Unusual Case of Right-Sided Ischemic Colitis Despite Therapeutic Anticoagulation
Document Type
Article
Abstract
Introduction:
Ischemic colitis occurs when the blood supply to the intestine is compromised leading to mucosal damage. Patients with underlying medical conditions affecting blood flow and coagulation are often at higher risk of developing ischemic colitis. We present a unique case of right-sided ischemic colitis occurring despite full anticoagulation on warfarin.
Case Description/Methods:
A 38-year-old woman with lupus nephritis on mycophenolate and tacrolimus, antiphospholipid syndrome on warfarin, sickle cell trait, stroke, and recent lupus flare on steroids presented with acute diffuse, cramping abdominal pain followed by hematochezia. Her vitals were unremarkable, and abdominal exam revealed tenderness without guarding. Labs revealed leukocytosis of 12.37, acute kidney injury with a creatinine of 1.91 from a baseline of 0.90, and supratherapeutic INR to 3.25. CT of the abdomen without contrast showed trace peri colonic fat stranding involving the transverse colon, suggestive of colitis. Over the next 2 days, she continued to have hematochezia, and her INR continued to rise to 4.51 despite holding warfarin. On day 4, her INR decreased to 1.4 and colonoscopy was performed, revealing erythematous, friable mucosa in the right side of the colon consistent with ischemic colitis (Figure 1). Biopsies confirmed ischemic colitis and magnetic resonance angiography of the abdomen showed no occlusion. She was treated with supportive care, her warfarin was changed to enoxaparin, and she was discharged in stable condition.
Discussion:
Ischemic colitis is a disease that is usually self-limiting but without early recognition can lead to dire complications. Our case revealed a patient that developed ischemic colitis despite being on warfarin with a supratherapeutic INR. While the true etiology of the patient's ischemic colitis was never found, it is hypothesized that her sickle cell trait may have contributed to her presentation. Sickling that may occur during times of physical stress has been reported as a cause of ischemic colitis. Patient’s recent prolonged steroid use due to a lupus flare may have led to sickling and subsequent ischemic colitis. There has been one other case reported of ischemic colitis in the setting of therapeutic warfarin dosing, suggesting that hypercoagulable states can still lead to thromboembolic events despite therapeutic anticoagulation. It is important for healthcare providers to be aware of the possibility of ischemic colitis development regardless of the anticoagulation status of their patients.
First Page
S1782
DOI
10.14309/01.ajg.0000959900.70648.cf
Publication Date
10-1-2023
Recommended Citation
Reddy-Patel N, Bajwa A, Prenatt Z, Patel H, Chaput K. S2565 Unusual Case of Right-Sided Ischemic Colitis Despite Therapeutic Anticoagulation. Official journal of the American College of Gastroenterology| ACG. 2023 Oct 1;118(10S):S1782.