Right Lower Quadrant Abdominal Pain and Focal Ischemic Colitis
1Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Ischemic colitis is the most common form of intestinal vasculopathy . Typical presentation include moderate left lower quadrant pain, tenderness and hematochezia . Right lower quadrant pain can occur if there is associated small bowel ischemia as well due to superior mesenteric artery occlusion and in that case patients present with severe pain, hematochezia and shock . We present an unusual case in which the patient presented with right lower quadrant pain without hematochezia or shock.
An 83 year old white female was admitted with sudden onset of severe, sharp, non-radiating right lower quadrant abdominal pain of one day duration. It happened few hours after eating food and was associated with nausea, vomiting and subjective fever and chills. She denied having any rectal bleeding. No prior history of any abdominal pain. She had a normal colonoscopy about 2 months prior to this episode. Her other medical problems included diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, gastroesophageal reflux disease, osteoarthritis and stress incontinence of urine. She was on metoprolol, ramipril, Lasix, potassium chloride, aspirin and clopidogrel. She was a non-smoker and non-drinker.
On examination: mildly obese woman. Pulse 88/minute, blood pressure 157/68 mm Hg, temperature 99.6. Abdomen, soft, mildly tender right lower quadrant , no mass palpable. Rest of the examination was unremarkable.
Lab: WBC 13,000/cmm, hemoglobin 13 g/dl and platelet count 141000,00/cmm. Urinalysis showed pyuria and urine culture grew Klebsiella pneumonia bacteria. CT showed circumferential thickening (about 7 cm long) and pericolonic stranding of ascending colon. Colonoscopy showed a mildly narrow segment of ascending colon with edematous pale and greyish looking mucosa and areas of ulceration. The biopsy material was comprised of ulceration with inflammation, granulation tissue and degenerative superficial mucosa suggestive of ischemic colitis.
Ischemic colitis is commonly seen in our daily clinical practice. It mostly occurs in elderly population possibly because of tortuous and narrow atherosclerotic blood vessels. Important risk factors include hypotension, cardiac thromboembolism, myocardial infarction, hypercoagulable states, long distance running, chronic constipation, risk factors for atherosclerosis like diabetes mellitus, hypertension, hyperlipidemia, and certain medications like estrogen, digitalis, nonsteroidal anti-inflammatory drugs, diuretics, tegaserod, sumatriptan and pseudoephedrine. But most of the time , the etiology remains unknown. Abdominal pain and hematochezia are the presenting symptoms in most of the cases. CT may show thickening of the colon wall. Diagnosis
is generally established by doing colonoscopy and biopsy (Figure-1). Colonoscopically, a segment of colon mucosa is seen to be abnormal. The mucosa may show erythema, congestion, linear ulceration, sometimes pale. Black mucosa indicates infarction. There can be narrowing of lumen due to submucosal hemorrhage. If infarction of the colon occurs, then the mucosa becomes black. Biopsy is not specific for ischemic colitis. It may show mucosal necrosis, edema and hemorrhage. Capillary thrombosis is frequently present. Hemosiderin is also frequently present in the mucosa and submucosa. Because of the transient nature of the colonic ischemia, mesenteric angiogram is not indicated. The management is mainly supportive. Most of the patients improve in few days time. Rarely, transmural infarction can occur and patient may need surgery.
This elderly female with multiple comorbidities presented with right lower quadrant abdominal pain without any hematochezia or melena and she was found to have focal ischemic colitis. Although ischemic colitis generally occurs in the left colon with predilection of the splenic flexure, it should also be considered in the differential diagnosis of pain in the right lower quadrant of the abdomen. Absence of hematichezia or melena does not exclude ischemic colitis.
Cite this article: Ahmed M. Right Lower Quadrant Abdominal Pain and Focal Ischemic Colitis. J J Gastro Hepato. 2014, 1(1): 006.