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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
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

slide17

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
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