What's your diagnosis? - October 2018

Article Type
Changed
Fri, 03/29/2019 - 16:51

Idiopathic myointimal hyperplasia of the mesenteric veins

Gross examination of the rectosigmoid colon resected from this patient demonstrated transmural fibrosis. The mucosa was necrotic and hemorrhagic with a granular and cobblestone pattern (Figure B). Histopathologic examination of the mucosa revealed veins with myointimal hyperplasia with sparing of arterial vasculature (Figure C; stain: elastin; original magnification, ×10). The combined findings via endoscopy and histopathology confirmed the diagnosis of idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV).

IMHMV is a rare cause of proctosigmoiditis first described in a case series of 4 patients in 1991 by Genta and Haggitt.1 Owing to its clinical presentation of lower quadrant abdominal pain, diarrhea, hematochezia, and mucous in the stools, the diagnosis is often mistaken for inflammatory bowel disease. However, the endoscopic and pathologic findings of IHMVH resemble ischemic colitis. IMHMV is refractory to medical treatment and its definitive diagnosis and curative management involves surgical resection of the involved segment (often the rectosigmoid colon). The precise pathophysiology of IMHMV is unclear. Histopathologic analysis of veins in the involved segment of colon can demonstrate changes similar to those of failed saphenous grafts from coronary artery bypass.2 Myointimal hyperplasia of the mesenteric veins occurs (best identified with elastin stain on histopathology) with near total occlusion of the venous lumen and without any associated inflammatory infiltrate or arterial involvement.3

After colectomy, our patient’s abdominal symptoms resolved and follow-up colonoscopy at 6 months did not reveal recurrence of IMHMV, at which time, the patient underwent take-down of his colostomy. In the year after colostomy take-down, the patient showed no clinical or endoscopic signs of colitis while off of all medical therapies. Here, we present the first case of a successful take-down of a curative colostomy for an IMHMV patient, a treatment course not described previously in the literature. Prompt diagnosis and timely surgical intervention may allow for avoidance of permanent colostomy in patients with IMHMV.

References

1. Genta R.M., Haggitt, R.C. Idiopathic myointimal hyperplasia of mesenteric veins. Gastroenterology. 1991;101:533-9.

2. Abu-Alfa A.K., Ayer U., West A.B. Mucosal biopsy findings and venous abnormalities in idiopathic myointimal hyperplasia of the mesenteric veins. Am J Surg Pathol. 1996;20:1271-8.

3. Chiang C.K., Lee C.L., Huang C.S., et al. A rare cause of ischemic proctosigmoiditis: Idiopathic myointimal hyperplasia of mesenteric veins. Endoscopy. 2012;44:54-5.
 

Publications
Sections

Idiopathic myointimal hyperplasia of the mesenteric veins

Gross examination of the rectosigmoid colon resected from this patient demonstrated transmural fibrosis. The mucosa was necrotic and hemorrhagic with a granular and cobblestone pattern (Figure B). Histopathologic examination of the mucosa revealed veins with myointimal hyperplasia with sparing of arterial vasculature (Figure C; stain: elastin; original magnification, ×10). The combined findings via endoscopy and histopathology confirmed the diagnosis of idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV).

IMHMV is a rare cause of proctosigmoiditis first described in a case series of 4 patients in 1991 by Genta and Haggitt.1 Owing to its clinical presentation of lower quadrant abdominal pain, diarrhea, hematochezia, and mucous in the stools, the diagnosis is often mistaken for inflammatory bowel disease. However, the endoscopic and pathologic findings of IHMVH resemble ischemic colitis. IMHMV is refractory to medical treatment and its definitive diagnosis and curative management involves surgical resection of the involved segment (often the rectosigmoid colon). The precise pathophysiology of IMHMV is unclear. Histopathologic analysis of veins in the involved segment of colon can demonstrate changes similar to those of failed saphenous grafts from coronary artery bypass.2 Myointimal hyperplasia of the mesenteric veins occurs (best identified with elastin stain on histopathology) with near total occlusion of the venous lumen and without any associated inflammatory infiltrate or arterial involvement.3

After colectomy, our patient’s abdominal symptoms resolved and follow-up colonoscopy at 6 months did not reveal recurrence of IMHMV, at which time, the patient underwent take-down of his colostomy. In the year after colostomy take-down, the patient showed no clinical or endoscopic signs of colitis while off of all medical therapies. Here, we present the first case of a successful take-down of a curative colostomy for an IMHMV patient, a treatment course not described previously in the literature. Prompt diagnosis and timely surgical intervention may allow for avoidance of permanent colostomy in patients with IMHMV.

