An unusual presentation of enterocolic lymphocytic phlebitis

Enterocolic phlebitis: a rare cause of bowel ischemia and review of the literature

Enterocolic phlebitis (EP) is a rare cause of bowel ischemia due to isolated venulitis of the bowel wall and mesentery without arterial involvement. EP is often misdiagnosed as inflammatory bowel disease, carcinoma, or diverticulitis due to non-specific symptoms as well as non-specific clinical and radiological findings. While unresponsive to pharmacotherapy, surgical resection of the affected bowel appears to be the only successful therapy with a very low recurrence rate. Etiology of EP remains unknown. We report a case of EP with rare presentation in the left hemicolon and unusual histological findings emphasizing the heterogeneity of this cause of enterocolic ischemia. The review and comparison of the three entities-EP, mesenteric inflammatory veno-occlusive disease (MIVOD), and idiopathic myointimal hyperplasia of mesenteric veins (IMHMV), all describing patterns of bowel ischemia due to isolated pathology of mesenteric veins-reveal that the current terminology is unclear. EP and MIVOD are very similar and may be considered the same disease. IMHMV, though, differs in localization, symptom duration, and histological findings but also shares features with EP and MIVOD. Further studies and harmonized terminology are inevitable for better understanding of the disease, prevention of unnecessary pharmacotherapy, and reduction in time to diagnosis.

Enterocolic Lymphocytic Phlebitis: Statistical Analysis of Histology Features in Viable and Ischemic Bowel

Enterocolic lymphocytic phlebitis is a rare cause of segmental ischemic enterocolitis. This artery-sparing transmural vasculitis is classically a circumferential phlebitis with perivenular lymphocyte cuffing and thrombi in the absence of systemic manifestations. Myointimal hyperplasia may represent a chronic phase of enterocolic lymphocytic phlebitis. Subclinical or early stage enterocolic lymphocytic phlebitis is not well delineated. We analyzed 600 submucosal and subserosal veins from both ischemic and intact bowel segments to discern if vascular morphology varied between sites. Crescentic and circumferential lymphocytic phlebitis is more common in viable bowel than in the ischemic segment. A nonsignificant trend was found for increased crescentic morphology between intact bowel remote from the ischemic focus compared with that adjacent to the ischemic focus. Hallmarks of ischemic bowel are necrotizing phlebitis and thrombi formation. Thrombophlebitis morphology is distinctly different in viable and ischemic bowel, changing from the classic lymphocytic to necrotizing lesions respectively.

Enterocolic Lymphocytic Phlebitis: Clinicopathologic Features and Review of the Literature

Enterocolic lymphocytic phlebitis (ELP) is a recently described entity and is of unknown etiology and pathogenesis. It is characterized by phlebitis of the bowel wall and mesentery, without arterial involvement or evidence of systemic vasculitis. The clinical presentation of ELP is varied, but it most commonly manifests with signs of an acute abdomen. Clinical, radiologic, and endoscopic findings are often conflicting and misdiagnosis is common as venous thrombosis is not suspected. The diagnosis of ELP is obtained histologically. There is a spectrum of histologic features associated with ELP, which includes lymphocytic phlebitis, necrotizing phlebitis, granulomatous phlebitis, and myointimal hyperplasia. Other features include venous thrombi and acute ischemic changes of the intestine. Surgical resection of the affected bowel is usually curative and recurrences are rare. The clinical and histopathologic features of ELP are reviewed.

Mesenteric Venulitis in a 71-Year-Old Man after Acute Appendicitis

Mesenteric inflammatory veno-occlusive disease (MIVOD) is a clinicopathological entity recently described for a case series of patients with intestinal ischemia of unknown etiology. MIVOD is characterized as a venulitis with lymphocytic, necrotizing, or mixed granulomatous morphology. The disease seems to be self-limiting with resolution of symptoms after surgical resection. We describe a 71-year-old man who developed focal intestinal ischemia in the postoperative period after laparoscopic appendectomy. At re-exploration, a 20-cm segment of grossly ischemic jejunum was identified and resected. The excised specimen demonstrated early ischemic mucosal injury and necrotizing mesenteric venulitis with thrombosis, consistent with verso-occlusive disease. The etiology of this rare vasculitis is currently unknown. We present our case report, which is followed by a review of the literature of MIVOD.

