Case Report/Clinical Vignette Highlights: Ulcerative Colitis

Of the nearly 400 clinical vignettes and case reports presented on Monday, two focused on ulcerative colitis. Highlights of each are provided here.

Simultaneous Occurrence of Ulcerative Colitis and Familial Adenomatous Polyposis: Case ReportFuzhan Parhizgar, MS, MBA, Wesam Frandah, MD, and Sreeram Parupudi, MD, FACG, each from Texas Tech University Health Sciences Center, Lubbock, TX, presented this case report of a 21-year-old Hispanic female with a medical diagnosis of ulcerative colitis. At age 15 years, she presented with rectal bleeding and frequent blood stool that had lasted for the previous week, but she had not received treatment of any kind for previous 3 years.

Colonoscopy revealed diffuse, severely congested, eroded, friable, granular, hemorrhagic, inflamed, nodular, hundreds of polyps and ulcerated mucosa from the sigmoid colon to the ascending colon, findings that are consistent with severe ulcerative colitis. A few sessile polyps were found in the gastric body, fundus, antrum, and ampullary region with esophagogastroduodenoscopy (EGD), without signs of active bleeding. Crypts, crypt atrophy, crypitis, viliform surface changes, basal plasmacytosis, lymphoid aggregates, and plasma cell sheets were seen with biopsies taken from the colonoscopy, without any dysplastic changes, accordant with severe ulcerative colitis. Findings that were consistent with tubular adenoma of the duodenum, mixed fundic and hyperplastic gastric polyps, villous adenoma, mild ileitis, chronic pancolitis, hyperplastic polyps with focal adenomatous changes in the descending and sigmoid colon, and proctitis were revealed with biopsies taken during the EGD. Bilateral pulmonary thromboembolisms and an IVC thrombus complicated the patient’s hospital course. Without a family medical history available, familial adenomatous polyposis was suspected because of findings from colonoscopy and EGD polyps, confirmed by adenomatous polyposis coli gene sequence testing.

Parhizgar and colleagues concluded, stating that “the incidence rate for UC and FAP are relatively low in themselves, but the co-incidence as demonstrated in this patient, is extremely rare, which was supported by the lack of evidence on literature review.”

An Incidental Radiologic Finding in a Patient with Ulcerative ColitisNicole Loo, MD, Joshua Max, MD, Matthew Butts, MD, Samantha Scanlon, MD, Brett Frodl, MD, Tasha Pike, BS, and Thomas Poterucha, MD, from the department of internal medicine, Mayo School of Graduate Medical Education, Rochester, MN, presented this case of a woman age 32 years who has ulcerative colitis and was looking for an evaluation for possible surgical intervention.

Infliximab and prednisone had been used to manager her ulcerative colitis up to the time of the evaluation. Because work-up with CT enterography showed a filling defect that made physicians suspicious of right-sided pulmonary embolism, the patient was admitted to the Mayo Clinic for further management. Though she denied any major modifiable risk factors and symptoms for thromboembolic disease, her NuvaRing was discontinued. Aside for persistent tachycardia, the patient’s vital signs and oxygen saturations both remained stable, with a physical exam showing palpable cords in her right calf and lab results showing slight leukocytosis and moderately elevated C-reactive protein. Further, thyroid stimulating hormone was at normal levels, and ultrasound showed extensive right lower extremity DVT.

When IV heparin and warfarin were administered, the patient developed bloody stools, with colonoscopy confirming pancolitis and friable mucosa with easy bleeding. Because of concern over erratic oral intake and future surgical procedures, the patient was prescribed low molecular weight heparin upon dismissal. Within hours, she was re-admitted with symptoms of dyspne and pleuritic chest pain. At that point, blood cultures were obtained, with knowledge of the recent colonoscopy and persistent tachycardia. Escherichia coli from two separate sites grew from the cultures, with Infectious Diseases determining that the most likely reason for her bacteremia was the recent colonoscopy, despite occurrence not being well documented in the literature. With oral levofloxacin, the patient improved and was discharged home with a 14-day course. While waiting for a colectomy, the patient is being treated with a low molecular weight heparin.

“Thromboembolic disease affects about 6-8% of patients with ulcerative colitis,” say the researchers. “The hypothesized mechanism for hypercoagulability is altered colonic mucosa from persistent inflammation leading to microvascular changes and a procoagulant state.” They add that modifiable risk factors for clotting—such as smoking, contraceptives, and surgery—should be addressed in these patients, keeping in mind that treatment recommendations for this population does not differ from those for patients in the general population with thromboembolism. “Interestingly, even after protocolectomy, the risk of recurrent deep vein thrombosis and pulmonary embolism in UC is unchanged,” they say, concluding that, “ultimately, clinicians should have a high index of suspicion for venous thromboembolism in ulcerative colitis patients given the high incidence in this population.”