Ischemic colitis of the cecum after renal transplantation masquerading as malignant disease

[Chronic mesenteric ischemia with consecutive ischemic colitis. Suggestions for diagnosis and therapy]

The incidence of acute mesenteric ischaemia has decreased over the last few years. However, cases of chronic mesenteric ischaemia have grown in number, as this disease is the most frequent disorder of the large intestine in the elderly. The typical clinical presentation of ischaemic colitis develops gradually and only becomes recognisable in the late stage of the disease. We present a 51-year-old woman with a history of unexplained abdominal pain. Multislice CT demonstrated an irregular stenosis of the truncus coeliacus and superior mesenteric artery. A Riolan's anastomosis was present and showed excellent perfusion. After a hemicolectomy 6 years previously, different radiologic procedures and endoscopy revealed a structural tumour at the colon transversum we suspected to be malignant. A sequential procedure was conducted. In a first vascular intervention, the truncus coeliacus was reconstructed with a vein patch, and the mesenteric superior artery was replanted. The second laparotomy was performed for revision of the superior mesenteric artery and resection of the intestinal tumour. However, no carcinoma was found in histological examination. In fact, the individual multidisciplinary considerations play an important role in determining the best treatment strategy, if intervention is warranted. Based on our experience, sequential intervention with a common clinical pathway is the safest and most suitable and economic procedure for curing complex pathologies.

"Nonspecific" erosions and ulcers of the colonic mucosa

A total of 26 cases of "nonspecific" erosions and ulcers of the colonic mucosa are reported. The most common causes were previous abdominal irradiation or ischemic disease due to arteriosclerosis. The lesions were localized to all segments of the colon. Of the 26 cases, five (19.2%) had erosions (ie, not penetrating beyond the muscularis mucosae) and the remaining 21, ulcers (ie, penetrating beyond the muscularis mucosae). In seven of the 26 cases (26.9%) more than one ulcer was found in the same specimen. Erosions may heal completely by epithelial regeneration (ie, restitutio ad integrum) while ulcers usually heal by replacing scarring tissue. Thus, the two lesions may not be clinically synonymous. The relatively high proportion of erosions among nonspecific ulcerations of the colonic mucosa has not been previously pointed out in the literature.

Ischemic colitis

Colon ischemia is a well-recognized clinical entity that often occurs spontaneously in patients over the age of 50 years. Many previous cases of nonspecific colitis are now felt to have been secondary to an ischemic event. In contrast to patients with acute mesenteric ischemia and extensive necrosis of the small bowel, the majority of patients with isolated colon ischemia follow a benign clinical course. Most patients present days, weeks, or months after the initial ischemic insult, and many may not have any recognizable antecedent episode of colon ischemia. However, some patients develop a fulminant form of the disease that causes colon infarction and death if not treated early. A high index of suspicion is necessary to make the diagnosis in the hospitalized patient. Endoscopy is recommended to confirm the diagnosis and the extent of injury and to monitor progression or resolution of disease. Aggressive management is of paramount importance to minimize the damage to the ischemic colon and reduce the otherwise high in-hospital mortality rate. Surgical intervention is indicated for patients with evidence of peritonitis or transmural infarction or perforation of the colon and for patients with chronic symptomatic colitis or stricture.