Chronic Antral Ulcer Associated With Gastroduodenal Lymphocytic Phlebitis

Enterocolic lymphocytic phlebitis (ELP) is a rare cause of gastrointestinal ischemia. Unlike most vasculitic diseases affecting the gastrointestinal tract, ELP involves only the mural and mesenteric veins, which are surrounded by a lymphocytic and sometimes granulomatous infiltrate. The mesenteric arterial system and the systemic vasculature are characteristically spared. Most patients with ELP present with an acute abdomen that resolves following surgical resection of the involved bowel. ELP has been reported to involve the small bowel, colon, or both, but involvement of the upper gastrointestinal tract has not been previously described. Here we report a case of lymphocytic phlebitis that affected only the stomach and duodenum. The patient, a 68-year-old man, had a nonhealing gastric antral ulcer and underwent hemigastrectomy with vagotomy and Billroth II reconstruction. Both the resected stomach and duodenum showed characteristic lymphocytic and granulomatous infiltrates that involved the submucosal and mural veins, with associated obliteration of vascular lumina; the adjacent arteries were completely spared. The patient developed late postoperative complications including bile reflux gastritis and erosive esophagitis, but he had no recurrence of gastrointestinal ulceration or ischemia over a 2-year follow-up. We hypothesize that there may be more cases of upper gastrointestinal ELP than are diagnosed as such, in part because the diagnosis can be made only on surgical resections specimens.

Enterocolic lymphocytic phlebitis with lymphocytic colitis, lymphocytic appendicitis, and lymphocytic enteritis

We describe a 53-year-old man with a history of diarrhea temporally related to the use of flutamide. He developed an acute abdomen, and presented with an ileocecal intussusception due to an edematous ischemic cecum. The ischemia was due to enterocolic lymphocytic phlebitis (ELP), with numerous associated thrombi. The phlebitis involved not only the ischemic area but also the grossly unaffected areas, including the entire right colon, terminal ileum, and appendix. All layers of the bowel wall were involved. Mesenteric veins were also prominently affected, but the arteries were spared. This rare form of vasculitis was associated with a marked lymphocytic infiltrate involving the epithelium of the entire right colon, ileum, and appendix. This is the first reported case of ELP occurring in conjunction with lymphocytic colitis, lymphocytic enteritis, and lymphocytic appendicitis. The temporal association of the patient's symptoms with flutamide use suggests that this peculiar form of lymphocytic inflammation of the veins and mucosa likely represents a drug reaction. We suggest that some cases of lymphocytic colitis may also be associated with ELP but are unlikely to be recognized unless affected submucosal vessels happen to be included in the biopsy.

Panniculitis of the descending colon caused by enterocolic phlebitis: a case report

A 73-year-old male was referred to our hospital for abdominal pain, diarrhea and general fatigue lasting for 3 weeks. Physical examination of the abdomen revealed a firm mass in the left abdominal region. Computed tomography revealed a mass around the descending colon. Colonoscopy and barium enema revealed poor extensibility of the lumen with edematous mucosa, and narrowing of the descending colon with rugged mucosal surface. Because of the clinical symptoms and findings, the patient was diagnosed clinically as suffering from panniculitis of the descending colon. He underwent the left hemi-colectomy with side-to-side colo-colostomy after making of a loop ileostomy. Histological analysis of the resected colon showed an infiltration of inflammatory cells, predominantly lymphocytes, into veins and venules of the submucosa, muscularis propria and fat tissue of the colonic mesentery, with an involvement of all layers of the vessel wall. Arteries were escaped from inflammatory changes. The histopathological diagnosis of enterocolic phlebitis and venulitis was made because of these findings.