This morning, Jerry Lipinski, one of our stellar R2s presented an interesting patient he recently took care of at the VA: a 53-year-old woman with a history of Rheumatoid Arthritis who presented with acute bloody diarrhea. Her initial presentation was notable for sinus tachycardia, LLQ tenderness, leukocytosis. We used the opportunity to work through our differential diagnosis and discuss the work-up to obtain.
A CT scan of the abdomen showed non-specific inflammation of the colon in the splenic flexure and adjacent bowel. We highlighted some of the common findings on imaging – mucosal thickening, edema, fat stranding, and “thumbprinting” (haustra of the large bowel becoming thickened and projecting into the intestinal lumen at regular intervals). The patient then underwent colonoscopy which showed patchy erythematous, edematous, and friable mucosa consistent with ischemic colitis. We were very lucky to have Dr. Cynthia Hsu, an alumnus of our residency and current GI fellow as a discussant to walk us through the findings.
We then talked about the causes of ischemic colitis, which can broadly be divided into occlusive and non-occlusive etiologies. We also discussed one common reason to have ischemia in “watershed” areas of the colon – episodic hypoperfusion. The exact cause of ischemic colitis in any given patient is often difficult to find, and in this case, there was reason to suspect that the patient’s TNF-alpha inhibitor (adalimumab) for RA was the culprit. This adverse event has been described in the literature for biologic agents. Additionally, the patient had been transitioned from etanercept to adalimumab two years prior due to colitis that at the time was not further specified.
Our surgical colleagues were consulted, but the patient did not require intervention and improved over several days of conservative management. She was treated for 5-day course of antibiotics – the routine use of antibiotics is not necessary, but this patient’s clinical status was concerning (rising leukocytosis and extensive colonic involvement on endoscopy) that the team needed to treat potential bacterial gut translocation.
A special thank you to Dr Hsu for all her high-yield clinical pearls!