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.

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.

[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.

Fulminant sepsis due to anaerobic bacterial infection in immuno-compromised state.

We experienced two autopsy cases of fulminant sepsis due to anaerobes. Case 1: A 67-year-old female with uncontrolled diabetes mellitus (DM) was admitted to a hospital because of sudden onset of mid-abdominal pain. She was diagnosed with infectious colitis and given a laxative and an enema. However, 9h later, her blood pressure suddenly dropped with metabolic acidosis, and she died 20 h after admission. Autopsy revealed massive pneumohemia and a dark-brown colored mucosal surface from the terminal ileum to the sigmoid colon. Histopathological findings were compatible with marginal ischemic colitis. Anaerobes were positive in blood culture. Case 2: A 53-year-old male with alcoholic liver cirrhosis (LC) was found dead in his room. He had been alive 24 h before the discovery, but postmortem changes appeared to accelerate more rapidly than usual cases. Autopsy revealed severe LC with muddy ascites and many Gram-negative rods in several organs. These cases suggest the possibility of sepsis as causes of death, especially in immuno-compromised hosts when unexplained putrefactive changes are seen on forensic autopsy.

[Ischemic anastomotic bowel perforation during treatment with bevacizumab 10 months after surgery]. / Ischämische Anastomosenperforation im Bereich einer Ileotransversostomie unter Therapie mit Bevacizumab.

BACKGROUND: Bevacizumab (Avastin) is a monoclonal antibody against vascular endothelial growth factor (VEGF) receptor that has demonstrated increased overall survival when added to standard chemotherapy regimens in patients with metastatic colorectal cancer. Gastrointestinal perforation is a known risk factor of unknown etiology associated with the use of bevacizumab. OBJECTIVE: We report a 61-year-old woman with adenocarcinoma of the colon ascendens who underwent hemicolectomy and adjuvant chemotherapy with oxaliplatin, 5-fluorouracil, and leucovorin. Eight months after the operation, we started therapy with bevacizumab combined with irinotecan, 5-fluorouracil, and leucovorin due to disease progression. Two months after completion of this therapy, ischemic anastomotic bowel perforation occurred and a resection of the anastomosis was performed. Because of anastomotic insufficiency 8 days later, a further revision had to be done and the terminal ileum and the colon were brought out through a stoma. DISCUSSION: This case is unusual because the time interval between the primary operation and the application of bevacizumab is regarded as safe with regard to the risk of perforation. An ischemic genesis of the perforation was considered on the basis of the histopathological workup. In case of perforations during therapy with bevacizumab, a safe surgical approach should be preferred, i.e., a transient stoma instead of a primary reconstruction of the bowel passage.

Membrane permeability and antipyrine absorption in a rat model of ischemic colitis.

The aim of this study was to determine whether the duration of ischemia affects antipyrine absorption in the large intestine. This was carried out in a rat model of ischemic colitis in which ischemia and associated inflammation was induced by marginal vessel ligation. Blood flow was disrupted by positioning an o-ring around the distal rectum and ligating the marginal vessel at two locations in the hind-gut ligament artery region. Ligation was performed for 1, 2, 3, and 5h. We assessed large intestine damage by measuring key indicators of inflammation, myeloperoxidase (MPO) activity and thiobarbituric acid reactant substrates (TBARS) in the mucosa and by histological staining with hematoxylin-eosin stain. Antipyrine membrane permeability was assessed in Ussing-type diffusion chambers, and related pharmacokinetics were calculated from antipyrine plasma concentration measurements following colon administration of the drug. Vessel ligation caused some sloughing of epithelial cells and elevated the MPO and TBARS levels. Prolonged ligation failed to affect the apparent permeability coefficient (P(app)) of antipyrine. Prolonged ligation, however, gradually increased plasma antipyrine concentrations to near control levels. This increase was paralleled by increases in the absorption rate constant AUC and antipyrine bioavailability. Taken together, these results suggest that the absorption kinetics of antipyrine may depend on blood flow changes in the large intestine that occur with inflammation.

Mesenteric phlebosclerosis: a new disease entity causing ischemic colitis.