References

1. Genta R.M., Haggitt, R.C. Idiopathic myointimal hyperplasia of mesenteric veins. Gastroenterology. 1991;101:533-9.

2. Abu-Alfa A.K., Ayer U., West A.B. Mucosal biopsy findings and venous abnormalities in idiopathic myointimal hyperplasia of the mesenteric veins. Am J Surg Pathol. 1996;20:1271-8.

3. Chiang C.K., Lee C.L., Huang C.S., et al. A rare cause of ischemic proctosigmoiditis: Idiopathic myointimal hyperplasia of mesenteric veins. Endoscopy. 2012;44:54-5.
 

Idiopathic myointimal hyperplasia of the mesenteric veins

Gross examination of the rectosigmoid colon resected from this patient demonstrated transmural fibrosis. The mucosa was necrotic and hemorrhagic with a granular and cobblestone pattern (Figure B). Histopathologic examination of the mucosa revealed veins with myointimal hyperplasia with sparing of arterial vasculature (Figure C; stain: elastin; original magnification, ×10). The combined findings via endoscopy and histopathology confirmed the diagnosis of idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV).

IMHMV is a rare cause of proctosigmoiditis first described in a case series of 4 patients in 1991 by Genta and Haggitt.1 Owing to its clinical presentation of lower quadrant abdominal pain, diarrhea, hematochezia, and mucous in the stools, the diagnosis is often mistaken for inflammatory bowel disease. However, the endoscopic and pathologic findings of IHMVH resemble ischemic colitis. IMHMV is refractory to medical treatment and its definitive diagnosis and curative management involves surgical resection of the involved segment (often the rectosigmoid colon). The precise pathophysiology of IMHMV is unclear. Histopathologic analysis of veins in the involved segment of colon can demonstrate changes similar to those of failed saphenous grafts from coronary artery bypass.2 Myointimal hyperplasia of the mesenteric veins occurs (best identified with elastin stain on histopathology) with near total occlusion of the venous lumen and without any associated inflammatory infiltrate or arterial involvement.3

After colectomy, our patient’s abdominal symptoms resolved and follow-up colonoscopy at 6 months did not reveal recurrence of IMHMV, at which time, the patient underwent take-down of his colostomy. In the year after colostomy take-down, the patient showed no clinical or endoscopic signs of colitis while off of all medical therapies. Here, we present the first case of a successful take-down of a curative colostomy for an IMHMV patient, a treatment course not described previously in the literature. Prompt diagnosis and timely surgical intervention may allow for avoidance of permanent colostomy in patients with IMHMV.

References

1. Genta R.M., Haggitt, R.C. Idiopathic myointimal hyperplasia of mesenteric veins. Gastroenterology. 1991;101:533-9.

2. Abu-Alfa A.K., Ayer U., West A.B. Mucosal biopsy findings and venous abnormalities in idiopathic myointimal hyperplasia of the mesenteric veins. Am J Surg Pathol. 1996;20:1271-8.

3. Chiang C.K., Lee C.L., Huang C.S., et al. A rare cause of ischemic proctosigmoiditis: Idiopathic myointimal hyperplasia of mesenteric veins. Endoscopy. 2012;44:54-5.
 

Publications
Publications
Article Type
Sections
Questionnaire Body

A 25-year-old obese, Africa American man with no significant past medical history except for recent weight loss of 70 pounds presented for evaluation of bloody diarrhea and abdominal pain. The patient described sharp, left lower quadrant pain that progressively worsened over a 6-month period, along with loose bowel movements containing blood and mucous that occurred 20-40 times daily. A computed tomography scan of the abdomen revealed colonic wall thickening from the descending colon to the rectum. A flexible sigmoidoscopy demonstrated an area of congested, friable, dusky mucosa with overlying whitish exudate in the rectosigmoid colon (Figure A). Endoscopic biopsies were most consistent with ischemic colitis. A comprehensive work up for infectious colitis (including Clostridium difficile, stool culture, ova and parasites, cytomegalovirus, syphilis, herpes simplex virus, gonorrhea, and chlamydia), hypercoagulability, vasculitis, and illicit drugs was negative. A computed tomography angiogram of the abdomen/pelvis showed widely patent mesenteric vasculature and diffuse mucosal thickening of the sigmoid colon with inflammatory stranding surrounding the mesentery of the sigmoid colon and rectum. There was no portal venous gas or pneumatosis coli.

 

 

Owing to ongoing abdominal pain and profuse bloody diarrhea despite optimal resuscitative measures, the patient underwent a laparoscopic-assisted sigmoid resection with end colostomy and a Hartmann procedure, leaving a short rectal stump (Figure B), which completely abolished his symptoms.

Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)
Alternative CME
Disqus Comments
Default
Use ProPublica
Hide sidebar & use full width
render the right sidebar.