“Mass-forming” Variant of Ischemic Colitis Is A Distinct Entity With Predilection for the Proximal Colon

Abstract

We systematically evaluated the clinicopathologic features and outcome of a rare, unusual variant of ischemic colitis that presents as a mass lesion mimicking malignancy on imaging or colonoscopy. A retrospective search was performed for cases with a histologic diagnosis of ischemic colitis and a clinical impression of malignancy. Of the 23 patients initially identified, 4 were excluded because clinical and histologic review showed mucosal prolapse (n=1), discrete colon polyp (n=2), and a diverticular mass (n=1) without concern for malignancy. The mass-forming variant of ischemic colitis (n=19) was seen predominantly in elderly (mean age 71.8 y) women (63.2%) with a striking predilection for the right colon (13/19), particularly the cecum (n=6). Abdominal pain (52.6%) and hematochezia (26.3%) were the most common presenting symptoms. A computed tomography scan showed segmental thickening suspicious for malignancy in 6/8 patients. Colonoscopy revealed an exophytic (n=16) or stricturing (n=3) mass with a mean size of 4.67 cm. Mucosal biopsies showed features typical for ischemic colitis in all cases. A colectomy was performed in 4 cases. In 2, the mass-like appearance was due to marked submucosal and mural edema, whereas in the other 2 cases, with a malignant stricture-like lesion, marked submucosal fibrosis and cholesterol emboli were present. No malignancy was identified on follow-up in any patient (mean 39.9 mo). Follow-up colonoscopy was performed in 7 patients 1 to 32 weeks after initial presentation and showed resolution of the mass in all cases. Awareness of this rare variant of ischemic colitis will prevent unnecessary resections in these patients.

Diagnostic methods and drug therapies in patients with ischemic colitis

“…"Single stripe" refers to a single line of erythema with inflammatory erosion or ulceration along the longitudinal axis of the colon, and is highly specific [1,29]. In a few rare cases, IC lesions can form tumor-like lesions that are similar to malignant tumors [51,52].…”

Mass-Forming Ischemic Colitis: A Potential Mimicker of Malignancy

“…Of the few patients in the literature who have undergone colectomy, submucosal and/or mural edema or submucosal fibrosis were the only histologic findings. Therefore, adequate evaluation of the patients' clinical and histologic findings is instrumental to avoid a more extensive treatment [3, 5]. As in our case, these patients can usually be managed conservatively with resolution of the mass-like lesion on follow-up endoscopy.…”

“…Clinically IC most commonly presents acutely with abdominal pain, hematochezia, and diarrhea, with more serious complications such as fever, perforation, peritonitis, and septic shock developing dependent on the duration and extent of colonic injury [4]. Often, the diagnosis can be made utilizing clinical, radiologic, colonoscopic, and mucosal biopsy findings; however, there have been reports of atypical pathologic manifestations, precluding the diagnosis [5]. The endoscopic appearance of transient ischemic colitis can vary including edematous and fragile mucosa; segmental erythema; scattered erosion; longitudinal ulcerations; petechial hemorrhages interspersed with pale areas; purple hemorrhagic nodules; worn vascular lakes; and sharply defined segment of involvement.…”

A case of stricture-type ischemic colitis from excessive alcohol consumption, with follow-up to rule out colon cancer

“…Second, imaging studies of IC may require differentiation from malignant tumors, but even stricturetype IC can be improved with conservative treatment. It has been reported that endoscopic and CT findings of IC may resemble those of malignant tumors 5,6) . In the present case, it was difficult to differentiate type 4 (invasive) colon cancer from the ulcerative, slightly constricted lesions of CI observed at the first endoscopy, along with thickening of the colonic intestinal wall on contrastenhanced CT, and mild elevation of CEA.…”

“…In cases in which the possibility of cancer cannot be ruled out, stricturetype IC with intestinal obstruction and gangrenoustype IC generally require surgery, but 80 -85% of all IC cases are expected to be improved by conservative treatment 4) . On the other hand, endoscopic and computed tomography (CT) findings of IC can be similar to those of malignant tumors 5,6) . These must be distinguished from each other, so careful followup is necessary.…”