Syed S. Karim, DO1, Rucha Jiyani, MD1, Bobby Jacob, MD1, Jarin Prasa, MS2, Kaleem Rizvon, MBBS, FACG1, Paul Mustacchia, MD1
1Nassau University Medical Center, East Meadow, NY; 2Touro University, Middletown, NY
Necrotizing colitis has historically been primarily a disease of premature infants, affecting about 3/1000 live births. Adult necrotizing enterocolitis (ANEC) has seldom been reported, and to our knowledge, only a few case reports exist. We present an adult with necrotizing colitis and hope to provide some insight about presentation, diagnosis, and management.
A 54 year old male with history of gastroesophageal reflux disease and hyperlipidemia presented with abdominal pain associated with vomiting, fever, and bloody diarrhea.
He had both an unremarkable upper endoscopy and colonoscopy 3 years ago. His abdomen was soft, but tender on the left, with no rebound or guarding. CT scan revealed infectious and inflammatory colitis. Stool studies for bacteria, parasites and clostridium difficile were negative. Initially, the patient deteriorated despite aggressive hydration and antibiotics. Colonoscopy showed extensive ulcerated friable boggy colon, and severe colitis with pseudomembranes. Pathology confirmed necrotizing inflammation suggestive of necrotizing colitis. Ischemic work up with CT angiography showed patent abdominal arteries. Surgery was premeditated, however the patient gradually improved with medical management alone and was eventually discharged.
Although the exact mechanism of ANEC is unknown, two possible explanations include infectious agents and bowel perfusion disturbances. Infection is the main cause in neonates due to an underdeveloped immune system. Both gram negative bacteria and viruses are culprits, most commonly, E. Coli and Klebsiella. In ANEC, the primary insult may be hypoxia-reperfusion injury due to vasoconstriction of non occlusive mesenteric vessels and bacterial overgrowth as a secondary insult. Patients present with abdominal pain, vomiting and hematochezia. Xray and CT usually show nonspecific findings. CT angiography rules out mesenteric occlusion. Histological analysis demonstrating necrotizing inflammation finalizes the diagnosis. Our patient’s diagnosis was based on histology and the exclusion of mesenteric occlusion. Although, stool studies did not identify a causative pathogen, our patient eventually improved with antibiotics. It is postulated that an initial ischemic damage contributed to the patient’s clinical deterioration but the second insult of bacterial translocation was treated with antibiotics. Although rare, ANEC is being reported and clinicians need to keep high index of suspicion for timely management.
Citation: Syed S. Karim, DO; Rucha Jiyani, MD; Bobby Jacob, MD; Jarin Prasa, MS; Kaleem Rizvon, MBBS, FACG; Paul Mustacchia, MD. P0170 - A RARE CASE OF NECROTIZING COLITIS IN AN ADULT. Program No. P0170. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.