Phlebosclerotic colitis
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Phlebosclerotic colitis. Dr. Phillip Leung Queen Elizabeth Hospital. Case presentation. M / 69 Good past health Admitted for increased right lower quadrant pain for 3 days Associated with diarrhea Mild paraumbilical pain for 3 weeks Poor appetite for recent few months. Examination.

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Phlebosclerotic colitis

Phlebosclerotic colitis

Dr. Phillip Leung

Queen Elizabeth Hospital


Case presentation

Case presentation

  • M / 69

  • Good past health

  • Admitted for increased right lower quadrant pain for 3 days

    • Associated with diarrhea

    • Mild paraumbilical pain for 3 weeks

    • Poor appetite for recent few months


Examination

Examination

  • BP / P stable

  • Afebrile

  • Tenderness over RLQ with rebound and guarding

  • PR: brownish stool, no mass

  • WCC 10.4, Hb 11.4

  • Na 133, K 4.8, Cr 69

  • Albumin 27, LFT otherwise normal

  • Amylase 18

  • Clotting profile normal


Abdominal xr

Abdominal XR


Ct scan

CT scan


Impression phlebosclerotic colitis

Impression: Phlebosclerotic colitis


Phlebosclerotic colitis1

Phlebosclerotic colitis

  • First reported cases by Koyama et al in 1989 in Japan; until 2000 Yao et al proposed the name “Phlebosclerotic colitis”

    Yao T etal (2000) Phlebosclerotic colitis: value of radiography in diagnosis–report of three cases. Radiology 214(1):188–192

  • An “Asian” disease

    • The only “non - asian” case report is from Canada which is a gentleman who is Taiwanese by birth but a resident in Canada


Phlebosclerotic colitis2

Phlebosclerotic colitis

  • Subtype of ischemic colitis caused by venous disease; in contrast to the commoner arterial cause, namely atherosclerosis, thrombosis and embolism

    • Symptom is caused by chronic venous insufficiency and venous congestion secondary to phlebosclerosis

    • Ischemic changes lead to hemorrhage and atrophy of mucosa, submucosal fibrosis and hence motility dysfunction and stenosis of the affected colon

  • Right hemicolon is affected initially and gradually extends to distal colon

    • Superior mesenteric territories are predominantly affected with the inferior mesenteric territories largely spared, unlike the usual arterial type of ischemic colitis


Etiology

Etiology

  • Cause of phlebosclerosis is unknown

    • Portal hypertension

      • Phlebosclerosis is an adaptive changes to increased venous pressure caused by portal hypertension

      • Kusanagi and Kang reported cases associated with portal hypertension

        Kusanagi M et al (2005) Phlebosclerotic colitis: imaging-pathologic correlation. AJR Am J Roentgenol 185(2):441–447

        Kang et al (2009) Phlebosclerotic colitis in a cirrhotic patient with portal hypertension: Med Sci. 2009 Dec;24(6):1195-9.

    • Alcohol consumption

      • Ho et al. proposed alcohol consumption may play role which is his case report, cessation was associated with reduction in disease severity

        Ho TJ et al (2005) Phlebosclerotic colitis: an unusual cause of ischemic colitis in a 65-year-old man. J HK Coll Radiol 8:53–58

    • Toxin ingestion

      • Causing longstanding hypoxic injury leading to necrosis of muscular coat of veins as suggested by Chang et al

        Chang KM et al (2007) . New histologic findings in idiopathic mesenteric phlebosclerosis. J Clin Med Assoc 2007; 70: 227–35.

    • Possible related condition includes

      • Diabetes mellitus, hyperlipidemia, cardiac disease, CREST syndrome, Churg-Strauss syndrome and lymphocytic phlebitis

  • Majority of patients have no associated disease and etiology remains unknown


  • Presentation

    Presentation

    • Relatively long period of subclinical stage which is usually irreversible and gradually deteriorative

      • Non – specific clinical manifestation but characteristic pathological, imaging and endoscopic findings

    • An under diagnosed disease

      • Subclinical cases were not detected mostly; real number of patients are much more than known cases


    Presentation1

    Presentation

    • Recurrent non specific symptom

      • Abdominal pain, diarrhea, constipation, nausea and vomiting, per rectal bleeding and tarry stool

    • Acute presentation with complication

      • Ileus

      • Mechanical obstruction

      • Perforation

      • Massive bleeding


    Presentation2

    Presentation

    • Examination usually showed tenderness without peritoneal sign, unless complication arises

    • Blood test is non specific

      • Increased white cell count and C reactive protein

      • Mild increase in amylase

    • Abdominal XR

      • Multiple tortuous thread – like calcifications

      • Small bowel dilation and free gas


    Imaging

    Imaging

    • Computed tomography

      • Multiple tortuous thread – like calcifications

      • Colonic wall thickening

      • Bowel dilatation or evidence of perforation

    Yoshikawa K et al (2009) Idiopathic phlebosclerosis: an atypical presentation of ischemic colitis treated by laparoscopic colectomy Surgery. 2009 Jun;145(6):682-4