PURPOSE: Nonthrombotic stenosis or occlusion of the mesenteric veins is a rare cause of intestinal ischemia. The aim of this study was to describe a new disease entity causing chronic ischemic colitis. METHODS: Seven patients were diagnosed as having mesenteric phlebosclerosis. All seven patients had calcifications in the small mesenteric veins and their intramural branches. No evidence of vasculitis or portal hypertension was recognized. None of the patients had a history of gastrointestinal disease or of prolonged drug use. We report clinical, laboratory, radiographic, endoscopic, and histopathologic findings. RESULTS: Clinical findings included abdominal pain and diarrhea of a gradual onset and chronic course. A positive fecal occult blood test and mild anemia were often found. The patients had linear calcifications and stenosis in the right colon, which were discovered by plain abdominal radiography and barium enema, respectively. Endoscopic findings included edematous, dark colored mucosa and ulcerations. Four patients underwent a subtotal colectomy because of persistent abdominal pain or ileus. The histopathologic findings were macroscopically characterized by a dark purple or dark brown colored colonic surface, the swelling and disappearance of plicae semilunares coli, and marked thickening of the colonic wall, while they were microscopically characterized by marked fibrous thickening of the venous walls with calcifications, marked submucosal fibrosis, deposition of collagen in the mucosa, and foamy macrophages within the vessel walls. CONCLUSIONS: These peculiar lesions have not previously been fully described. The cause and pathogenesis still remain unknown. We conclude that such lesions represent a new clinicopathologic disease entity and propose the term "idiopathic mesenteric phlebosclerosis."

Usefulness of CT in patients with ischemic colitis proximal to colonic cancer.

OBJECTIVE: The purpose of this study was to assess the usefulness of CT scans for distinguishing ischemic from tumoral segments in patients with colonic carcinoma complicated by proximal bowel ischemia. MATERIALS AND METHODS: CT scans of 20 patients with ischemic colitis proximal to obstructing colonic carcinoma were reviewed retrospectively. The concomitant presence of ischemia was proven on pathologic examinations in 12 patients and on barium enema studies in the remaining eight patients. CT scans were analyzed for the involved site and length, bowel wall thickness, enhancing pattern of both tumoral and ischemic segments, and changes in the pericolic space. The results of tumor staging on CT scans were compared with those of pathologic findings. RESULTS: Distinction of ischemic from tumoral segments could be made on CT in 15 (75%) of the 20 patients. Of the 20 patients, 18 had ischemic segments contiguously proximal to the tumoral segment, and the remaining two patients had a skipped zone with intervening normal mucosa. Tumoral segments were irregularly thickened in most patients. Maximum thickness ranged from 0.8 to 4.5 cm (mean, 2.0 cm). Most often the ischemic segment was concentrically and smoothly thickened, ranging from 0.6 to 1.5 cm (mean, 1.0 cm). The tumoral segments enhanced heterogeneously in 12 patients and enhanced homogeneously in the remaining eight, whereas ischemic segments enhanced homogeneously in 14 (70%) patients and heterogeneously in six. On CT scans, we saw the target or double halo sign in four (20%) patients. Pericolic vascular engorgement was 19 patients, two of whom were overstaged because pericolic vascular engorgement was interpreted as tumor infiltration. CONCLUSION: Although CT findings are not specific for certain groups of patients, they are often helpful in distinguishing tumoral from ischemic segments in patients with ischemic colitis proximal to colonic carcinoma. An understanding of this pathologic entity may increase the accuracy of CT for staging colonic carcinoma.

[Segmental ischemic colitis in lymphocytic thrombotic venulitis]. / Colite ischémique segmentaire sur veinulite lymphocytaire thrombosante.

This case illustrates the difficulty of diagnosing a colonic stenosis of ischemic origin. A 70-year-old lady presents with abdominal pain, fever and melaena. Lc are 15.2, ESR 39 mm, CEA 2.7 ng/ml. A barium enema shows a stenosis of the transverse colon that is suspicious of neoplasia. At time of operation, an induration of the transverse colon is found with edema of the corresponding mesocolon but no tumour is palpated. A resection of this area is performed and an end to end anastomosis performed. Pathology shows an ischemic colitis secondary to a lymphocytic thrombotic venulitis. The patient is discharged home one month postoperatively. 4 weeks later she is readmitted with the same symptoms. A gastrograffin enema shows a similar stenosis in the transverse colon including the anastomosis. The diagnosis is made of a recurrent ischemic stenosis. The patient improves over a 10-day period of conservative treatment (anticoagulation, TPN, steroids). A control barium enema shows a near resolution of the stenosis. The majority of ischemic colitis are of arterial origin nevertheless ischemic colitis of venous origin exists. The factor causing venous ischemia are not known. It is though thought to be associated with hypersensitivity vasculitis of drug origin. Its initial diagnosis versus neoplasia is difficult but once made there is a good response to a conservative treatment.