A 23-year-old female with a history of acne presented with abdominal pain and bloody diarrhea for 1 day. The pain was crampy in nature and located in her lower abdomen, without radiation or modifying factors. She was passing frequent watery bowel movements with a small amount of blood. She denied any recent travel, sick contacts, antibiotics, tobacco or drug use. She is an active softball player and played her last game one week ago. Her home medications included an oral contraceptive that she took for acne, and ibuprofen as needed. Notable labs on admission were an elevated WBC of 13.9 with a left shift, and a CRP of 2.6. A CT scan in the ER demonstrated circumferential wall thickening of the descending colon. The patient was started on intravenous metronidazole and ciprofloxacin and admitted to the observation unit. Stool studies were negative for an infectious etiology. After two days of intravenous antibiotics, fluids and supportive care, the patient’s symptoms had still not improved. Therefore, gastroenterology was consulted and performed a flexible sigmoidoscopy that demonstrated mild colitis in the sigmoid colon and, in the descending colon, severe colitis with ulcerations. Multiple biopsies were taken during the procedure that were consistent with ischemic colitis. Her oral contraceptive was discontinued and supportive care continued. The patient’s symptoms improved and she was discharged home two days later with instructions to avoid NSAIDs and oral contraceptives. On office follow-up two weeks later, she was doing well and back to her normal state of health.
Discussion:
Ischemic colitis is the most common form of intestinal ischemia, and accounts for 1 in 1,000 hospitalizations. It commonly occurs in adults 60 and older. Clinically, it manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa, carrying a good prognosis, to acute fulminant ischemia with transmural infarction, which may progress to necrosis and death. In this case of ischemic colitis, the diagnosis was not initially suspected given the patient’s age and good health. However, ischemic colitis is not unheard of in young healthy patients; and this case highlights some clinical clues to look for when evaluating such patients with colitis. This patient was an active softball player. Though the sport demands great athletic ability, it requires short bursts of exertion that are unlikely to precipitate a bout of ischemic colitis. On the other hand, long-distance runners are prone to this condition. More telling in this case were the patient’s medications, especially her oral contraceptive. Though this type of medicine is ubiquitous among young females, the therapy is not entirely benign. Oral contraceptives, along with NSAIDs and many other medications, are associated with ischemic colitis. Once the etiology of this patient’s colitis was recognized, it was appropriately treated by removing the insulting factors.
Conclusions:
Colitis is one of the most common diagnoses seen in hospitalized patient. Early recognition of ischemic colitis is important to minimize the morbidity of unnecessary antibiotic therapy and hospitalizations in mild to moderate disease as well as morbidity and mortality associated with severe manifestations of ischemic colits.