxic material and extent of disease.

Phlebosclerotic colitis that was difficult to distinguish from collagenous colitis.

Phlebosclerotic colitis is a rare and recently known disease entity and its etiology is still to be elucidated. Some phlebosclerotic colitis cases are difficult to distinguish from collagenous colitis because of the similarity of pathological findings. In all Japanese case reports of phlebosclerotic colitis in which an association with the use of Chinese herbal medicine is suspected, sansisi (gardenia fruit) was included, suggesting pathogenesis of this disease. We report a case of phlebosclerotic colitis that wasdifficult to be distinguished from collagenous colitis, and an association with the use of Chinese herbal medicine was suspected as the cause of the disease.

A Case of Ischemic Colitis Presenting as Bloody Diarrhea after Glycerin Enema

Enema has frequently been used for diagnostic or therapeutic purpose. However, cases of colitis from physical, chemical, and thermal injury due to enema have been reported. In severe cases, life threatening complications (perforation, rupture, peritonitis, etc.) may occasionally occur. Reports of ischemic colitis after enema is rare and there have been only 1 case of ischemic colitis after normal saline enema reported in South Korea. Sigmoidoscopy on a 58 year old female, presenting with sudden abdominal pain and hematochezia after glycerin enema, revealed ischemic injury of the rectosigmoid colon, which was improved after using antibiotics and conservative therapy.

[The clinical features and risk factors for 89 cases of ischemic colitis].

OBJECTIVE: To investigate the clinical manifestations, pathological features by endoscopy and possible risk factors of ischemic colitis (IC). METHODS: A retrospective analysis was made upon 89 hospitalized patients diagnosed as IC. Logistic regression analysis was performed to determine morbidity risk factors. RESULTS: The majority of patients with IC in our study group had histories of hypertension, heart disease, hyperlipidemia, diabetes, etc. The common features included abdominal pain (80.9%, 72/89), hematochezia (76.4%, 68/89), etc. Colonic mucosal lesions presented regional distribution under colonoscope (80%, 72/89), with manifestations of petechial hemorrhages, edema, segmental erosion, pleomorphism ulcerations, visible lesion edge and sharply defined segment of involvement, even be characterized by lumens stricture (13.5%, 12/89). Histopathological examination revealed mucosa edema, necrosis, hemorrhage and formation of ulceration, inflammatory cell infiltration, and submucous hemorrhage, etc. Laboratory examination showed that white blood cells, neutrophils, serum fibrin, D-Dimer, serum TC, TG and serum apolipoprotein B were higher than normal. Colonic mucosal roughness, thumbmark symptoms, etc, and even bowel limited spasm, stricture or curtailment were visible in 47 patients underwent barium enema. Colonic wall thickening was visible in 29 patients underwent mesentericography, however, strictured or closed blood vessels were not found logistic regression analysis showed that hypertension, diabetes, higher TG, atrial fibrillation were strongly associated with onset of IC (all P values < 0.05). CONCLUSIONS: Since IC symptoms are not typical, it requires early colonoscopy to clarify diagnosis. Hypertension, diabetes, hyperlipidemia, and atrial fibrillation are risk factors for IC.

Therapeutic effect of hyperbaric oxygen on inclusion body myositis.

An inflammatory myopathy, inclusion body myositis (IBM) presents with progressive muscle weakness against a background of elevated creatine kinase and diffuse endomysial damage. Typically occurring in patients greater than 50 years of age, it is commonly misdiagnosed as polymyositis or other rheumatological disease and is often ineffectively treated with steroids [1]. The approach to IBM is frequently a clinical challenge due to its unique and often aberrant response to common treatment modalities. Here we report an apparent improvement in the clinical course of and associated laboratory findings in a patient with co-existing IBM following the use of hyperbaric oxygen therapy as an adjunct for managing ischemic colitis.

Jujitsu kick to the abdomen: a case of blunt abdominal trauma resulting in hematochezia and transient ischemic colitis.

Blunt abdominal trauma is a common presentation to the emergency department. Ischemic colitis is a rare complication of this and its possible sequelae are important for an emergency physician to recognize. A 21-year-old man presented to the emergency department with abdominal pain and hourly episodes of bright red blood per rectum shortly after being kicked in the stomach at his jujitsu class. He had no significant medical history, and results of his systems review were otherwise unremarkable. On examination, he appeared well, with normal vital signs. He had mild lower abdominal tenderness, but there were no peritoneal signs present. There was blood on the digital rectal examination. His hemoglobin, platelet, and international normalized ratio levels were normal and his abdominal radiograph was unremarkable. The gastroenterology service was contacted because of the hematochezia and a flexible sigmoidoscopy was performed. The sigmoidoscopy showed erythema, ulceration, and edema of a segment in the left colon, consistent with ischemic colitis. This was later confirmed on biopsy. A computed tomography (CT) scan of the abdomen was conducted, which revealed left colonic inflammation consistent with colonic ischemia. There was no mesenteric vascular thrombosis or mesenteric hematoma found on CT. His hematochezia and abdominal pain subsided spontaneously, and he was discharged home. This case illustrates transient ischemic colitis as a potential presentation of blunt abdominal trauma, and emergency physicians should consider this uncommon diagnosis in the differential diagnosis of patients presenting after abdominal trauma.

A Case of Right Side Ischemic Colitis Associated with Herbal Medication for Weight Reduction in a Young Woman

Ischemic colitis has a relatively high prevalence in the elderly population with underlying vascular disorders such as hypertension and usually occurs on the left side of the colon. However, ischemic colitis also rarely occurs in healthy young adults with no risk factors. Herbal medication use is increasing, particularly for weight loss. Ischemic colitis associated with herbal medication use has been rarely reported. Here, we describe a case of right-sided ischemic colitis in a young woman that was potentially linked to the use of herbal medication. An 18-year-old woman was admitted to our emergency department with abdominal pain and bloody diarrhea for 1 day. Her medical history was unremarkable for bowel ischemia risk factors. However, she had taken herbal medication for weight loss for the past 2 weeks. Abdominopelvic CT showed diffuse wall thickening with decreased mucosal enhancement from the ascending to the transverse colon. A colonoscopic biopsy specimen showed coagulative necrosis of the mucosa, hemorrhage, and inflammatory cell infiltration. The abdominopelvic CT, colonoscopy, and biopsy findings were compatible with ischemic colitis. Her abdominal pain and bloody diarrhea improved completely with conservative management, and she was advised to discontinue the use of herbal medications.

NO-Xplode: a case of supplement-associated ischemic colitis.

The most common cause of ischemic colitis (IC) is a sudden and transient reduction in splanchnic perfusion. In the younger population, medications are an increasingly recognized cause of ischemic bowel disease. Over-the-counter supplements may also lead to the development of ischemic colitis through similar effects. We present a case of ischemic colitis in a 42-year-old active duty service member after using the performance-enhancing supplement, NO-Xplode. In this report, we review the pharmacology of this supplement and its proposed mechanism of injury.