    Ba enema

    Ba enema

    • Ba enema

      • Luminal narrowing

      • Thumbprinting

      • Disappearance of semilunar folds

    • Yao T etal (2000) Phlebosclerotic colitis: value of radiography in diagnosis–report of three cases. Radiology 214(1):188–192


    Endoscopy

    Endoscopy

    • Endoscopy

      • Dark purple, edematous mucosa

      • Rigid wall

      • Small round ulcers

    • Right side colon is predominantly affected

    Yoshikawa K et al (2009) Idiopathic phlebosclerosis: an atypical presentation of ischemic colitis treated by laparoscopic colectomy Surgery. 2009 Jun;145(6):682-4


    Phlebosclerotic colitis

    Hu P et al Phlebosclerotic colitis: three cases and literature review Abdom Imaging. 2013 Dec;38(6):1220-4

    Jan YT et al Phlebosclerotic colitis. J Am Coll Surg. 2008 Nov;207(5):785.


    Ct colonoscopy

    CT colonoscopy

    Kang et al (2009) Phlebosclerotic colitis in a cirrhotic patient with portal hypertension: Med Sci. 2009 Dec;24(6):1195-9


    Angiography

    Angiography

    Kang et al (2009) Phlebosclerotic colitis in a cirrhotic patient with portal hypertension: Med Sci. 2009 Dec;24(6):1195-9


    Histology

    Histology

    • Histology

      • Thickened and tortuous submucosal veins with fibrosis and calcified degeneration

      • Atrophic mucosa with hemorrhage

      • Fibrotic submucosa

      • Chronic active inflammation with wall thickening

    Yoshikawa K et al (2009) Idiopathic phlebosclerosis: an atypical presentation of ischemic colitis treated by laparoscopic colectomy Surgery. 2009 Jun;145(6):682-4


    Treatment

    Treatment

    • No uniform standard

    • Conservative management was adopted for mild cases in most case report, even in progressive disease

      Ho TJ et al (2005) Phlebosclerotic colitis: an unusual cause of ischemic colitis in a 65-year-old man. J HK Coll Radiol 8:53–58

      Hoshino Y et al (2008) Gastrointestinal: phlebosclerotic colitis. J Gastroenterol Hepatol 23(4):670.

      Yu CJ et al (2009) Phlebosclerotic colitis with nonsurgical treatment. Int J Colorectal Dis 24(10):1241–1242.

    • Hoshino followed a patient for 5 years which disease progression was noted on CT and endoscopy; patient remained asymptomatic and with no complication

      Hoshino Y et al (2008) Education and imaging. Gastrointestinal: Phlebosclerotic colitis J Gastroenterol Hepatol. 2008 Apr;23(4):670.


    Treatment1

    Treatment

    • Surgery was suggested in severe disease and complication, e.g. perforation, intestinal obstruction

    • Bowel resection from terminal ileum to sigmoid colon is usually required to removed all diseased bowel

      Kato et al (2010) Perforated phlebosclerotic colitis--description of a case and review of this condition Colorectal Dis. 2010 Feb;12(2):149-51

      Markos V et al (2005) Phlebosclerotic colitis: imaging findings of a rare entity. AJR Am J Roentgenol. 2005 May;184(5):1584-6. (IO)


    Take home message

    Take home message

    • Phlebosclerotic colitis is a subtype of ischemic colitis

    • Non – specific clinical manifestation but characteristic pathological, imaging and endoscopic findings, as simple as an abdominal XR could suggest the diagnosis

    • Mild disease could be managed conservatively; severe colitis with complication required surgery


    Case presentation1

    Case presentation

    • CT report

      • Long segment mural thickening in ascending colon and transverse colon

      • Calcifications along mesenteric veins, mainly in right sided colon

      • Impression: phlebosclerotic colitis

      • 2.8cm rim enhancing collection with small extraluminal gas pocket in close association with caecum; Small 8mm defect noted in caecum

      • Findings suggestive of probable perforation at the caecum with associated collection


    Progress

    Progress

    • Emergency laparotomy was performed

      • Caecal inflammatory mass with perforation and abscess formation

      • Bowel gangrene from terminal ileum extending to proximal sigmoid colon

      • Thrombosed calcified vessels at mesentery of gangrenous bowel

      • Fecal peritonitis with gross contamination


    Progress1

    Progress

    • Subtotal colectomy with exteriorization of small bowel and sigmoid colon performed

    • Post – op uneventful except wound infection

    • Patient’s condition gradually improved and was discharged 3 weeks after operation


    Question

    Question?


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