Johns Hopkins University Hospital Baltimore, MD, United States
Award: Presidential Poster Award
Danse Bi, MD1, Mark Lazarev, MD2 1Johns Hopkins University Hospital, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore, MD
Introduction: Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare clinical entity. Clinically and endoscopically it can mimic inflammatory bowel disease (IBD) or ischemic colitis. IMHMV can be challenging to diagnosis with average time to diagnosis being greater than 5 months.
Case Description/Methods: A 25 year old male with PMH of morbid obesity (BMI 50) presented with lower abdominal pain, tenesmus, episodes of bright red blood per rectal and weight loss of 50 lbs over the course of 4 months. No family history of IBD. Initial labs were notable for WBC 13 x109/L, ESR 14, and fecal calprotectin 163. Infectious stool studies were negative. Physical exam showed moderate tenderness in the lower abdomen without rebound or guarding. CT abdomen/pelvis showed rectosigmoid wall thickening, pericolonic inflammation, prominent inferior mesenteric and perirectal veins. Colonoscopy showed scattered erosions, erythema, edema, and friability with luminal narrowing at 40 cm from the anal verge. Colonic biopsy showed ischemic pattern of injury and prominent lamina propria vascular changes in both the sigmoid colon and rectum; there were no features of chronicity. He was placed on IV methylprednisolone 15 mg Q8H and received one empiric dose of infliximab 10 mg/kg with initial improvement of his symptoms. He was discharged on prednisone 40 mg with plans to taper. He was re-admitted few days later given worsening symptoms and bloody diarrhea. Repeat CT abdomen/pelvis showed diffuse inflammatory changes in sigmoid colon similar to prior scan. Surgical option was discussed and patient preferred to avoid surgery. He received a second empiric dose of infliximab 10 mg/kg without further improvement. He eventually proceeded to laparoscopic sigmoidectomy with Hartman’s pouch. Surgical pathology showed myointimal hyperplasia of veins associated with mucosa ischemic injury and transmural vascular changes. His symptoms resolved after surgery.
Discussion: IMHMV is due to idiopathic myointimal proliferation of the mesenteric vein which results in colonic ischemia and ulceration. Clinically, it presents with diarrhea often with blood, lower abdominal pain, and weight loss. It occurs most often in men and commonly effects the rectosigmoid region. Often IMHMV is misdiagnosed as IBD or ischemia given its similar presentation. Colonic biopsy would show ischemic changes without characteristic features of IBD. Although rare, it is important to recognize IMHMV, since surgical resection of the involved colon is curative.
Disclosures: Danse Bi indicated no relevant financial relationships. Mark Lazarev indicated no relevant financial relationships.
Danse Bi, MD1, Mark Lazarev, MD2. P0195 - 25-Year-Old Male With Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.